MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION Program Quality Assurance Services PROGRAM REVIEW CORRECTIVE ACTION PLAN Special Education Agency: Germaine Lawrence, Inc. Program Review Onsite Year: 2012-2013 Programs under review for the agency: A - Germaine Lawrence Day Program B - Germaine Lawrence Residential Program 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 05/28/2013. Mandatory One-Year Compliance Date: 05/28/2014 Summary of Required Corrective Action Plans in this Report Criterion PS 6.1 Criterion Title Daily Instructional Hours Applies To A,B PS 8.8 IEP - Progress Reports A,B PS 9.1(a) Student Separation Resulting from Behavior Management Staffing for Instructional Groupings A,B Teachers (Special Education Teachers and Regular Education Teachers) Master Staff Roster A,B PS 10.1 PS 11.4 PS 11.6 A,B A,B PR Rating Partially Implemented Partially Implemented Partially Implemented Partially Implemented Partially Implemented Partially Implemented Criterion PS 12.2 Criterion Title In-Service Training Plan and Calendar Applies To A,B PS 15.1 A,B PS 16.7 Parental Involvement and Parents' Advisory Group Preventive Health Care PS 18.1 Confidentiality of Student Records A,B PS 19 Anti-Hazing A,B PS 20 Bullying Prevention and Intervention A,B A,B PR Rating Partially Implemented Partially Implemented Partially Implemented Partially Implemented Partially Implemented Partially Implemented PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 6.1 Daily Instructional Hours Partially Implemented Applies To: All Department Program Review Findings: A review of documentation indicates that both programs do not provide students with the required annual instructional hours for a 12 month program. Description of Corrective Action: School calendar to be adjusted to include more time on learning. Early release days have been reduced along with the number of professional development days. Title/Role(s) of Responsible Persons: Expected Date of Principal Completion: Education Liaison 08/30/2013 Evidence of Completion of the Corrective Action: Approved school calendar will be used as evidence of completion. Description of Internal Monitoring Procedures: Using the Structured Learning Time Worksheet to ensure we have enough time on learning for our program. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: PS 6.1 Daily Instructional Hours Corrective Action Plan Status: Approved Status Date: 07/09/2013 Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): Germaine Lawrence must submit a copy of the 2013/2014 school calendar along with a completed learning time worksheet both of which must demonstrate that minimum instructional hours are being offered. Progress Report Due Date(s): 08/30/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 3 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 8.8 IEP - Progress Reports Partially Implemented Applies To: All Department Program Review Findings: A review of student records indicates that while Progress Reports are being sent to parents or guardians, there is no evidence that they are also being sent to the public school district. Description of Corrective Action: Germaine Lawrence will create a system to track who IEP progress notes are sent to, the date sent, and who sent them. All staff responsible for sending IEP progress notes will be trained to the new system. Title/Role(s) of Responsible Persons: Expected Date of Education Liaison Completion: Principal 08/30/2013 Evidence of Completion of the Corrective Action: Progress notes from the tracking system will be used as evidence of completion as well as copies in the students education file. Description of Internal Monitoring Procedures: Progress notes from the tracking system will be used to ensure that notes are being sent at the end of each quarter. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: PS 8.8 IEP - Progress Reports Corrective Action Plan Status: Approved Status Date: 07/09/2013 Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the tracking system that will be used to monitor to whom IEP progress notes are being sent. Second Progress Report - Germaine Lawrence must submit evidence that progress reports are being sent to all required parties by sampling 10 student files between 8/30/13 and 12/13/13 and summarizing for the Department the outcome of that sampling and describing any follow-up steps that were needed and taken. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 4 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 9.1(a) Student Separation Resulting from Behavior Partially Implemented Management Applies To: All Department Program Review Findings: A review of student records and interviews with staff indicate that Germaine Lawrence does not have a means of documenting the use of time-out for an individual student, including, at a minimum, length of time, reasons for this intervention, who approved the procedure, and who monitored the student during the time-out. Description of Corrective Action: It is essential for learning that youth in the Germaine Lawrence Campus School who leave the classroom for behavioral reasons return to the classroom as soon as they are able. The lead day counselor will be responsible on a daily basis for tracking youth movement in and out of the classroom so that behavioral patterns and effective interventions can be implemented to assure adequate time on learning for all youth. Each tracking form (see attached) will track the following areas: -Youth name -The reason that the youth had time out of class -The initials of the staff person who approved time out of class -The initials of the staff person who worked with the youth so that they could return to class -Total time the youth was out of class for that incident Title/Role(s) of Responsible Persons: Expected Date of Shift Supervisor Completion: Program Manager 08/30/2013 Principal Evidence of Completion of the Corrective Action: Documentation will be collected and stored in the principal's office. Description of Internal Monitoring Procedures: The shift supervisor will be responsible to ensure that the information is collected daily, that weekly tracking is collected in a tracking binder, and that copies of weekly tracking sheets are submitted to the Principal. The Principal will review the material weekly with the day school staff and leadership team to identify behavioral patterns and identify and implement interventions that lead to a youth being more successful in the classroom. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 9.1(a) Student Separation Resulting Status Date: 07/09/2013 from Behavior Management Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the tracking form that includes the length of time, reasons for this intervention, who approved the procedure, and who monitored the student during the separation. MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 5 Second Progress Report - Germaine Lawrence must submit evidence that the tracking form has been used to document students' time out of class due to behavioral reasons, and that it has been reviewed weekly and should indicate whether behavioral patterns have been identified and interventions implemented. Additionally, Germaine Lawrence must submit evidence that staff members have been trained on the utilization of the timeout tracking form. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 6 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 10.1 Staffing for Instructional Groupings Partially Implemented Applies To: All Department Program Review Findings: Documentation and interviews indicate that Germaine Lawrence has instructional groupings that exceed the approved Student: Licensed Educator Ratio of 5:1. Description of Corrective Action: In classrooms where it is necessary to assure the presence of two adults due to the number of students, at times, it is necessary for the classroom aide to accompany the youth out of the room and briefly support the youth prior to behavioral staff responding. It is the responsibility of the shift supervisor to assure that the classroom aide is able to return to the classroom within 5 minutes to assure an adequate learning environment. If the shift supervisor finds that circumstances prohibit their ability to release the classroom aide back to the classroom, the shift supervisor must notify the day shift supervisor and the day manager, who can proceed to the classroom and support the youth so that the classroom aide can return to the classroom. The assistant principal and principal will also be accessed as necessary to support in or out of the classroom. If there is more than two instances in a day when campus school leaders are called to the classroom to support so that the teacher or aide can return to the classroom, the day team will convene at the end of the day to review classroom or youth functioning as necessary and to create a plan for the next day that will decrease adult and youth time out of the classroom. If there are more than two days in a week where special planning is necessary, the campus director will be notified and the educational leadership team will convene and complete additional planning. Title/Role(s) of Responsible Persons: Expected Date of Principal Completion: Program Manager 08/30/2013 Evidence of Completion of the Corrective Action: Each classroom will be maintained at a 1:5 licensed educator/youth ratio. Description of Internal Monitoring Procedures: If there is more than two instances in a day when campus school leaders are called to the classroom to support so that the teacher or aide can return to the classroom, the day team will convene at the end of the day to review classroom or youth functioning as necessary and to create a plan for the next day that will decrease adult and youth time out of the classroom. If there are more than two days in a week where special planning is necessary, the campus director will be notified and the educational leadership team will convene and complete additional planning. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 10.1 Staffing for Instructional Status Date: 07/09/2013 Groupings Basis for Partial Approval or Disapproval: Department Order of Corrective Action: MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 7 Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit block schedules for the 2013/2014 school year that indicate the number of students and licensed educators in all classrooms. Also indicate if there were two instances in any day when campus school leaders were called to the classroom to support teacher or aide, and if so, whether the day team convened at the end of the day to review classroom or youth functioning and created a plan for the next day? Also indicate if there were more than two days in any week where special planning was necessary, and if so was the campus director notified and the educational leadership team convened and was additional planning completed? Second Progress Report - Indicate if there were two instances in any day between 8/30/13 and 12/13/13 when campus school leaders were called to the classroom to support teacher or aide, and if so, whether the day team convened at the end of the day to review classroom or youth functioning and created a plan for the next day? Also indicate if there were more than two days in any week between 8/30/13 and 12/13/13 where special planning was necessary, and if so was the campus director notified and the educational leadership team convened and was additional planning completed? Before 12/13/2013 the Department will also conduct an unannounced visit to verify that 5:1 and 9:1:1 ratios are being maintained. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 8 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 11.4 Teachers (Special Education Teachers and Regular Partially Implemented Education Teachers) Applies To: All Department Program Review Findings: Interviews, documentation and a review of staff records indicate that not all teaching staff are appropriately licensed or on an approved waiver. Description of Corrective Action: Germaine Lawrence will work to hire appropriately licensed teachers for open slots. We will work with the recruiting department to make sure that job postings are accurate. When/if we would require a hardship waiver we would follow and submit the required information to the Licensure Office: - proof of specific actions taken to recruit a licensed and qualified person - list containing the names of all appropriate applicants and an explanation as to why they weren't hired - an explanation as to why we hired the unlicensed applicant - proof that the candidate holds a degree Title/Role(s) of Responsible Persons: Expected Date of Principal Completion: Recruiting Department 08/30/2013 Evidence of Completion of the Corrective Action: Documentation and review of staff records will be used as evidence of completion. Description of Internal Monitoring Procedures: Audit of the applicants when there is an open position. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 11.4 Teachers (Special Education Status Date: 07/09/2013 Teachers and Regular Education Teachers) Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a revised policy which indicates how teacher licenses will be monitored to ensure that all teachers (new hires and existing teachers) are appropriately licensed or on approved waivers. Second Progress Report - Germaine Lawrence must submit an updated teaching roster, along with proof of licensure/waiver for all teachers for the 2013/2014 school year. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 9 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 11.6 Master Staff Roster Partially Implemented Applies To: All Department Program Review Findings: Documentation indicates that staff positions do not correspond to the last approved Program Budget and an explanation was not provided to explain the discrepancies. Description of Corrective Action: Germaine Lawrence will work to ensure all apporved staffing plans, titles and functions are assigned correctly according to the last approved budget and will make adjustments as necessary. Title/Role(s) of Responsible Persons: Expected Date of Principal Completion: Campus Director 08/30/2013 Evidence of Completion of the Corrective Action: Correct Master Staff roster will be used as evidence of completion. Description of Internal Monitoring Procedures: The Master Staff roster will be reviewed quarterly by the Principal and Campus Director. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: PS 11.6 Master Staff Roster Corrective Action Plan Status: Approved Status Date: 07/09/2013 Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the most recently approved budget and an updated Master Staff Roster along with an explanation for any discrepancies. Second Progress Report - Germaine Lawrence must show evidence that the Principal and Campus Director reviewed the master staff roster quarterly, as the program stated they would, and indicate whether any changes were made as a result of that review. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 10 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 12.2 In-Service Training Plan and Calendar Partially Implemented Applies To: All Department Program Review Findings: A review of documentation indicates that all required trainings are not included on the inservice training plan and calendar. In addition, the calendar does not reflect a minimum of 24 hours for a twelve month program as required. A review of staff records also indicates that staff members are not receiving annual training on all ESE required topics. Description of Corrective Action: The In-Service Training Plan will inlcude all required trainings and reflect a minimum of 24 hours for our program. Staff running the trainings will ensure that all staff attending fill in the attendance sheet. Performance Improvement Department will use the training database to aduit and ensure all staff are receiving the required trainings annually. Title/Role(s) of Responsible Persons: Expected Date of Performance Improvement Department Completion: Residential Coordinator 08/30/2013 Program Managers Unit Supervisors Evidence of Completion of the Corrective Action: Attendance sheets and reports from the training database will be used as evidence of completion. Description of Internal Monitoring Procedures: Periodic audits to ensure all staff are receiving the required traninings. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 12.2 In-Service Training Plan and Status Date: 07/09/2013 Calendar Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the updated In-Service Training Plan and Calendar which reflects a minimum of 24 hours of professional development training and includes all required trainings. Second Progress Report - Germaine Lawrence must submit attendance sheets and reports from the training database indicating that staff members are participating in the scheduled trainings. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 11 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 15.1 Parental Involvement and Parents' Advisory Group Partially Implemented Applies To: All Department Program Review Findings: While Germaine Lawrence has a written plan for involving parents, document review and interviews indicate that they do not have a Parents' Advisory Group that advises both programs on matters that pertain to the education, health and safety of the students in the programs. Description of Corrective Action: At the beginning of each school year, the Principal will submit a schedule of annual parent advisory meetings. Parents will be given a copy of the annual schedule, and receive additional notification 30 days prior to each meeting. These meeting will be scheduled at the beginning of each academic period and consist of the following agenda: -Introductions and Greetings -A summary of classroom activities from the previous academic period -A description of the classroom activities expected in the upcoming academic period -A summary of progress made on previous suggestions for improvement and solicitation of feedback from parents about successes and challenges faced in the previous academic period -Suggestions for improvement in the upcoming academic period -Optional break out session for residential school parents to talk about programmatic activities, progress, and concerns Additional parent advisory mini sessions will be offered in each residential school program before or after monthly parent and youth activity nights. Program managers will be responsible to take action on concerns or issues, working with the Principal on any day school related issues. The PM will submit notes from the meeting to the Principal for inclusion in parent advisory records, and to provide the Principal with information that may influence formal Parent Advisory Meeting agendas. Title/Role(s) of Responsible Persons: Expected Date of Principal and/or Program Managers Completion: 08/30/2013 Evidence of Completion of the Corrective Action: Documentation of the meeting notes will be kpet on file. Description of Internal Monitoring Procedures: The Principal will be responsible for maintaining records of parent advisory meetings. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 15.1 Parental Involvement and Status Date: 07/09/2013 Parents' Advisory Group Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit their new policy on the creation of the Parent Advisory Group, along with their plan for inviting parents to participate. MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 12 Additionally, Germaine Lawrence must submit a schedule for the Parent Advisory Group for the 2013/2014 school year. Second Progress Report - Germaine Lawrence must submit a copy of the meeting agenda for the Parent Advisory Group meeting that has occurred since the beginning of the 2013/2014 school year. Additionally, Germaine Lawrence must submit a copy of the invitation that was sent out to parents notifying them of the Parent Advisory Group meeting. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 13 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 16.7 Preventive Health Care Partially Implemented Applies To: All Department Program Review Findings: A review of student records indicates that there is no evidence that both programs, in cooperation with the student's parents and/or human service agency which is responsible for payment, are making provision for all students to receive a physical examination upon enrollment and an annual comprehensive dental examination. Additionally, there is no evidence of the programs' efforts to develop a plan to ensure that vision and hearing screenings are conducted for all students. Description of Corrective Action: Physical Exams and Postural Screenings ? Physical examinations with evidence of postural screenings are requested upon acceptance into the program. If written reports from the physician of the results of the examination 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 will be contained in the student medical files. Dental Exams ? Dental examinations are requested upon acceptance into the program. If written reports from the dentist of the results of the examination 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 will be contained in the Student Medical files. Annual Vision & Hearing Screenings ? Youth Villages Germaine Lawrence Campus is currently contracting with The New England Eye Institute; a teaching affiliate of the New England College of Optometry to provide annual Vision Screening for students? . Documentation of the annual screening will be held in the Student Medical Files. Youth Villages Germaine Lawrence Campus is currently contracting with Boston University Sargent College of Health and Rehab. Science Dept. of Communication Disorders to provide annual Hearing Screening for students?. Documentation of the annual Hearing Screening will be held in the Student Medical Files. Title/Role(s) of Responsible Persons: Expected Date of Nurse Manager Completion: 08/30/2013 Evidence of Completion of the Corrective Action: Documentation will be contained in the Student Medical Files. Description of Internal Monitoring Procedures: A tracking log of telephone contact will be maintained. Copies of letters requesting this information will be contained in the student medical files. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: PS 16.7 Preventive Health Care Corrective Action Plan Status: Approved Status Date: 07/09/2013 Basis for Partial Approval or Disapproval: Department Order of Corrective Action: MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 14 Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit copies of the letters that will be sent requesting proof of physical and dental examinations, as well as the log that will be used to track phone calls. Germaine Lawrence must also submit an explanation for how this information will be monitored, and if it is through the use of a spreadsheet an example of that spreadsheet must also be submitted. Second Progress Report - Germaine Lawrence must submit evidence of efforts made to obtain proof of physical and dental examinations, along with tracking information that indicates which students have documentation of having received all necessary preventative care elements and which students do not have complete documentation. For students who have missing documentation for the receipt of screenings and examinations Germaine Lawrence must submit evidence of the efforts that have been made to obtain documentation. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 15 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 18.1 Confidentiality of Student Records Partially Implemented Applies To: All Department Program Review Findings: Student record review indicates that a log of access is not maintained in all student records and in all parts of student records as required. Description of Corrective Action: A log of access will be maintained in all student records. A memo will be placed in the student file that indicates that the medical files will be kept in the wellness center. Title/Role(s) of Responsible Persons: Expected Date of Medical Records Specialist Completion: Clinical Manager 08/30/2013 Evidence of Completion of the Corrective Action: The log of access will be used as evidence of completion. Description of Internal Monitoring Procedures: The Medical Records Specialist will ensure that the log of access is signed off and will pull any requested files. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 18.1 Confidentiality of Student Status Date: 07/09/2013 Records Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the log of access it will use in its student files. Second Progress Report - Germaine Lawrence must sample 10 student records and summarize the results of its review of the logs of access for the Department. As part of the Department's unannounced visit, student files will also be selected for review to ensure that a log of access is present in all parts of the file. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 16 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 19 Anti-Hazing Partially Implemented Applies To: All Department Program Review Findings: Student record review indicates that Germaine Lawrence does not maintain evidence of the disciplinary code being distributed to students or evidence of each secondary school age student's receipt of a copy of the programs' anti-hazing disciplinary policy approved by the programs' Board of Directors. Description of Corrective Action: All students will recieve a copy of the student code of conduct, distributed at intake and annually thereafter. Title/Role(s) of Responsible Persons: Expected Date of Education Liaison Completion: Principal 08/30/2013 Program Managers Evidence of Completion of the Corrective Action: Acknowledgment forms will be used as evidence of completion. Description of Internal Monitoring Procedures: A tracking system will be developed to ensure the annual handout and the signed acknowledgement form will be kept in the students file. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: PS 19 Anti-Hazing Corrective Action Plan Status: Approved Status Date: 07/09/2013 Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the student code of conduct that contains the required anti-hazing law and relevant disciplinary policy. Second Progress Report - Germaine Lawrence must submit evidence that the student code of conduct was distributed at intake to any new student that was admitted to the program between 8/30/13 and 12/13/13. As part of the Department's unannounced visit, student files will also be reviewed to ensure that a signed receipt of the anti-hazing law and disciplinary policy is present in students' files. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 17 PROGRAM REVIEW CORRECTIVE ACTION PLAN Criterion & Topic: PR Rating: PS 20 Bullying Prevention and Intervention Partially Implemented Applies To: All Department Program Review Findings: A review of staff records indicates that Germaine Lawrence does not maintain evidence that staff members have received Bullying Prevention and Intervention Training. Additionally, interviews indicate that some staff members are not aware of the proper procedures to follow if a bullying incident were to occur. Description of Corrective Action: Germaine Lawrence will ensure that tranining records relfect staff recieved the appropriate bullying prevention and intervention training. Ensure there is ongoing efforts to talk about bullying during staff meetings. Title/Role(s) of Responsible Persons: Expected Date of Principal Completion: Education Liaison 08/30/2013 PRogram Manager Evidence of Completion of the Corrective Action: Training records will be used as evidence of completion. Description of Internal Monitoring Procedures: Develop a training schedule that inlcudes state requirements. CORRECTIVE ACTION PLAN APPROVAL SECTION Criterion: Corrective Action Plan Status: Approved PS 20 Bullying Prevention and Status Date: 07/09/2013 Intervention Basis for Partial Approval or Disapproval: Department Order of Corrective Action: Required Elements of Progress Report(s): First Progress Report - Germaine Lawrence must submit a copy of the bullying prevention training that will be presented to staff, along with a training schedule that highlights when the training will be offered. Second Progress Report - Germaine Lawrence must submit evidence of staff meetings that occurred at which staff discussed the topic of bullying. As part of the Departments unannounced visit, staff records will also be reviewed to ensure that staff members are participating in the required training. Additionally, staff members may be interviewed to ensure that they have received bullying prevention training and understand the appropriate procedures to follow in the event that a bullying incident were to occur. Progress Report Due Date(s): 08/30/2013 12/13/2013 MA Department of Elementary & Secondary Education , Program Quality Assurance Services Germaine Lawrence, Inc. Corrective Action Plan 18