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 July 20, 2012.
Mandatory One-Year Compliance Date: 07/17/2013
Summary of Required Corrective Action Plans
Hillcrest Educational Centers, Inc.
CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agency
A - Intensive Residential Treatment Program
15569
1.2
1.2
Criterion Title
CPR Rating
Program & Student Description, Program
Capacity
Program & Studen 480
8.5
Current IEP & Student Roster
Current IEP & Stu
Partially
Implemented
Applies To
A,B,C
A,B,C
CAP Status
Approved
Approved
Partially Implemen
40
8.5
A - Intensive Res
B - Residential Pr
B - Residential Program
C - Housatonic Academy Program
Criterion #
15568
492
41
Partially
Implemented
C
Approved
C
Approved
Partially Implemen
8.5
8.5
Current IEP & Student Roster
Current IEP & Stu
492
42
Partially
Implemented
A,B
A,B
Approved
Approved
Partially Implemen
8.8
IEP - Progress Reports
IEP - Progress Re
Partially
C
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
Approved
1
8.8
493
Implemented
43
C
Approved
Partially Implemen
8.8
8.8
10.2
10.2
10.2
10.2
11.2
11.2
IEP - Progress Reports
493
Age Range
IEP - Progress Re
44
B
Approved
B
Approved
Partially Implemen
Age Range
Partially
Implemented
501
45
Age Range
Partially
Implemented
B,C
B,C
Approved
Approved
Partially Implemen
Age Range
Partially
Implemented
501
46
Approved
A
Approved
Partially Implemen
Administrative Responsibility
Administrative Re
A
503
47
Partially
Implemented
A,B
A,B
Approved
Approved
Partially Implemen
11.3
11.3
Educational Administrator Qualifications
Educational Admi
504
48
Partially
Implemented
A,B,C
A,B,C
Partially Approved
Partially Approve
Partially Implemen
11.4
11.4
Teachers (Special Education Teachers and Partially
Regular Education Teachers)
Implemented
Teachers (Specia 505
11.6
11.6
11.9
11.9
12.1
12.1
Master Staff Roster
507
49
Master Staff Ros
50
Organizational St
51
Partially Approved
Partially Approve
Partially Implemen
Partially
Implemented
A,B,C
A,B,C
Approved
Approved
Partially
Implemented
A,B,C
A,B,C
Approved
Approved
Partially Implemen
New Staff Orientation and Training
New Staff Orient
A,B,C
Partially Implemen
Organizational Structure
508
A,B,C
509
52
Partially
Implemented
A,B,C
A,B,C
Approved
Approved
Partially Implemen
12.2
12.2
In-Service Training Plan and Calendar
In-Service Trainin
510
53
Partially
Implemented
A,B,C
A,B,C
Approved
Approved
Partially Implemen
15.1
15.1
Parental Involvement and Parents'
Advisory Group
514
15.5
15.5
Parental Involvem
516
A,B,C
A,B,C
Approved
Approved
Partially Implemen
54
Parent Consent and Required Notification
Parent Consent a
Partially
Implemented
55
Partially
Implemented
A,B,C
A,B,C
Approved
Approved
Partially Implemen
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
2
16.7
16.7
523
18.1
18.1
Preventive Health
Preventive Health Care
56
C
Approved
C
Approved
Partially Implemen
Confidentiality of Student Records
Confidentiality of
Partially
Implemented
526
Partially
Implemented
57
B
Approved
B
Approved
Partially Implemen
19
19
Anti-Hazing
Anti-Hazing
Partially
Implemented
530
58
20
20
A,B,C
A,B,C
Approved
Approved
Partially Implemen
Bullying Prevention and Intervention
Bullying Preventio 531
Partially
Implemented
59
A,B,C
Approved
A,B,C
Partially Implemen
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Hillcrest Educational Centers, Inc.
CPR/Program Review Onsite Year: 2011-2012
Applies To:
15568
Intensive Residen A
182
595
915
true
A
183
595
916
true
B
191
595
917
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #1.2 - Program & Student Description, Program Capacity
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While program descriptions were provided for all Hillcrest programs, a review of documentation indicates the
following required elements were not addressed: behavioral characteristics unique to each program; how
educational services are implemented for the described student population; and how related services are or will
be provided for the students in the program whose IEPs indicate such services. In addition, the Intensive
Residential Treatment Program is serving students with substantially different needs and lower cognitive
abilities than the student population Hillcrest is approved by the Department to serve in that program.
* Indicates required field
District/Agency Corrective Action Plan
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
3
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description The issues of behavioral characteristics, implementation of education services and
provision of related services as they relate to the program description for each campus and
program were discussed at meetings held on June 27th, July 12th, July 17th and July 24th.
Attendees at each of these meetings included various combinations of Chris Smith, Vice
President of Residential Programming; Shaun Cusson, Executive Vice President; Allison
Billard, Program Director, Housatonic Academy; Peter Lopenzina, Program Director, ITU;
Dan Johnson, consultant; Tresa Devereaux, Interim Academic Compliance Administrator
and Susanna Wall, Assistant Director of Education. The accuracy of and revisions to each
program description were discussed and agreed upon. Each description will specifically
addresses Behavioral Characteristics unique to each campus program; how educational
services are being implemented for the described student population; and how related
services are being provided for the students in the program whose IEPs indicate such
services. The format for each program description was revised to present this information
in a standardized fashion. Each program description will include a section entitled "
Educational Services" where the new information can be found. Program descriptions for
Housatonic Academy and the Residential program have been completed. The revision for
the Intensive Residential Treatment Program is still in process.
* Evidence of
Completion of
Corrective
Action
Revised program descriptions will be submitted to DESE. Revised program descriptions
will be maintained on file at each respective campus/program. Revised program
descriptions will be maintained on file with the Agency. Evidence of meetings will be
available upon DESE request.
* Description Program despcriptions will be reviewed and/or updated for accuracy and completeness
of Internal when deemed necessary.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
The issues of beh
Revised program
Program despcrip On
For PQA Use Only
Corrective
Action Plan
Status
Approved
Plan
Status
Date
08/23/2012
Correction
Status
Not Corrected
Basis for The Agency revised the individual policies for each program to ensure accuracy and
Status compliance with ESE to include areas identified as non compliant at the time of the
Decision Program Review.
Department
Order of
Corrective
Action
Progress
Progress Report Due Date(s)
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
4
Reports
Required
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit the revised program and student descriptions for the three approved
programs, including behavioral characteristics unique to each program; how educational
services are implemented for the described student population; and how related services
are or will be provided for the students in the program whose IEPs indicate the need for
such services.
PQA Review Complete
Applies To:
22819
Housatonic Acad
C
191
607
953
true
C-
Housatonic Academy Program
PS Criterion #8.5 - Current IEP & Student Roster
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While a current IEP and student roster was submitted for the Housatonic Academy Program, the IEP and
student roster does not contain the agencies supporting any part of the students' tuition and the portion of
tuition supported by such agencies as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
09/01/2012
* Description Housatonic Academy has enter information in all required areas and will submit an
accurate and complete roster based on census in April 2012 as directed by Amy Krukonis.
* Evidence of Housatonic Academy will provide a completed roster to submit to DESE as required
Completion of
Corrective
Action
* Description of n/a (on-going monitoring not required as this was a one time error on a form)
Internal
Monitoring
Process
Complete
Shaun Cusson, E
09/01/2012
Housatonic Acad
Housatonic Acad
n/a (on-going mon On
For PQA Use Only
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
5
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for Housatonic Academy states all required elements have now been included on the student
Status roster. While Housatonic Academy states this was a one time error on a form, the agency
Decision or agencies supporting any part of the students' tuition and the portion of tuition
supported by such agencies for each student must be accurately documented and
maintained on a consistent basis.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Housatonic Academy must submit an IEP and Student Roster to include all required
elements based on the student enrollment as of November, 2012. The IEP & Student
Roster template can be found in the Document Library under the Private School
Templates heading.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
651
951
true
A
651
952
true
B
- Intensive Residential Treatment Program
15569
Residential Progra B
183
- Residential Program
PS Criterion #8.5 - Current IEP & Student Roster
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Student record review and interviews indicate that the program does not have on file a current IEP for each
enrolled Massachusetts student that has been issued by the responsible public school district and consented to
and dated by the student's parent(s) as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
09/01/2012
* Description The Academic Case Managers have reviewed all MA student files for signatures on most
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
6
currently written IEP. For any student without a current, signed IEP, Academic Case
Managers will contact and record requests to districts to obtain a signed IEP.
* Evidence of As received, signature pages from deficient IEPs will be supplied to DESE.
Completion of
Corrective
Action
* Description IEPs will be self-audited on a quarterly basis for compliance and the report of the results
of Internal will be reviewed by the Director of Education, Executive Vice President and Vice President
Monitoring of Residential Programs.
Process
Complete
Shaun Cusson, E
09/01/2012
The Academic Ca
As received, sign IEPs w ill be self-a On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for Hillcrest states that all MA student files for the Residential and Intensive Residential
Status Programs have been reviewed to ensure that each contains a current IEP. Hillcrest states
Decision they have also developed a plan to ensure ongoing compliance through self-auditing on a
quarterly basis.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
The Residential Program must submit copies of the current IEP signature pages for the 8
Massachusetts students whose records were reviewed by the Department onsite at the time
of the Program Review. The Intensive Residential Program must submit copies of the
current IEP signature pages for the 3 Massachusetts students whose records were reviewed
by the Department onsite at the time of the Program Review. By 1/17/13, Hillcrest must
submit the results of the self-audit they conduct of the review of student records, specific
to having a current IEP for each enrolled Massachusetts student that has been issued by
the responsible school district and consented to and dated by the student's parent(s) as
required. In the submission, any follow-up efforts should be indicated.
PQA Review Complete
Applies To:
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
7
22819
Housatonic Acad
C
191
608
956
true
C-
Housatonic Academy Program
PS Criterion #8.8 - IEP - Progress Reports
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program Review
Finding
A review of student records indicates Housatonic Academy Program did not document to whom IEP
progress reports were sent until May, 2012.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
09/01/2012
* Description Housatonic Academy has adopted the practice of drafting a letter which is sent with all
progress reports and keeping a copy as record to whom the report was sent.
* Evidence of A copy of a letter sent from June/ July 2012 will be submitted.
Completion of
Corrective
Action
* Description Progress reports will be self-audited on a quarterly basis for compliance and the report of
of Internal the results will be reviewed by the Director of Education, Executive Vice President and
Monitoring Vice President of Residential Programs.
Process
Complete
Shaun Cusson, E
09/01/2012
Housatonic Acad
A copy of a letter
Progress reports
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for The program has drafted a letter which will be sent with all progress reports and states
Status that a copy will be kept in the student records as documentation to whom the progress
Decision report was sent to ensure ongoing compliance.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Progress Report Due Date(s)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
8
Add Due Date
Required
Elements of
Progress
Report(s)
Hillcrest must submit a copy of the letter sent to the responsible parties from the last
progress report for the 6 Massachusetts students whose records were reviewed onsite by
the Department at the time of the Program Review. For the 01/17/2013 progress report,
Hillcrest must submit the results of the self-audit conducted by the Director of Education,
Executive Vice President and Vice President of Residential Programs showing how they
have verified that records to whom progress reports are sent are being documented in
student records. Any additional follow-up conducted should be documented and
submitted.
PQA Review Complete
Applies To:
15569
Residential Progra B
183
656
955
true
B
- Residential Program
PS Criterion #8.8 - IEP - Progress Reports
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
A review of student records for the Residential Program indicates that not all IEP progress reports reflect
progress made towards the goals of the last approved IEP. Documentation that progress reports were sent to
parents was not always evident.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
09/01/2012
* Description Residential program will ensure progress reports are being written based on the mostrecent signed IEP. The education department has implemented an IEP tracking sheet to
include student name, date of last signed IEP, last IEP meeting date, efforts to obtain a
singed IEP if needed and a check to make sure progress reports are indeed being written
based on last-signed IEP. Hillcrest will enhance IEP training to cover the need to report on
the most-recently signed IEP. Highpoint campus [242 W. Mountain Rd., Lenox, MA] does
attach a letter to each progress report sent and keeps a copy of the letter in the student's
chart. Although Hillcrest Center [349 Old Stockbridge Rd., Lenox] does now do the same,
this process was not in place in the recent past.
* Evidence of Tracking sheet, recently written Progress reports, evidence of enhancement of IEP training
Completion of information, copies of letters sent from June/July will be provided upon request.
Corrective
Action
* Description Progress reports will be self-audited on a quarterly basis for compliance and the report of
of Internal the results will be reviewed by the Director of Education, Executive Vice President and
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
9
Monitoring Vice President of Residential Programs.
Process
Complete
Shaun Cusson, E
09/01/2012
Residential progra
Tracking sheet, re Progress reports
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for Hillcrest states that the Residential Program now ensures that progress reports will be
Status written based on the most recently issued and consented to IEP through the
Decision implementation of an IEP tracking sheet. The Residential Program will enhance IEP
training to address the need to report on the most recently issued and consented to IEP.
The two residential campuses now use the same process and attach a letter to each
progress report sent and maintain a copy of the letter in the student's record.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
The Residential Program must submit a copy of the tracking sheet for all currently
enrolled Massachusetts students. The program must submit evidence that copies of
progress reports were sent to parents, school districts and/or agencies for the 8
Massachusetts student records the Department reviewed onsite at the time of the Program
Review for the final quarter in the 2011-2012 school year. The program must also submit
the agenda for the training specific to IEP progress reports, the name and job title of the
person conducting the training, the date and time of the training, the length of time of the
training and the attendance sheet which includes the name and job title of the staff
participants. For the 01/17/2013 progress report, Hillcrest must also submit the results of
the self-audit conducted by the Director of Education, Executive Vice President and Vice
President of Residential Programs showing how they have verified that progress reports
are being issued based on the most recently consented to IEP. Any additional follow-up
conducted should be documented and submitted.
PQA Review Complete
Applies To:
15569
Residential Progra B
183
616
- Residential Program
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
979
true
B
10
22819
Housatonic Acad
C
191
616
980
true
C-
Housatonic Academy Program
PS Criterion #10.2 - Age Range
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Documentation and interviews indicate that there are instructional groupings of students in the Residential
Program and in the Housatonic Academy Program that are beyond the 48 month age span requirement and
the programs have not been granted waivers.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
09/15/2012
* Description Classroom groupings have been reorganized to eliminate age-ranges exceeding 48 months.
All department heads, teachers, and managers have been instructed to not transfer
students to alternate groupings resulting in need for an age-range waiver without prior
approval from DESE via a waiver.
* Evidence of Hillcrest will submit all current classroom groupings upon request.
Completion of
Corrective
Action
* Description Classroom groupings will be self-audited on a quarterly basis for compliance and the
of Internal report of the results will be reviewed by the Director of Education, Executive Vice
Monitoring President and Vice President of Residential Programs.
Process
Complete
Shaun Cusson, E
09/15/2012
Classroom group
Hillcrest w ill subm Classroom group
On
For PQA Use Only
Corrective
Action Plan
Status
Approved
Plan
Status
Date
08/29/2012
Correction
Status
Not Corrected
Basis for While the Residential Program and Housatonic Academy have reorganized classroom
Status groupings to ensure that all classrooms will not exceed the 48 age month span, it is unclear
Decision to the Department how the department heads, teachers, and managers have been
instructed to organize instructional groupings that will not exceed the 48 age month span
prior to seeking approval from ESE via a waiver.
Department
Order of
Corrective
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
11
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
Progress Report Due Date(s)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
The Residential Program must submit evidence of documentation (memorandum) shared
with appropriate staff (department heads, teachers, and managers) indicating that the age
range for instructional groupings cannot exceed 48 months without prior approval from
the Department. The programs must also submit block schedules for every classroom and
every period indicating the initials of students with corresponding dates of birth. For the
1/17/13 progress report, Hillcrest must submit block schedules for every classroom and
every period indicating the initials of students with corresponding dates of birth as well as
the results of their self-audit.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
648
978
true
A
- Intensive Residential Treatment Program
PS Criterion #10.2 - Age Range
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While interviews indicate that the Intensive Residential Treatment Program ensures that any instructional
grouping shall not differ by more than forty-eight months, documentation submitted one week after the onsite
review indicated that there were in fact instructional groupings of students that exceeded the forty-eight month
age span requirement.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
09/15/2012
* Description Classroom roupings have been reorganized to eliminate age ranges exceeding 48 months.
All department Heads, teachers, and managers have been instructed to NOT transfer
students to alternate groupings resulting in a need for an age range waiver without PRIOR
approval from DESE via a waiver.
* Evidence of Hillcrest submit all current groupings uopn request.
Completion of
Corrective
Action
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
12
* Description Classroom groupings will be self-audited on a quarterly basis for compliance and the
of Internal report of the results will be reviewed by the Director of Education, Executive Vice
Monitoring President and Vice President of Residential Programs.
Process
Complete
Shaun Cusson, E
09/15/2012
Classroom roupin
Hillcrest submit al
Classroom group
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for While the Intensive Residential Treatment Program has reorganized classroom groupings
Status to ensure that all classrooms will not exceed the 48 age month span, it is unclear to the
Decision Department how the department heads, teachers, and managers have been instructed to
not regroup students where they may exceed the 48 age month span prior to seeking
approval from ESE via a waiver.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
The Intensive Residential Treatment Program must submit evidence of documentation
(memorandum) shared with appropriate staff (department heads, teachers, and managers)
indicating that the age range for instructional groupings cannot exceed 48 months without
prior approval from the Department. The program must also submit block schedules for
every classroom and every period indicating the initials of students with corresponding
dates of birth. For the 1/17/13 progress report, Hillcrest must submit block schedules for
every classroom and every period indicating the initials of students with corresponding
dates of birth as well as the results of their self-audit.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
619
987
true
A
183
619
988
true
B
191
619
989
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
13
PS Criterion #11.3 - Educational Administrator Qualifications
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Documentation and interviews indicate that the Educator Administrator position is currently vacant in all three
programs. While the person temporarily serving in this position is appropriately qualified, she is not assuming
the primary roles of supervising the provision of special education services in the programs and ensuring that
the services specified in each student's IEP are delivered as required.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Hillcrest continues to search for a new Director of Education. This person will meet all
Massachusetts standards. The Assistant Ed. Director, or a licenced education
adminstrator, will be present at every IEP meeting to assure IEP-specified services are
delivered as reqired.
* Evidence of
Completion of
Corrective
Action
Hillcrest will notify DESE in writing when the new Director is identified. The goal is to
have a new director in place by the start of the Fall semester, Sept. 4, 2012. Hillcrest will
submit copies of advertisements and other recruitment efforts for Ed. Director and
supporting documentation as requested.
* Description Hillcrest will continue to recruit an appropriately qualified Director as evidenced by
of Internal additional recruitment efforts as needed.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
Hillcrest continue
Hillcrest w ill notify Hillcrest w ill conti
On
For PQA Use Only
Corrective
Action Plan
Status
Partially Approved
Plan
Status
Date
08/23/2012
Correction
Status
Not Corrected
Basis for Hillcrest states their goal was to have an Education Administrator in place by Fall, 2012.
Status As stated in the finding, the person temporarily serving in this position while appropriately
Decision qualified is not assuming the primary roles of supervising the provision of special
education services in the programs and ensuring that the services specified in each
student's IEP are delivered as required.
Department
Order of
Corrective
Action
Progress
Reports
Progress Report Due Date(s)
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
14
Required
(Check all
Due Dates
that apply)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Required
Elements of
Progress
Report(s)
Hillcrest must submit the name, qualifications, and job description of the Educational
Administrator for each program. If the Education Administrator is delegating any of these
responsibilities, the name(s), qualifications and what specific responsibilities that
person/people is/are performing must also be submitted.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
620
990
true
A
183
620
991
true
B
191
620
992
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #11.4 - Teachers (Special Education Teachers and Regular Education Teachers)
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program Review
Finding
Documentation and interviews indicate that not all teaching staff are appropriately licensed or on approved
waivers for the grade and/or subject level being taught.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
10/01/2012
* Description Annual Professional Development Plans will be generated as necessary outlining required
steps towards licensure and will be implemented by 9/30/2012. Progress made towards
licensing and courses taken will be reviewed during individual staff supervison sessions.
On-going communication with DESE Office of Educator Licensure
* Evidence of Hillcrest will submit teacher rosters upon request.
Completion of
Corrective
Action
* Description Credentials for all teaching staff will be reviewed for compliance on a quarterly basis for
of Internal compliance by the Education Director with a report to the Executive Vice President, Vice
Monitoring President of Residential Programs, and Human Resources.
Process
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
15
Complete
Shaun Cusson, E
10/01/2012
Annual Professio
Hillcrest w ill subm Credentials for al
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Partially Approved
08/29/2012
Correction
Status
Not Corrected
Basis for While Hillcrest stated it will generate annual professional development plans outlining
Status required licensure steps for teaching staff and will review during individual staff
Decision supervision sessions, it is not evident to the Department how these efforts ensure that all
teaching staff are currently appropriately licensed or on approved waivers for the grade
and/or subject level being taught.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit a current teaching staff roster for all programs that includes all UFR
115's Special Education Teachers and UFR 116's Regular Education Teachers in the
program that contains the required information identified on the WBMS Teacher Roster
form in the Document Library. Copies of each teacher's license or approved waiver must
also be submitted. For the 01/17/2013 progress report, Hillcrest must also submit the
report of the results of the audit conducted by the Education Director and any follow-up
activities Hillcrest found to be necessary.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
622
996
true
A
183
622
997
true
B
191
622
998
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #11.6 - Master Staff Roster
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
07/17/2013
16
Program
Review
Finding
Documentation and interviews indicate that the most recently approved staffing plan is not being accurately
implemented. The job titles and functions of certain positions are not being appropriately categorized using
the Uniform Financial Report (UFR) definitions.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Hillcrest will work with Ed. Consultant to review all approved staffing plans, titles and
functions as compared to UFR definitions for errors and will adjust accordingly.
* Evidence of A corrected Master Staff Roster will be submitted to WBMS.
Completion of
Corrective
Action
* Description of Chief Financial Officer, Executive Vice President, Ed. Consultant, and Ed. Director will
Internal review Master Staff Roster on a semi-annual basis and prior to Oct. 1, 2012.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
Hillcrest w ill w ork
A corrected Mast
Chief Financial Of
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for Hillcrest is reviewing the Master Staff Roster for all programs to ensure that staff are
Status appropriately categorized based on ESE's last approval of their staffing plan according to
Decision Uniform Financial Report (UFR) definitions.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all Due
Dates that
apply)
Progress Report Due Date(s)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Required Hillcrest must submit the Master Staff Roster for all programs to include all required
Elements of elements found on the WBMS Master Staff Roster Form in the Document Library.
Progress Hillcrest must also submit a copy of the last approved Program Budget for each program.
Report(s)
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
17
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
623
999
true
A
183
623
1000
true
B
191
623
1001
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #11.9 - Organizational Structure
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Documentation and interviews indicate that the organizational structure for all three programs does not
provide for the effective and efficient operation of the school, supervision of school staff, and supervision of
students. In particular, the lines of supervision are not clear or understood by most staff.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Each program director/manager will review the program's organizational chart to ensure
that it is both clear and compliant. Each staff member will be presented with a copy of the
chart and will receive clarification as to appropriate lines of supervision. Guided discussion
at that meeting will include the proper chain of command, the role and function of shift
supervisors, teachers, and management, and the evaluation process.
* Evidence of A copy of each organizational chart will be submitted upon request. Submit update org
Completion of chart by Sept. 1, 2012 for Amy's feedback, once approved then train. Trainings by October
Corrective 1, 2012. Hillcrest submit evidence of training upon request.
Action
* Description Program directors/managers will periodically determine whether current and new staff
of Internal clearly understand the lines of supervision.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
Each program dir
A copy of each o
Program directors On
For PQA Use Only
Corrective
Action Plan
Approved
Plan
Status
08/23/2012
Correction
Status
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
Not Corrected
18
Status
Date
Basis for Hillcrest will submit an organizational chart for each approved program that demonstrates
Status a clear line of supervision for all staff. In addition, Hillcrest has scheduled a training to
Decision ensure all staff are aware of the proper chain of command, the role and function of shift
supervisors, teachers and management.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit an organizational chart for all programs that only reflects positions
approved on the last ESE Program Budget and that illustrates and describes lines of
supervision for staff and students. Hillcrest must also submit the agenda for the training
on the revised organizational structure, the name and job title of the person conducting the
training, the date and time of the training and the attendance sheet which includes the
name and job title of the staff participants.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
624
1002
true
A
183
624
1003
true
B
191
624
1004
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #12.1 - New Staff Orientation and Training
Program
Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
While interviews indicate that new staff receive orientation training prior to their direct care duties with
Review Finding students, a review of documentation indicates that not all required trainings are provided.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
09/15/2012
* Description Director of Workforce Learning will realign New Staff Orientation training topics to
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
19
coincide more accurately with DESE requirements. HEC will include description of
particular trainings - runaway procedures, emergency procedures and civil rights
responsibilites.
* Evidence of Hillcrest will submit training schedule upon request.
Completion of
Corrective
Action
* Description Director of Workforce Learning will continue to stay abreast of DESE training
of Internal requirements and will make any necessary changes to training programs.
Monitoring
Process
Complete
Shaun Cusson, E
09/15/2012
Director of Workf
Hillcrest w ill subm Director of Workf
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for Hillcrest is revising the New Staff Orientation and Training requirements to include all
Status required ESE trainings.
Decision
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit a description of their New Staff Orientation and Training which
specifically includes the following: philosophy, organization, program, practices, goals,
abuse and neglect, behavior management/restraint, run away, emergency procedures, and
civil rights topics. Hillcrest must submit a copy of the checklist template used to document
training for the two most recently hired staff from each program.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
625
1005
true
A
625
1006
true
B
- Intensive Residential Treatment Program
15569
Residential Progra B
183
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
20
- Residential Program
22819
Housatonic Acad
C
191
625
1007
true
C-
Housatonic Academy Program
PS Criterion #12.2 - In-Service Training Plan and Calendar
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While interviews with staff indicate that all required trainings are provided, a review of documentation reveals
that all required trainings are not included on the In-Service Training Plan and Calendar. In addition, the
calendar does not reflect a minimum of 24 training hours for a twelve month program as required, and some
required documentary elements are missing. For example, the name and job title of the person conducting the
individual training sessions is not included as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
09/01/2012
* Description Director of Workforce Learning will produce an annual training calendar to include all
required trainings and information.
* Evidence of Hillcrest will submit modified training calendar to WBMS.
Completion of
Corrective Action
* Description of Director of Workforce Learning will review all current DESE training requirements
Internal when developing the annual training calendar.
Monitoring
Process
Complete
Shaun Cusson, E
09/01/2012
Director of Workf
Hillcrest w ill subm Director of Workf
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/23/2012
Correction
Status
Not Corrected
Basis for Hillcrest is devising an annual training calendar that will include all required training and
Status information.
Decision
Department
Order of
Corrective
Action
Progress
Reports
Required
Progress Report Due Date(s)
31
11/30/2012
11/30/2012
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
21
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit an In-Service Training Plan and Calendar for the 2012-2013 school
year that will reflect a minimum of 24 training hours for a twelve month program, and all
training topics provided; the name and job title of the person conducting the individual
training sessions; the audiences to whom the training will be offered; the dates and times
when the various training topics will be offered; and the length of time allotted for each
topic.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
630
1020
true
A
183
630
1021
true
B
191
630
1022
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #15.1 - Parental Involvement and Parents' Advisory Group
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While interviews indicate that the Parent Advisory Group meeting is conducted quarterly and provides
opportunities for parent involvement, the position, title and job description of the staff person assigned to work
with the Parents' Advisory Group, evidence of schedules and agendas were not provided as requested.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
11/15/2012
* Description While each of the four campus schools has an active Parent Advisory Group, schedules of
meetings were not always created and copies of agendas and attendance were not always
maintained. In addition, the group was not always called a "Parent Advisory Group".
Beginning Fall 2012, all groups will reflect that name. Each school will develop a schedule
of meetings for the 2012-2013 school year and copies of agendas , attendance and minutes
will be maintained. A staff person has been indentified on each campus to coordinate the
activities of the Parent Advisory Group.
* Evidence of Copies of invitations to indicate the correct use of the name of the group and
Completion of implemenation of the schedule.
Corrective
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
22
Action
* Description Academic case managers will maintain records of groups. Director of Education, or
of Internal designee, will review periodicaly documentation in the file (eg. agendas, invitations,
Monitoring attendance sheets, minutes, schedules) to ensure that these procedures are followed.
Process
Complete
Shaun Cusson, E
11/15/2012
While each of the
Copies of invitatio Academic case m On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for Hillcrest has adjusted the name of the group to reflect it as a Parent Advisory Group and
Status states that they will now maintain copies of schedules and agendas when the group is held.
Decision Hillcrest has also identified a staff person on each campus to coordinate the activities of
the Parent Advisory Group.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit the parent involvement plan describing outreach to parents and
steps to be taken to seek parental input on matters pertaining to student health, education
and safety; position title and job description of each staff person on each campus assigned
to work with Parents' Advisory Group; and copies of schedules and agendas for the most
recently held Parents' Advisory Group. For the 01/17/2013 progress report, Hillcrest must
submit the results of the self-audit conducted by the Director of Education, or designee, to
show that the procedures and follow-up for the Parent Advisory Group are being followed.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
632
1026
true
A
183
632
1027
true
B
191
632
1028
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
23
PS Criterion #15.5 - Parent Consent and Required Notification
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
A review of student records indicates that emergency medical treatment and restraint consents are not
obtained annually for each student as required. In addition, notification concerning curriculum that primarily
involves human sexual education was not obtained annually for each student as stated in the program's policy.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Hillcrest's revised written policy requires that parental consent be obtained annually in
relation to: Emergency medical treatment; restaints; photographs; sexual education;
medication administration. This is first accomplished as a part of the admissions process.
For each child remaining in the program beyond one year, Hillcrest now seeks annual
consent at the child's IEP meeting, if the parent/guardian is present, or, if not present at
the IEP meeting, mails the consent forms to the parent/guardian requesting such
consents. Academic Case managers are responsible for securing these consents. Hillcrest
will immediately identify all students missing required consents and work with
parents/guardians to obtain them if the next IEP meeting is beyond 60 days from the
DESE final report.
* Evidence of Hilllcrest will submit tracking information of consents upon request.
Completion of
Corrective
Action
* Description The Director of Education will periodically select student files at random to see if all
of Internal consents are current.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
Hillcrest's revised
Hilllcrest w ill subm The Director of Ed On
For PQA Use Only
Corrective
Action Plan
Status
Approved
Plan
Status
Date
08/29/2012
Correction
Status
Not Corrected
Basis for Hillcrest has revised its policy to require consents to be obtained annually for the required
Status ESE consents. Hillcrest will continue to require notification concerning curriculum that
Decision primarily involves human sexual education annually per their policy. Hillcrest has a plan
in place to obtain such consents beyond the admission year and follow-up if such consents
are obtained at IEP meetings.
Department
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
24
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
that apply)
Required
Elements of
Progress
Report(s)
Progress Report Due Date(s)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit a copy of the tracking information that includes each students name
and the date of parental consent for each of the required consents. For consents which are
not applicable due to the students age or grade level, please indicate so by writing "Not
Applicable." For the 01/17/2013 progress report, Hillcrest must submit the results of the
self-audit conducted by the Director of Education to show that all consents are current for
each student. Documentation of any efforts to obtain such consents should be included for
any consents which may not be current at the time of the submission to show Hillcrest's
ongoing efforts to obtain such documents.
PQA Review Complete
Applies To:
22819
Housatonic Acad
C
191
649
1049
true
C-
Housatonic Academy Program
PS Criterion #16.7 - Preventive Health Care
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Documentation, student record review and interviews indicate that the Housatonic Academy Program does
not obtain annual comprehensive dental examinations and did not provide documentation of efforts to obtain
dental examinations.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Shaun Cusson, Executive Vice President
* Expected
Date of
Completion
09/01/2012
* Description The Hillcrest Admissions process now requires admission staff to obtain documentation of
the most recent dental exam for students entering the Housatonic Academy. Academy staff
have also developed a form to be sent to each parent (copy attached) requesting proof that
a dental examination has been obtained within the last 12 months.
* Evidence of Hillcrest will submit copies of forms and documentation of attempts to obtain dental
Completion of exams upon reuqest.
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
25
Corrective
Action
* Description Program Director will periodically review individual records to ensure continiued
of Internal compliance
Monitoring
Process
Complete
Shaun Cusson, E
09/01/2012
The Hillcrest Adm
Hillcrest w ill subm Program Director
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for Housatonic Academy Program now requires admission staff to obtain documentation of
Status the most recent dental exam for students entering the program and developed a form to be
Decision sent to each parent requesting proof that a dental examination has been obtained in the
last twelve months.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Housatonic Academy Program must submit evidence of dental examinations and/or
documentation of efforts to obtain dental examinations for the 6 Massachusetts students
whose records the Department reviewed onsite for the Program Review. For the
01/17/2013 progress report, Hillcrest must submit the results of the self-audit conducted
by the Program Director to show that dental examinations are being obtained and/or
efforts to obtain dental examinations are being documented.
PQA Review Complete
Applies To:
15569
Residential Progra B
183
642
1057
true
- Residential Program
B
PS Criterion #18.1 - Confidentiality of Student Records
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
Program Review
Student record review indicates that a log of access is not maintained in all student records in the
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
07/17/2013
26
Finding
Residential Program.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
09/01/2012
* Description Log of Access is now maintained in each student file. Where more than one file is
maintained in a different location for a student, all such files will have an access log.
* Evidence of Hillcrest will submit a statement verifying that log of access has bee placed in all
Completion of necessary areas.
Corrective
Action
* Description of Periodic review of student charts.
Internal
Monitoring
Process
Complete
Shaun Cusson, E
09/01/2012
Log of Access is
Hillcrest w ill subm Periodic review o
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for The Residential Program states that it now maintains a log of access in each student file
Status and ensures that when more than one file is maintained in a different location for a
Decision student all such files will have a log of access.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
The Residential Program must submit the name and position(s) of the person(s)
responsible for oversight and maintenance of student records, as well as the date that staff
verified the log of access was updated to include all required elements and is placed in all
student records. Hillcrest must also submit a copy of the updated log of access.
PQA Review Complete
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
27
Applies To:
15568
Intensive Residen A
182
643
1059
true
A
183
643
1060
true
B
191
643
1061
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #19 - Anti-Hazing
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
Documentation, student record review and interviews indicate that none of the three programs provide
evidence of the disciplinary code distributed to students or evidence of student receipt of a copy of the school
program's anti-hazing disciplinary policy approved by the program's Board of Directors.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Admissions forms have been changed to include the student signature attesting to the fact
that he/she was shown the agency's anti-hazing disciplinary policy. These forms have been
put into use beginning July 1, 2012. Additionally, Hillcrest is in the process of reviewing
and distributing the Anti-hazing policy to all students in revised student handbooks. All
current students are being required to sign a statement attesting that they have received
Hillcrest's Anti-Hazing policy.
* Evidence of Hillcrest will submit forms upon request.
Completion of
Corrective
Action
* Description Student charts will be self-audited on a quarterly basis for compliance and the report of the
of Internal results will be reviewed by the Director of Education, Executive Vice President and Vice
Monitoring President of Residential Programs.
Process
Complete
Shaun Cusson, E
10/01/2012
Admissions forms
Hillcrest w ill subm Student charts w
On
For PQA Use Only
Corrective
Action Plan
Status
Approved
Plan
Status
Date
08/28/2012
Correction
Status
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
Not Corrected
28
Basis for Hillcrest continues to review and revise student handbooks with regard to the Anti-Hazing
Status policy. Hillcrest has developed a system that the Anti-Hazing policy is signed by each
Decision student during the Admissions process.
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit copies of student handbooks or disciplinary code distributed to
students for all programs, as well as a summary that includes the name and age of each
secondary aged student and the date they signed the anti-hazing disciplinary policy
approved by the programs' Board of Directors. For the 01/17/2013 progress report,
Hillcrest must submit the results of the self-audit conducted by the Director of Education,
Executive Vice President and Vice President of Residential Programs showing how they
have verified that the disciplinary code has been distributed to students and that students
have received a copy of the Anti-Hazing policy as approved by the program's Board of
Directors.
PQA Review Complete
Applies To:
15568
Intensive Residen A
182
644
1062
true
A
183
644
1063
true
B
191
644
1064
true
C-
- Intensive Residential Treatment Program
15569
Residential Progra B
- Residential Program
22819
Housatonic Acad
C
Housatonic Academy Program
PS Criterion #20 - Bullying Prevention and Intervention
Program
Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/17/2013
Program
Review
Finding
While a description of the process followed to amend its' student admissions materials/handbook to include an
age-appropriate summary of their Bullying Prevention and Intervention Plan was provided, a description of how
it was distributed was not submitted. In addition, while the Bullying training is presented online to staff ,
documentation and interviews indicate that staff do not know of the specific Bullying Prevention and
Intervention Plan or the procedures to follow if they were to witness a bullying incident.
* Indicates required field
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
29
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Shaun Cusson, Executive Vice President
10/01/2012
* Description Hillcrest has prepared a statement addressing the process followed to distribute an ageappropriate summary of the Bullying Prevention and Intervention Plan. All staff will be
trained to Hillcrest's Bullying Prevention and Intervention Plan with particular attention
to proper response to a bullying incident. The annual on-line training will be enhanced
accordingly, to ensure that staff are well-prepared to follow the appropriate procedures.
* Evidence of Hillcrest will submit evidence of the trainings as well as the revised on-line training upon
Completion of request.
Corrective
Action
* Description Program directors/managers will periodically review with staff the policy/plan to ensure
of Internal staff understanding. Additional trainings will be held should that be necessary.
Monitoring
Process
Complete
Shaun Cusson, E
10/01/2012
Hillcrest has prep
Hillcrest w ill subm Program directors On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/29/2012
Correction
Status
Not Corrected
Basis for Hilllcrest states they have prepared an age-appropriate summary for Bullying Prevention
Status and Intervention and that staff will receive an enhanced on-line training.
Decision
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)
31
11/30/2012
11/30/2012
32
01/17/2013
01/17/2013
Add Due Date
Hillcrest must submit a description of how the Bullying Prevention and Intervention Plan
information was distributed and a description of the professional development plan
developed by the program for all staff for the 2012-2013 school year by submitting the
agenda, the name and job title of the person conducting the training, the date and time of
the training and the attendance sheet which includes the name and job title of the staff
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
30
participants. Hillcrest must also submit a copy of the on-line training provided to staff.
PQA Review Complete
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Hillcrest Education Centers, Inc. PR Corrective Action Plan
31