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
November 8, 2011
Steven Yerdon, Executive Director
The Devereux Foundation, Inc.
60 Miles Road
Rutland, MA 01543
Re:
Mid-cycle Review and Verification of previous Program Review Corrective Action Plan
Dear Mr. Yerdon:
Enclosed is the Department of Elementary and Secondary Education’s (“Department”) Mid-cycle
Report based upon the Mid-cycle review conducted in your private school program in November
2011. 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 January 5, 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.
We are pleased to indicate that the Department has found your program’s approved Corrective
Action Plan to be substantially implemented and effective in remedying previously identified
noncompliance issues. Additionally, we have determined that your program is in substantial
compliance with any new state or federal special education requirements enacted since your last
Program Review. You and your entire staff are to be congratulated for your efforts in
implementing all necessary improvements. Your program will now receive an updated status of
“Full Approval.” This approval shall remain in effect for three (3) years and will be contingent
upon continued compliance with all regulations contained within 603 CMR 28.00 “Special
Education Regulations” and 603 CMR 18.00 “Program And Safety Standards For Approved
Public Or Private Day And Residential Special Education School Programs.” The Department
may change this approval status at any point during this three-year period if circumstances arise
that warrant such a change.
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 2014-2015 school year, unless the Department determines that
there is some reason to schedule this visit earlier.
Page 1 of 2
Please be advised that the attached Department Approval Certificates 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 781-338-3704.
Sincerely,
Kerri Zeldis, 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
Rob Kreider, President, Board of Directors
Sherry Lynn MacNeil, Local Program Review Coordinator
Encl.: Mid-cycle Review Report
Full Private School Approval Certificates, Expiration Date: August 31, 2015
Page 2 of 2
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
PRIVATE SCHOOL MID-CYCLE REVIEW
The Devereux Foundation, Inc.
Day Program
Residential Program
Westmeadow Residential Program
MID-CYCLE REVIEW REPORT
Previous Program Review Corrective Action Plan Submitted on February 3, 2010
Progress Reports Submitted on August 19, 2010; November 12, 2010; and February 22, 2011
Mid-cycle Onsite Visit Conducted on November 1-3, 2011
Date of this Report November 8, 2011
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 1 of 16
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

Documentation
Review
Devereux submitted copies of
current licenses, approvals, and
certificates of inspection for
each of its programs.

Documentation
Review
Devereux submitted current,
full licenses from the
Department of Early Education
and Care (EEC) for its
Residential and Westmeadow
programs.
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
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 2 of 16
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


only)
8.5 Current
IEP & Student
Roster

Documentation
Review
Student Record
Review
28.09(5)(a)
Devereux has on file a current
IEP for each enrolled
Massachusetts student that has
been issued by the responsible
school district.
For any unsigned IEPs, the
program has documented its
efforts or steps it has taken to
work with the sending public
school district(s) to obtain
current, signed IEPs.
11.3
Educational
Administrator
Qualifications

Documentation
Review
Devereux submitted the name
of its educational
administrator, who meets all of
the requirements under this
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 3 of 16
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
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(5)(a);
28.09(7)(a);
603 CMR
44.00
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
criterion.
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 4 of 16
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
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

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


11.4 Teachers
(Special
Education
Teachers and
Regular
Education
Teachers)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
Documentation
Review
Staff Record
Review
Staff Interviews
18.05(11)(f);
28.09(5)(a);
28.09(7)(b, c);
34 CFR
300.321
Devereux submitted a current
teacher staff roster for each of
its programs indicating the
name, title, role of each teacher
in the program, grade level
being taught, subject area
being taught, and copies of
ELAR activity sheets for each
teacher.
.
11.5 Related
Services Staff

Documentation
Review
Devereux submitted a current
staff roster for all related
service providers for each of its
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 5 of 16
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


Staff Record
Review
28.09(7)(d)
Staff Interviews
11.6 Master
Staff Roster
M.G.L. c. 269,
§§ 17 through
19
programs which includes the
provider’s name, title, role in
the program, and a copy of the
provider’s license issued by the
Massachusetts State Board of
Registration.

Documentation
Review
Devereux submitted a current
master staff roster for each of
its programs that aligns with
the last approved Program
Budgets.

Documentation
Review
Devereux submitted a copy of
its anti-hazing policy and
documentation of students’
receipt of the program’s antihazing policy approved by the
Board of Directors.
28.09(7)
19 Anti-Hazing
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
Student Record
Review
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 6 of 16
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
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


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
Documentation
Review
Staff Record
Review
Devereux submitted a copy of
its Bullying Prevention and
Intervention Plan, a description
of how it was distributed, and a
description of the professional
development plan developed
by the program for all staff for
the 2010-2011 and 2011-2012
school years.
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 7 of 16
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
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 Previous Program Review or Other Areas of Concern
1.2 Program &
Student
Description,
Program
Capacity

6.4 School Day
Per Year

Documentation
Review
Staff Interviews
Documentation
Review
Staff Interviews
8.4 Program
Modifications
and Support

Documentation
Review
Devereux submitted a detailed
narrative that describes all of
the requirements under this
criterion.
Review of documentation and
staff interviews indicate that
the Day Program is operating
as a 12 month program as
approved.
Devereux submitted a written
policy that contains all of the
requirements under this
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 8 of 16
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


Staff Interviews
Services for
Limited
English
Proficient
Students
9.1 Policies
and
Procedures
for Behavior
Management
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
criterion.
In addition, review of
documentation and staff
interviews indicate that staff is
aware of the requirement to
accept and serve Limited
English Proficient (LEP)
students.

Documentation
Review
Staff Interviews
Devereux submitted a written
policy that contains all of the
requirements under this
criterion.
In addition, review of
documentation and staff
interviews indicate that the
current policies and procedures
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 9 of 16
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
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


for behavior management are
implemented consistently
between each of its programs.
9.4 Physical
Restraint (Day
Programs
Only)

Documentation
Review
Devereux Day Program
submitted a written policy that
contains all of the requirements
under this criterion.
10.1 Staffing
for
Instructional
Groupings

Documentation
Review
Devereux submitted block
schedules that clearly display
the numbers and initials of
students, and the numbers and
initials of certified educators
and aides in all classrooms for
all periods throughout the
school day.
Staff Interviews
Observations
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 10 of 16
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
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


In addition, review of
documentation and staff
interviews indicate that staff is
aware of the approved student:
licensed educator ratio of 8:1
and the approved student:
licensed educator: aide ratio of
9:1:2.
10.2 Age
Range

Documentation
Review
Staff Interviews
Devereux submitted block
schedules for every classroom
and every period including the
initials of students with
corresponding dates of birth
indicating that the ages of the
youngest and oldest child in
each instructional grouping
does not differ by more than 48
months.
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 11 of 16
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
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
Review
Staff Interviews
12.2 In-Service
Training Plan
and Calendar
Partial
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
Review of staff records
indicated that staff
attendance at some of
the required in-service
trainings was not
consistently tracked or
documented in all of the
staff files that were
reviewed.
Devereux must develop a
tracking system to ensure
that all staff attend the
required in-service trainings
and that attendance is
consistently documented in
staff records.


11.9
Organizational
Structure
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
Documentation
Review
Staff Record
Review
Review of documentation and
staff interviews indicate that
the organizational structure of
the program provides for the
effective and efficient
operation of the school,
supervision of school staff, and
supervision of students.
Devereux submitted a copy of
its 2010-2011 and 2011-2012
in-service training plans and
calendars.
Partial
Staff Interviews
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 12 of 16
In addition, Devereux must
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


review a random sample of
fifteen (15) staff members to
ensure that all of the required
trainings are documented in
staff records. Please submit
the results of this review to
the Department by
December 15, 2011.
13.4 Physical
Facility/
Architectural
Barriers

Documentation
Review
Staff Interviews
Observation of the physical
facilities indicates that the
residential home for PDD boys
is now accessible for students
with limited physical mobility.
Observations
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 13 of 16
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


15.1 Parental
Involvement
and Parents’
Advisory
Group

Documentation
Review
Devereux submitted
documentation indicating that
its Parents’ Advisory Group
now meets to advise the
program on matters that pertain
to the education, health, and
safety of the students in the
program.
15.3
Information to
be Translated
into Languages
other than
English

Documentation
Review
Devereux submitted a written
plan that describes how it will
ensure that important school
information is sent to parents
or guardians with limited
English language skills in a
timely manner and provided to
them in a language that they
understand, either through
Student Record
Review
Staff Interviews
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 14 of 16
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
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


written translations of
documents or through oral
interpreters.
15.5 Parent
Consent and
Required
Notifications

16.2 Physician
Consultation

Documentation
Review
Devereux submitted the name
and address of the licensed
physician employed/contracted
by the program, as well as a
description of the services
provided to the program.
16.11 Student
Allergies

Documentation
Review
Observations and staff
interviews indicate that student
Documentation
Review
Student Record
Review
Student record review indicates
that annual consents are
consistently maintained in the
student records.
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 15 of 16
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
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


Staff Interviews
Observations
18.1
Confidentiality
of Student
Records

Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or Additional
Issues
Identified
Documentation
Review
Observations
allergy information is updated
frequently and is consistently
shared with staff and posted in
appropriate locations.
Observations indicate that
student medical records are
kept separately in the nursing
office and include a complete
log of access.
The Devereux Foundation, Inc. Mid-cycle Review Report
November 8, 2011
Page 16 of 16
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
Commonwealth of Massachusetts
Department of Elementary and Secondary
Education
The Devereux Foundation, Inc.
Day Program
A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO
603 CMR 18.00 AND 28.09
60 Miles Road, Rutland, MA 01543
Program Rate Based on: 19 Students
Approved Enrollment: 40 Students
Day Program
Summer Program
10 month program
Residential Program
11 month program
12 month program
APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1
APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: 9:1:2
APPROVAL STATUS
FULL APPROVAL
Expires on: August 31, 2015
The current approval is a result of a Mid-cycle Review conducted in the 2011-2012 school year
and the next review is scheduled for the 2014-2015 school year.
KERRI ZELDIS, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES
CARYN N. GOLDBERG, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES
DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES
DATE ISSUED:
November
8, 2011
Commonwealth of Massachusetts
Department of Elementary and Secondary
Education
The Devereux Foundation, Inc.
Residential Program
A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO
603 CMR 18.00 AND 28.09
60 Miles Road, Rutland, MA 01543
Program Rate Based on: 17 Students
Approved Enrollment: 17 Students
Day Program
Summer Program
10 month program
Residential Program
11 month program
12 month program
APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1
APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: 9:1:2
APPROVAL STATUS
FULL APPROVAL
Expires on: August 31, 2015
The current approval is a result of a Mid-cycle Review conducted in the 2011-2012 school year
and the next review is scheduled for the 2014-2015 school year.
KERRI ZELDIS, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES
CARYN N. GOLDBERG, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES
DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES
DATE ISSUED:
November
8, 2011
Commonwealth of Massachusetts
Department of Elementary and Secondary
Education
The Devereux Foundation, Inc.
Westmeadow Residential Program
A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO
603 CMR 18.00 AND 28.09
60 Miles Road, Rutland, MA 01543
Program Rate Based on: 92 Students
Approved Enrollment: 92 Students
Day Program
Summer Program
10 month program
Residential Program
11 month program
12 month program
APPROVED STUDENT:LICENSED EDUCATOR RATIO: 8:1
APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: 9:1:2
APPROVAL STATUS
FULL APPROVAL
Expires on: August 31, 2015
The current approval is a result of a Mid-cycle Review conducted in the 2011-2012 school year
and the next review is scheduled for the 2014-2015 school year.
KERRI ZELDIS, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES
CARYN N. GOLDBERG, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES
DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES
DATE ISSUED:
November
8, 2011