MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY
EDUCATION
Program Quality Assurance Services
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
All corrective action must be fully implemented and all noncompliance corrected as soon
as possible and no later than one year from the issuance of the Program Review Final
Report dated 3/30/2012.
Mandatory One-Year Compliance Date: 4/2/2013
Summary of Required Corrective Action Plans
Farr Academy, Inc
CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agency
15557
A - Farr Academy Day Program
B - Farr Academy Summer Program
Criterion #
12.1
12.1
Criterion Title
New Staff Orientation and
Training
New Staff Orient
509
12.2
12.2
13
In-Service Training Plan and
Calendar
In-Service Trainin
510
16.7
16.7
14
Preventive Health Care
Preventive Health
523
16.7
Preventive Health Care
Preventive Health
CPR Rating
Partially
Implemented
Applies To
A,B
A,B
CAP Status
Approved
Approved
Partially Implemen
Partially
Implemented
A,B
A,B
Approved
Approved
Partially Implemen
Partially
Implemented
A
Approved
A
Approved
Partially Implemen
15
16.7
A - Farr Academy
523
Partially
Implemented
B
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
Approved
B
Approved
1
16
back
Partially Implemen
34
N
PCPR
102
CPR/Program Rev
Farr Academy
8
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Farr Academy, Inc
CPR/Program Review Onsite Year: 2011-2012
PS Criterion #12.1 - New Staff Orientation and Training
Program
Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
04/02/2013
Program
Review Finding
While interviews revealed that new staff orientation occurs, documentation and staff record reviews
revealed that orientation for new staff members is not documented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Director and Associate Director
02/16/2012
* Description New Staff Orientation and Training documentation is now included in the new staff
records as a separate document from the annual Inservice Training document and will
continue to be maintained as such.
* Evidence of Evidence of New Staff Orientation and Training and attendance sheets are maintained in
Completion of the staff files and will be uploaded to DESE.
Corrective
Action
* Description Upon the completion of any New Staff Orientation the Program Director will review new
of Internal staff files to ensure that documentation of participation of the new staff is contained
Monitoring therein.
Process
Complete
Director and Ass
02/16/2012
New Staff Orient
Evidence of New
Upon the complet
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
On
2
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
06/15/2012
Correction
Status
Not Corrected
Basis for Farr Academy has indicated their understanding of this requirement and discussed with
Status the liaison ways to come into compliance and ongoing monitoring of this criterion by
Decision stating that the required training document is now included in the New Staff records.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
Progress Report Due Date(s)
15
09/17/2012
17
11/17/2012
09/17/2012
11/17/2012
Add Due Date
Farr Academy must submit a New Staff Orientation checklist that includes all of the
following required elements: 1.Program's Philosophy; 2.Organization; 3.Program;
4.Practices; 5.Goals: 6. ESE required topics (12.2 a-e); and Provisions for orientation of
intern, volunteers or others who work at the program, if applicable. Farr Academy must
upload copies of all completed orientation checklists for all new staff hired for the 20122013 school year that includes the name of the staff member, date of hire and completion
date for all required training topics.
PQA Review Complete
PS Criterion #12.2 - In-Service Training Plan and Calendar
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
04/02/2013
Program Review
Finding
While interviews revealed that in-service training occurs, documentation and staff record reviews revealed
that staff in-service training is not documented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
Director and Associate Director
* Expected
Date of
Completion
06/29/2012
* Description The Annual Inservice Training Plan and Calendar for individual staff members will now
reflect wording that states the staff attended the trainings listed on the documentation
contained in their file as well as signed attendance for each training attended.
* Evidence of Evidence of Annual Inservice Training Plan and Calendar and signed attendance forms are
Completion of maintained in the staff files and will be uploaded to DESE.
Corrective
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
3
Action
* Description The Program Director and Associate Director will annually review staff files to ensure
of Internal documentation of attendance and participation in Staff Inservice Training is contained
Monitoring therein.
Process
Complete
Director and Ass
06/29/2012
The Annual Inser
Evidence of Annu The Program Dire
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
06/15/2012
Correction
Status
Not Corrected
Basis for Farr Academy has indicated their understanding of this requirement and discussed with
Status this liaison ways to come into compliance and ongoing monitoring of this criterion by
Decision revising their Annual In-Service Training Plan to include signed attendance for each
training which will be kept in individual staff files.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
Progress Report Due Date(s)
15
09/17/2012
17
11/17/2012
09/17/2012
11/17/2012
Add Due Date
Farr Academy must submit evidence of its procedure to ensure documentation that all new
and returning staff members have participated in all required in-service training topics
which must be provided annually and also submit evidence of at least two hours of training
per month and that this documentation is kept for each staff member in their personnel
files. Farr Academy must submit the In-Service Training documentation for the records of
at least five staff in various positions for the 2012-2013 school year.
PQA Review Complete
PS Criterion #16.7 - Preventive Health Care
Program
Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
04/02/2013
Program
Review
Finding
Documentation, student record review, and interviews revealed that not all students in the Day Program had
evidence of physical and dental examinations and vision, hearing and postural screenings as required.
* Indicates required field
District/Agency Corrective Action Plan
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
4
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Director, Associate Director and the Parent Clinical Coordinator
06/29/2012
* Description Physical Exams and Postural Screenings - Physical examinations with evidence of postural
screenings are requested upon acceptance into the program. If a written report from the
physician of the results of the examination and any recommendations and/or
modifications of the students' activity are not submitted a second written request will be
issued to the parent/guardian as well as telephone contact. A tracking log of telephone
contact will be maintained. Copies of letters requesting this information currently
contained in the Student Records will be contained in the Student Medical Files. Dental
Exams - Dental examinations are currently requested upon acceptance into the program. If
a written report from the dentist of the results of the examination and any
recommendations and/or modifications of the students' activity are not submitted a
second written request will be issued to the parent/guardian as well as telephone contact.
A tracking log of telephone contact will be maintained. Copies of letters requesting this
information currently contained in the Student Records will be contained in the Student
Medical Files. Vision and Hearing Screenings - Vision and Hearing Screenings are
conducted annually by a technician from the Cambridge Public Health Department.
Following the screenings any positive findings are sent to each students' parent/guardian
along with any recommendations. Written notification of these screenings has been moved
from the Student Record files to the Student Medical Files.
* Evidence of Documentation will be contained in the Student Medical Files.
Completion of
Corrective
Action
* Description The Parent Clinical Coordinator will review, track and maintain a log of the requests for
of Internal and receipt of the evidence of Physical and Dental examinations.
Monitoring
Process
Complete
Director, Associa
06/29/2012
Physical Exams a
Documentation w
The Parent Clinica On
For PQA Use Only
Corrective
Action Plan
Status
Approved
Plan
Status
Date
06/15/2012
Correction
Status
Not Corrected
Basis for Farr Academy has indicated their understanding of this requirement and discussed with
Status this liaison ways to come into compliance and ongoing monitoring of this criterion and
Decision have proceeded to require proof of exams and screenings and documentation of efforts to
receive them from parents/guardians based on annual or Department of Public Health
requirements.
Department
Order of
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
5
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Progress Report Due Date(s)
15
09/17/2012
17
11/17/2012
09/17/2012
11/17/2012
Add Due Date
Required Farr Academy must submit a chart containing the dates of the following for all currently
Elements of enrolled students: 1. Last physical exam 2. Last dental exam 3. Last vision screening 4.
Progress Last hearing screening 5. Last postural screening
Report(s)
PQA Review Complete
PS Criterion #16.7 - Preventive Health Care
Program
Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
04/02/2013
Program
Documentation, student record review, and interviews revealed that not all students in the Summer Program
Review Finding had evidence of physical and dental examinations and vision and hearing screenings as required.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Director, Associate Director and the Parent Clinical Coordinator
* Expected
Date of
Completion
06/29/2012
* Description Physical Exams - Physical examinations are requested upon acceptance into the program.
If a written report from the physician of the results of the examination and any
recommendations and/or modifications of the students' activity are not submitted a
second written request will be issued to the parent/guardian as well as telephone contact.
A tracking log of telephone contact will be maintained. Copies of letters requesting this
information currently contained in the Student Records will be contained in the Student
Medical Files. Dental Exams - Dental examinations are currently requested upon
acceptance into the program. If a written report from the dentist of the results of the
examination and any recommendations and/or modifications of the students' activity are
not submitted a second written request will be issued to the parent/guardian as well as
telephone contact. A tracking log of telephone contact will be maintained. Copies of letters
requesting this information currently contained in the Student Records will be contained
in the Student Medical Files. Vision and Hearing Screenings - Vision and Hearing
Screenings are conducted annually by a technician from the Cambridge Public Health
Department. Following the screenings any positive findings are sent to each students'
parent/guardian along with any recommendations. Written notification of these
screenings has been moved from the Student Record files to the Student Medical Files.
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
6
* Evidence of Documentation will be contained in the Student Medical Files.
Completion of
Corrective
Action
* Description The Parent Clinical Coordinator will review, track and maintain a log of the requests for
of Internal and receipt of the evidence of Physical and Dental examinations.
Monitoring
Process
Complete
Director, Associa
06/29/2012
Physical Exams -
Documentation w
The Parent Clinica On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
06/15/2012
Correction
Status
Not Corrected
Basis for Farr Academy has indicated their understanding of this requirement and discussed with
Status this liaison ways to come into compliance and ongoing monitoring of this criterion and
Decision have proceeded to require proof of exams and screenings and documentation of efforts to
receive them from parents/guardians based on annual or Department of Public Health
requirements.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Progress Report Due Date(s)
15
09/17/2012
17
11/17/2012
09/17/2012
11/17/2012
Add Due Date
Required Farr Academy must submit a chart containing the dates of the following for all currently
Elements of enrolled students: 1. Last physical exam 2. Last dental exam 3. Last vision screening 4.
Progress Last hearing screening 5. Last postural screening
Report(s)
PQA Review Complete
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Farr Academy, Inc. PR Corrective Action Plan
7