Massachusetts Department of Elementary and Secondary Education 75 Pleasant Street, Malden, Massachusetts 02148-4906 Telephone: (781) 338-3700 TTY: N.E.T. Relay 1-800-439-2370 May 21, 2013 Stephen M. Wilkins, Executive Director Carroll School Carroll School Day Program 25 Baker Bridge Road Lincoln, MA 01773 Re: Mid-cycle Review and Verification of previous Program Review Corrective Action Plan Dear Mr. Wilkins: Enclosed is the Department of Elementary and Secondary Education’s (“Department”) Midcycle Report based upon the Mid-cycle review conducted in your private school program in November 2012. This Mid-cycle Review Report contains the Department's findings regarding the implementation status and effectiveness of corrective steps taken in response to your previous Program Review Report issued on September 9, 2010. This report also includes a report on the status of implementation for new state or federal special education requirements enacted since your program’s last Program Review. The Department will notify you of your program’s next regularly scheduled Program Review several months before it is to occur. At this time we anticipate the next routine monitoring visit to occur sometime during the 2015-2016 school year, unless the Department determines that there is some reason to schedule this visit earlier. While the Department found certain noncompliance issues to be resolved, others were partially corrected, not addressed at all and/or new issues were identified by the Department’s onsite team. Therefore, the Department is issuing a “Provisional Approval” status effective from the date of this letter and indicated on your approval certificate. Your “Provisional Approval” will expire on June 28, 2013. The reasons for the “Provisional Approval” are clearly indicated on the attached Mid-cycle Review Report. As the Department previously informed you, in cases where a program fails to fully and Page 1 of 2 effectively implement a Corrective Action Plan which was proposed by your program and approved by the Department, the Department must then prepare a Corrective Action Plan for the program which must be implemented without further delay. You will find these requirements for corrective action and further progress reporting included in the attached report, together with any steps that must be taken by the program to fully implement new special education requirements. Please provide the Department with your written assurance that the Department's requirements for corrective action will be implemented by your program within the timelines specified. Your statement of assurance must be submitted to the Department's Onsite Chairperson by May 31, 2013. Please be advised that the attached Department Approval Certificate must be conspicuously posted in a public place within the program as required by 603 CMR 28.09. Your staff's cooperation throughout these follow-up monitoring activities is appreciated. Should you require additional clarification of information included in our report, please do not hesitate to contact the Onsite Team Chairperson at 781-338-3713. Sincerely, Helen M. Murgida, Mid-cycle Review Chairperson Program Quality Assurance Services Darlene Lynch, Director Program Quality Assurance Services c: Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education J. Sam Foster, Jr., Chairperson, Board of Directors Mary Ellen Frechette, Local Program Review Coordinator Encl.: Mid-cycle Review Report Provisional Private School Approval Certificate, Expiration Date: October 17, 2013 Page 2 of 2 MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION PRIVATE SCHOOL MID-CYCLE REVIEW CARROLL SCHOOL CARROLL SCHOOL DAY PROGRAM MID-CYCLE REVIEW REPORT Previous Program Review Corrective Action Plan Submitted on September 9, 2010 Progress Reports Submitted on February 14, 2011 and June 14, 2011 Mid-cycle Onsite Visit Conducted on November 6, and November 7, 2012 Date of this Report: May 21, 2013 Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 1 of 18 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Selected Approved Private School Program Mid-cycle Review Criteria 2.2 Approvals, Licenses, Certificates of Inspection 18.04(1); 28.09(2)(b)(5); 28.09(5) (b); 28.09(6) (b, c) 2.3 EEC Licensure 102 CMR 3.00 (Residential Programs only) Not Applicable Documentation Carroll School submitted all current approvals, licenses, and certificates of inspection by state and local agencies as required. Carroll School is a day program; therefore this criterion is not applicable. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 2 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic 6.1 Daily Instructional Hours 603 CMR 27.04 & 6.4 School Days Per Year Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation Carroll School submitted the Learning Time Worksheet regarding the instructional hours and the number of school days per year for both the Lower and Middle Schools. Staff interviews confirmed that both the Lower School (grades 1-5) and Middle School (grades 6-9) students are scheduled for the required number of hours of instructional time per year. Carroll School has on file a current IEP for each Massachusetts enrolled student that has been issued by the responsible public school district and consented to and dated by the student’s Interviews Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance 603 CMR 27.05(2); 28.09(9)(a) 8.5 Current IEP & Student Roster Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation Student Record Reviews 28.09(5)(a) Interviews Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 3 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 11.3 Educational Administrator Qualifications 28.09(5)(a); 28.09(7)(a); 603 CMR 44.00 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting The Special Education Administrator for the Lower School is not licensed and does not have a waiver in Special Education for grades 4 and 5. Another teacher who acts as a designee to the Special Education Administrator does not have a special education license or waiver as required. By September 26, 2013 Carroll School must submit a license or waiver for the Lower School Special Education Administrator through grade 5. Documentation Staff Record Reviews Interviews parent(s) as required. In instances where the parent(s) have not consented, Carroll has documented their efforts to obtain such signatures. The Educational Administrator for the Middle School meets the required qualification to serve in this position. The Special Education Administrator for the Lower School has a Special Education license through grade 3, but is not licensed and does not have a waiver in Special Education for grades 4 and 5. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 4 of 18 Carroll School must also submit: Copy of licensure as a special education administrator or all of the following: Copy of ESE license as a Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting special educator or copy of ELAR activity sheet; and, Evidence of Master’s Degree in special education or a related field; and Evidence of a minimum of one year of administrative experience for the teacher who serves as a designee to the Special Education Administrator. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 5 of 18 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation Carroll School has a total of twenty-two teachers who do not have a current license or waiver, are teaching outside of their licensed subject area or have a license that has expired. 11.4 Teachers (Special Education Teachers and Regular Education Teachers) Staff Record Reviews Interviews Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified 18.05(11)(f); 28.09(5)(a); 28.09(7)(b, c); 34 CFR 300.321 11.5 Related Documentation Carroll School has a School Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Carroll School has seven Special Education Teachers who are not licensed and do not have a waiver, thirteen Regular Education Teachers without a license or waiver, one Regular Education Teacher teaching outside of his licensed area, and one Regular Education Teacher with an expired license. By September 26, 2013 Carroll School must submit licenses or approved waivers for the seven Special Education Teachers and thirteen Regular Education Teachers who are not appropriately licensed or on approved waivers. Carroll School must also submit a license or waiver for the Regular Education Teacher who is teaching outside of his subject area and a current license or approved waiver for the Regular Education Teacher who was teaching with an expired license. Carroll School has one By September 26, 2013 Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 6 of 18 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 11.6 Master Staff Roster Staff Record Reviews Interviews Documentation Interviews 28.09(7) 19 Anti-Hazing Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting related service staff School Adjustment Counselor who is not licensed and does not have waiver. Carroll School must submit a copy of the license or most current ELAR activity sheet for the School Adjustment Counselor. Adjustment Counselor who is not appropriately licensed and not on an approved waiver. Services Staff 28.09(7)(d) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation During the Mid-cycle Review, Carroll School Day Program documentation indicated that staff positions included on the Master Staff Roster are aligned as last approved by the Department of Elementary and Secondary Education. Carroll School Day Program does not enroll secondary Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 7 of 18 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation M.G.L. c. 269, §§ 17 through 19 20 Bullying Prevention and Intervention M.G.L. c. 71, s. 37H, as amended by Chapter 92 of the Acts of 2010. M.G.L. c. 71, s. 37O(e)(1) & (2). M.G.L. c. 71, s. 370(d). Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Interviews students. Documentation Carroll School has amended its handbook/admission material to include an age-appropriate summary of their Bullying Prevention Plan and included a description of how it was distributed. The program also submitted a description of the professional development plan developed by the program for all staff for the 2012-2013 School Year and provided evidence of its implementation including dates, format used, and a sign-in sheet indicating staff attendance. Interviews Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 8 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Identified Areas of Non-Compliance from the 2009-2010 Program Review or Other Areas of Concern 5.1 Student Admissions Documentation Interviews 28.09(11); 18.05(1)(b)(117); 18.05(2); 18.05(3)(c) During the last Program Review, Carroll School had a written admissions policy, but it did not include a statement that the program provided written notice to the parents of enrolled students that copies of its policies and procedures were available upon request as required. This was to be included in the 2010-2011 Admissions Policies and Procedures and in the 20102011 Parent Student Handbook. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 9 of 18 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 8.8 IEP – Progress Reports 28.07(3); 34 CFR 300.320(a) (3)(i, ii) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Documentation Student Record Reviews Interviews During the Mid-cycle Review, Carroll School submitted a copy of its Admissions Policies and Procedures that contains all required elements including a statement that the program provides written notice to the parents of enrolled students that copies of its policies and procedures are available upon request. During the last Program Review, Carroll School staff wrote progress reports for students four times a year that were thorough and specific, however, a review of documentation and interviews indicated that progress reports for previous school years were Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 10 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance not consistently maintained. 9.4 Physical Restraint (Day programs only) 18.05(5); 603 CMR 46.00 Documentation Student Record Reviews Interviews During the Mid-cycle Review, documentation, student record reviews and interviews indicate that progress reports for the previous school years since the 2010 Program Review are now consistently maintained in student records. During the last Program Review, while the student population at Carroll School did not display behaviors that indicate the need for physical restraint as a typical behavioral intervention, Carroll School was required to seek written consent to restrain from parents annually included as Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 11 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance part of their physical restraint policy. During the Mid-cycle Review, documentation, student record reviews, and interviews indicate that Carroll School now seeks written consent to restrain from parents annually as part of their physical restraint policy as required. 10.1 Staffing for Instructional Groupings Documentation Observations Interviews 28.06(6)(d); During the last Program Review, classroom observations, staff interviews, and documentation revealed that Carroll School maintained an average of 8:1 student to Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 12 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 28 09(7)(e) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance licensed educator ratio, while they were originally approved via their initial application to have a 6:1 ratio. Carroll School met with the Department regarding this matter and it was determined that the issue would be addressed and corrected through the Reconstruction Application that was on file at the Department. The 8:1 ratio was approved through Reconstruction on May 25, 2012. During the Mid-cycle Review, documentation, observations and interviews indicate that the approved Student: Licensed Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 13 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 11.1 Personnel Policies and Procedures Manual 18.05(11); 18.05(11)(c) (1); 28.09(7); 28.09(11)(a); M.G.L. c. 71, § 38R; ESE Advisory on CORI revised 5/7/07 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Documentation Staff Record Reviews Interviews Educator Ratio of 8:1 is implemented. While Carroll School had a written policies and procedures manual, it did not include procedures for evaluating staff. Carroll does employ a method of teacher evaluation that they call TRIADS, which is observation and feedback from the staff member observed and two colleagues; however these forms were not consistently signed and dated. New staff did have close supervision and verbal feedback through a Mentoring plan. A plan for using volunteer and/or intern services was written and was Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 14 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance to be in place for the 20102011 school year. 12.1 New Staff Orientation Documentation During the Mid-cycle Review, documentation, staff record reviews and interviews indicated that employee TRIADS, which is observation and feedback from the staff member observed and two colleagues are now signed and dated. Staff members also receive a performance evaluation by their manager on a yearly basis. There is also now a plan for using interns and volunteers in place as required. During the last Program Review, while Carroll School Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 15 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 18.05(11)(g, i); 28.09(7)(f) 12.2 In-Service Training Plan and Calendar 28.09(7)(f); had developed an orientation and training plan for new staff, review of personnel records and interviews indicated that documentation regarding this orientation and training was not maintained. Interviews Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Staff Record Reviews and Training Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation Staff Record Reviews At the time of the Mid-cycle Review, documentation, staff record reviews, and interviews indicate that documentation regarding new staff orientation and training is now maintained. During the last Program Review, documentation and staff interviews indicated that all mandated trainings were being conducted for staff Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 16 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 28.09(9)(b); 28.09(10); 18.03(3); 18.05(9)(e)(1); 18.05(10); 18.05(11)(h) Title VI: 42 U.S.C. 2000d; 34 CFR 100.3; EEOA: 20 U.S.C. 1703(f); Title IX: 20 U.S.C. 1681; 34 CFR 106.31-106.42; M.G.L. c. 76, § 5; 603 CMR 26.00, esp. 26.07(2, 3) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Interviews annually. However, a review of personnel records indicated that attendance at all mandated trainings was not documented and administrative interviews revealed that that the master sign-in sheet for the 20092010 school year was missing. During the Mid-cycle Review, documentation, staff record reviews, and interviews indicate that attendance at all mandated trainings is now documented as required. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 17 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 15.5 Parent Consent and Required Notification 18.05(5)(c); 18.05(8); 18.05(9)(f)(1); 18.05 (9)(j); M.G.L. c. 71, § 32A Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Documentation Student Record Reviews Interviews During the last Program Review, while Carroll School had a policy and procedure to work with school districts to obtain required parent consents, it did not include obtaining annual parental consent to restrain. During the Mid-cycle Review, documentation, student record reviews and interviews indicate that the Carroll School policy and procedure to work with school districts to obtain required parent consents now includes obtaining annual parental consent to restrain. Carroll School, Carroll School Day Program Mid-cycle Review Report May 21, 2013 Page 18 of 18 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting Commonwealth of Massachusetts Department of Elementary and Secondary Education CARROLL SCHOOL CARROLL SCHOOL DAY PROGRAM A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO 603 CMR 18.00 AND 28.09 25 Baker Bridge Road Lincoln, MA 01773 Program Rate Based on: 370 Students Approved Enrollment: 370 Students Day Program Summer Program Residential Program 10 month program 11 month program 12 month program APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1 APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: Not Applicable APPROVAL STATUS PROVISIONAL APPROVAL Expires on: October 17, 2013 The current approval is a result of a Mid-cycle Review conducted in the 2012-2013 school year and the next review is scheduled for the 2015-2016 school year. HELEN M. MURGIDA, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES NINA M. MARCHESE, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES DATE ISSUED: 05/21/2013