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 7/13/2012.
Mandatory One-Year Compliance Date: 7/12/2013
Summary of Required Corrective Action Plans
Stetson School, Inc
CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agency
A - Stetson Residential Program
Criterion #
5.2(a)
5.2(a)
8.8
8.8
15657
Criterion Title
Contracts
Contracts
487
34
IEP - Progress Reports
IEP - Progress Re
493
35
9.1(a)
9.1(a)
A - Stetson Resid
CPR Rating
Partially
Implemented
A
CAP Status
Approved
A
Approved
Partially Implemen
Partially
Implemented
A
Approved
A
Approved
Partially Implemen
Student Separation Resulting from Partially
Behavior Management
Implemented
Student Separatio 495
Applies To
A
Approved
A
Approved
Partially Implemen
36
11.1
11.1
Personnel Policies and Procedures Partially
Implemented
Personnel Policies
Manual
A
Approved
A
Approved
Partially Implemen
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
1
502
12.2
12.2
37
In-Service Training Plan and
Calendar
In-Service Trainin
510
16.7
16.7
Partially
Implemented
Approved
A
Approved
Partially Implemen
38
Preventive Health Care
Preventive Health
A
Partially
Implemented
523
A
Approved
A
Approved
Partially Implemen
39
34
PCPR
102
N
15
CPR/Program Rev
Stetson School, In
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Stetson School, Inc
CPR/Program Review Onsite Year: 2011-2012
PS Criterion #5.2(a) - Contracts
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/12/2013
Program Review
Finding
Student record review indicates that written contracts for some enrolled students do not include all
required language nor are they signed by the sending district.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Kathleen Lovenbury, Executive Director
* Expected
Date of
Completion
01/31/2013
* Description If Stetson does not receive a signed contract from a sending district upon the child's
admission, a letter will be sent to the district requesting the signed contract. If the contract
does not have the required five elements, Stetson will send an amendment that includes
the required elements and request that the amendment be signed.
* Evidence of A tracking matrix, letters to school systems, and copies of the signed contracts will be used
Completion of as evidence of completion of the corrective action.
Corrective
Action
* Description Stetson will create a matrix to track contracts received, signatures, and contains the five
of Internal required elements.
Monitoring
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
2
Process
Complete
Kathleen Lovenbu 01/31/2013
If Stetson does n
A tracking matrix,
Stetson w ill creat
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/28/2012
Correction
Status
Not Corrected
Basis for Stetson states that a letter will be sent to the district requesting the signed contract.
Status Stetson will also send an amendment if the contract does not have the required five
Decision elements and request it be signed.
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)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
Add Due Date
Stetson must submit the matrix developed to track contracts received for all currently
enrolled Massachusetts students. If the contract is not signed by the district and/or it does
not include the five required elements, Stetson must submit a copy of the letter sent to the
district requesting the signed contract and a copy of the amendment to be signed that
includes the required language.
PQA Review Complete
PS Criterion #8.8 - IEP - Progress Reports
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/12/2013
Program Review
Finding
Documentation and student record review indicate that the person who is to receive the progress reports
is not evident for all students.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Becky Leyva, Education Director
* Expected
Date of
Completion
01/31/2013
* Description Stetson will create an online database to track who IEP progress reports are sent to, the
date sent, and who sent them. All staff responsible for sending IEP progress reports will be
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
3
trained in the use of the new system. The secretary-education will ensure all progress
reports are sent and tracked properly at the end of each marking quarter.
* Evidence of Reports from the online database will be used as evidence of completion.
Completion of
Corrective
Action
* Description Attendance sheets from the database training will be used to ensure that all staff needed to
of Internal be trained in the system are trained. Reports from the online database will be used to
Monitoring check and ensure that progress reports are being sent at the end of each marking quarter.
Process
Complete
Becky Leyva, Edu 01/31/2013
Stetson w ill creat
Reports from the
Attendance shee
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/28/2012
Correction
Status
Not Corrected
Basis for Stetson will utilize a created online database to track who is to receive IEP progress
Status reports, the date sent and who sent them. Stetson will train staff who are responsible for
Decision sending the IEP progress reports on this new system.
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)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
Add Due Date
Stetson must submit an updated report from the online database that includes to whom
progress reports are sent, the date sent, and who sent the progress reports for all currently
enrolled Massachusetts students sent for the first quarter. Stetson must also submit
attendance sheets from the training conducted for the staff on the new system including
the date of the training, the name and title of the trainer, the date and time of the training
and the names and titles of all staff who are trained.
PQA Review Complete
PS Criterion #9.1(a) - Student Separation Resulting from Behavior Management
Program
Partially Implemented
Review Rating
Program
Review
Mandatory One-Year Compliance Date
07/12/2013
Documentation, student record review, and interviews indicate that while Stetson maintains a time out log as
required, the reasons for intervention and who monitored the student during the time out are not included as
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
4
Finding
required.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Becky Leyva, Education Director
01/31/2013
* Description Stetson School's Separation From General Community procedure will be updated to
include that staff must document the use of the time out room for individual students
utilizing a Time Out Room Log. A Time Out Room Log will be created and will include the
date of the time out, the length of time the student was in the time out room, the reasons
for the time out, name of staff who approved the time out, and the name of the staff who
monitored the student during the time out. Staff will be trained in the new procedure and
use of the new log.
* Evidence of Stetson will provide the updated procedure, attendance sheets for the staff training, and
Completion of copies of the filled in logs as evidence of completion of the corrective action.
Corrective
Action
* Description
of Internal
Monitoring
Process
Our Staff Development and Performance Quality Improvement (PQI) Coordinator will
ensure all staff who need to be trained in this procedure are trained. Completed logs will be
kept in binders in the school for the school time out rooms and on the residence for the
residential time out rooms. The Education Director and Residential Director will be
responsible for checking periodically to ensure logs are being used consistently and
properly.
Complete
Becky Leyva, Edu 01/31/2013
Stetson School's
Stetson w ill provi
Our Staff Develop On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/28/2012
Correction
Status
Not Corrected
Basis for Stetson will update their Separation from General Community Procedure to include all
Status required elements. Stetson will train staff in the new procedure and use of the time out log.
Decision
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all
Due Dates
Progress Report Due Date(s)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
5
that apply)
Required
Elements of
Progress
Report(s)
Add Due Date
Stetson must submit a copy of the updated Separation from General Community
Procedure and a copy of time out logs for the months of October 2012 through January
2013. The updated form must include the date of the time out, the length of time the
student was in the time out room, the reasons for the time out, the name of staff who
approved the time out and the name of the staff who monitored the student during the
time out. Stetson must also submit attendance sheets for all staff required to be trained on
the new Separation from General Community Procedure and use of the time out log
including the date of the training, the name and title of the trainer, the date and time of the
training and the names and titles of all staff who were trained.
PQA Review Complete
PS Criterion #11.1 - Personnel Policies and Procedures Manual
Program Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/12/2013
Program Review Finding Staff record review indicates that not all staff received written performance evaluations.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
* Expected
Date of
Completion
Frank Sendrow ski, Human Resources Director
01/31/2013
* Description The Personnel Records procedure will be updated to include an auditing procedure . As
part of the procedure and audit, Human Resources will check all personnel files once a
year to ensure all staff have received written performance evaluations in accordance with
our policies and procedures regarding staff evaluation. If an evaluation has not been
completed, H.R. will follow up with the appropriate department head to ensure that the
evaluation is completed.
* Evidence of Copies of the updated procedure and one completed audit will be provided as evidence of
Completion of completion of the corrective action.
Corrective
Action
* Description The annual audit will serve as our internal monitoring process.
of Internal
Monitoring
Process
Complete
Frank Sendrow sk 01/31/2013
The Personnel Re
Copies of the upd The annual audit
On
For PQA Use Only
Corrective
Approved
Plan
08/29/2012
Correction
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
Not Corrected
6
Action Plan
Status
Status
Date
Status
Basis for Stetson will update the personnel records procedure to include an auditing procedure to
Status ensure that all staff receive written performance evaluations.
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)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
Add Due Date
Stetson must submit a copy of the updated personnel procedure. Stetson must submit a
timeline that includes the the following: the date of the most recent written performance
evaluation that was reviewed and signed by both the employee and supervisor for each
employee; the date each staff is scheduled to be reviewed; and when Human Resources
will follow-up if necessary. For the May 6, 2013 progress report: Stetson must submit
evidence of the one completed audit and provide a detailed narrative on any follow up
required by Human Resources.
PQA Review Complete
PS Criterion #12.2 - In-Service Training Plan and Calendar
Program
Review Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/12/2013
Program
Review
Finding
Documentation, staff record review and interviews indicate that Program Directors and Unit Directors who
conduct trainings and are involved in policy making do not receive the other required trainings annually.
* Indicates required field
District/Agency Corrective Action Plan
*
Title/Role(s)
of
Responsible
Person(s)
Pete Lew is, Staff Development and Performance Quality Improvement (PQ
* Expected
Date of
Completion
01/31/2013
* Description Program directors and administrators will sign all attendance sheets even when
conducting the training. Our Staff Development and Performance Quality Improvement
(PQI) Coordinator will use our training database to audit and ensure that all program
administrators are receiving all required trainings annually. Our Staff Development and
Performance Quality Improvement (PQI) Coordinator will use the weekly Program
Administrators Meeting to make up any trainings missed by program administrators.
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
7
* Evidence of Reports from our training database will be created to show the trainings each program
Completion of administrator received during 2012 and the date they received those trainings. Attendance
Corrective sheets from those trainings can also be provided.
Action
* Description Our Staff Development and Performance Quality Improvement (PQI) Coordinator will use
of Internal our training database to do periodic audits to ensure all program administrators are
Monitoring receiving required trainings.
Process
Complete
Pete Lew is, Staff
01/31/2013
Program directors
Reports from our
Our Staff Develop On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/28/2012
Correction
Status
Not Corrected
Basis for Status Stetson has assigned the Staff Development and Performance Quality Improvement
Decision (PQI) Coordinator to audit and ensure that all program administrators receive all
required trainings annually.
Department
Order of
Corrective
Action
Progress
Reports
Required
(Check all Due
Dates that
apply)
Progress Report Due Date(s)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
Add Due Date
Required Stetson must submit the names of all program administrators and copies of each person's
Elements of training sheets for all required trainings conducted prior to the submission of this
Progress progress report for the 2012-2013 school year.
Report(s)
PQA Review Complete
PS Criterion #16.7 - Preventive Health Care
Program Review
Rating
Partially Implemented
Mandatory One-Year Compliance Date
07/12/2013
Program Review
Finding
Student record review indicates that not all students have a record of hearing screenings at the grade
levels required.
* Indicates required field
District/Agency Corrective Action Plan
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
8
* Title/Role(s)
of Responsible
Person(s)
* Expected
Date of
Completion
Michelle LaFountain, Nurse Manager
01/31/2013
* Description Hearing Screenings are completed as part of the student's annual physical at Barre Health
Center. We will create a form for the doctor to fill out during the annual physical to
indicate all tests completed including hearing, vision, and posture.
* Evidence of A copy of the matrix used for the internal monitoring process will be provided as evidence
Completion of of completion of the corrective action.
Corrective
Action
* Description A matrix will be completed to track all screenings required in Criteria 16.7.
of Internal
Monitoring
Process
Complete
Michelle LaFounta 01/31/2013
Hearing Screenin
A copy of the ma
A matrix w ill be c
On
For PQA Use Only
Corrective
Action Plan
Status
Plan
Status
Date
Approved
08/28/2012
Correction
Status
Not Corrected
Basis for Stetson will develop a matrix to track all required hearing, vision and postural screenings.
Status Stetson will create a form for the doctor to fill out at the annual physical at Barre Health
Decision Center to indicate all tests are conducted at the time of the annual physical visit.
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)
27
02/08/2013
02/08/2013
28
05/06/2013
05/06/2013
Add Due Date
Stetson must submit a copy of the form developed for the Barre Health Center which
includes the information for hearing, vision and postural screenings. Stetson must submit
a copy of the matrix for all currently enrolled Massachusetts students. The program must
also submit evidence of hearing screenings that have since been conducted for the 8
records the Department reviewed onsite at the time of the program review.
PQA Review Complete
MA Department of Elementary & Secondary Education, Program Quality Assurance Services
Stetson School, Inc. PR Corrective Action Plan
9