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 April 15, 2009 Gerard E. Burke, Chief Executive Officer Hillcrest Educational Centers, Inc. P.O. Box 4699 Pittsfield, MA 01202 Re: Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan Verification and Mid-cycle Review Dear Mr. Burke: Enclosed is the Department's Program Review Follow-up Monitoring Report together with findings regarding your private school’s Mid-cycle Program Review. This report contains the Department's findings based on the onsite activities conducted in your school to verify the implementation status and effectiveness of corrective steps taken in response to your Program Review Report issued on September 25, 2007. This report also includes a report on the status of implementation for new state or federal special education requirements enacted since your school’s last Program Review. We are pleased to indicate that the Department of Elementary and Secondary Education has found your residential school’s approved Corrective Action Plan to be substantially implemented and effective in remedying previously identified noncompliance issues. Additionally, we have determined that your school is in substantial compliance with any new state or federal special education requirements enacted since your last Program Review. The findings of the Department are included in the attached Follow-up Monitoring Report. While the Department of Elementary and Secondary Education found certain noncompliance issues to be resolved, others were partially corrected or new issues were identified by the Department’s onsite team. Please note the date progress reports are due. Since areas requiring further progress reports do not concern issues of student health or safety, your private school will now receive an updated status of “Full Approval.” This approval shall remain in effect for three (3) years from the date of this letter and attached approval certificate. This approval 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 of Elementary and Secondary Education 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 school’s next regularly scheduled Program Review several months before it is to occur. At this time we anticipate the Department's next routine monitoring visit to occur sometime during fiscal year 2012, unless the Department determines that there is some reason to schedule this visit earlier. 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 Sandra Hanig at 413-858-4591 extension 2. Sincerely, Sandra K. Hanig, Program Review Follow-up Chairperson Program Quality Assurance Services Darlene Lynch, Director Program Quality Assurance Services C: Pat Greco, Director of Special Education, Hillcrest Educational Centers, Inc. Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education Encl.: Follow-up Monitoring Report Full Private School Approval Certificate, Expiration Date: August 31, 2012 MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION PRIVATE SCHOOL MID-CYCLE PROGRAM REVIEW HILLCREST EDUCATIONAL CENTERS, INC. Hillcrest Residential Program and Hillcrest Intensive Treatment Residential Program ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION Action Plan Submitted on November 13, 2007 Progress Reports Submitted on April 30 and August 6, 2008 Onsite Visit Conducted on October 16 & 17, 2008 Date of this Report: April 15, 2009 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 Mid-cycle Review Criteria 2.2 Approvals, Licenses, Certificates of Inspection 18.04(1); 28.09(2)(b)(5); Documentation review Hillcrest Educational Centers, Inc. (HEC) submitted a copy of all required inspections and permits for each building in the approved Residential and Intensive Treatment programs to which students have access as well as a copy of the local school committee approval Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 1 of 25 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 from each public school district within which Hillcrest operates a private school. Documentation review Hillcrest Educational Centers, Inc. submitted a copy of the current EEC license for each residential location. Documentation interview and student record review Hillcrest Educational Centers, Inc. has developed a written plan to address how it will effectively serve limited English proficient (LEP) students in its residential programs that meets Department requirements. EEC Licensure 102 CMR 3.00 (Residential Schools only) 8.4 Program Modifications and Support Services for Limited English Proficient Students M.G.L. c. 71A; Title VI Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance 28.09(5) (b); 28.09(6) (b, c) 2.3 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified No Massachusetts student currently enrolled has been identified as limited English proficient by the sending public school district. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 2 of 25 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 8.5 Current IEP & Student Roster 28.09(5)(a) 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 and student record review NOTE: Hillcrest Educational Centers, Inc. is not required to submit an IEP & Student Roster for its approved Intensive Residential Treatment Program (ITU.) None of the 12 students currently enrolled in the ITU are funded by Massachusetts public school districts or other Massachusetts state agencies. Hillcrest Educational Centers, Inc. submitted an IEP & Student Roster for its approved Hillcrest Center Residential Program, which indicates the private school has a current and signed IEP on file for all students or has documented its efforts to obtain a current signed IEP from the responsible school district. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 3 of 25 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 11.4 Teachers (Special Education Teachers and Regular Education Teachers) 18.05(11)(f); 28.09(5)(a); 28.09(7)(b, c); 34 CFR 300.321 Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Documentation and personnel record review Hillcrest Educational Centers, Inc. submitted documentation that indicates the Director of Education holds current Massachusetts license as a Special Education Administrator. Review of personnel records indicates that the private school maintains a copy of the Director’s professional license on site. Documentation and personnel record review Hillcrest Educational Centers, Inc. submitted separate rosters for each of its two approved residential programs, the ITU and Hillcrest Center Schools residential programs. 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 These rosters indicate that all teachers have a current license or approved waiver to lead classes for the grade level and in the subject matter for which they are Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 4 of 25 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 assigned. Personnel records for teachers include copy of their current license. Files of teachers with a professional level teaching license include a Professional Development Plan. 11.5 Related Services Staff Documentation and personnel record review 28.09(7)(d) Hillcrest Educational Centers, Inc. submitted separate rosters for each of its two approved residential programs, the ITU and Hillcrest Center Schools residential programs. These rosters indicate that all related services providers maintain their professional license. Personnel records for related services providers include copy of their current license. 11.6 Master Staff Roster Documentation and personnel record review Hillcrest submitted a current Master Staff Roster for each of its two approved residential programs. It Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 5 of 25 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 indicates that the private school is staffing its programs as approved by the Department of Elementary and Secondary Education. Personnel records for all staff indicate information reported on Master Staff Roster is consistent with what is found in personnel records. 28.09(7) Identified Areas of Non-Compliance During 2006 Program Review or Other Areas of Concern 1.2 Program & Student Description Documentation review Hillcrest Educational Centers, Inc. submitted two separate narratives, one for each of the approved Intensive Treatment Program and the Hillcrest Center Schools Residential Program. For each approved residential program, these written descriptions describe the operational capacity, population of students served, program philosophy and how it will ensure that Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 6 of 25 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 students enrolled in receive all required IEP services. 3.1 Documentation review Hillcrest Educational Centers, Inc. has developed a Policies and Procedures Manual that contains written policies, procedures and/or plans for each topic required by the Department. Hillcrest Educational Centers, Inc. also submitted a copy of the letter Hillcrest Educational Centers, Inc. sends to parents at the time of admission and annually thereafter to notify them that they may request a copy of the Policies and Procedures Manual at any time Documentation review Hillcrest Educational Center’s policy on reporting suspected abuse or neglect contains all required elements. Policies & Procedures Manual 3.1(c) Child Abuse Reporting Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 7 of 25 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 3.2 Advanced Notice of Proposed Program/ Facility Change 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 Hillcrest Educational Centers, Inc. submitted an articulate and detailed description of its procedures to ensure that the Department receives prior notification of proposed changes to its approved programs. Submit a Form 1 notification to the Department regarding the addition of classroom space to the school building at Highpoint. Attach the following documents: Written plan for use of new school building Plan includes expected number of staff and students that will be assigned to each classroom Floor plan that designates use of space for each room. Statement regarding current use of room in Documentation review Health Care Manual 4.4 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation review and observation Hillcrest Educational Centers, Inc. submitted a copy of the table of contents from the Health Care Manual. It contains all required policies. Observation indicates that Hillcrest Educational Centers did not make prior notification to the Department before beginning to construct an addition to the school building on the Highpoint campus. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 8 of 25 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 gym and recreation room to hold classes Building permit Building occupancy permit Building inspection Fire inspection Health inspection Statement regarding disturbance of lead paint and asbestos when conducting renovation, if applicable. Documentation must be received by May 29, 2009. 4.5 Immediate Notification Documentation and student record review Hillcrest Educational Centers, Inc. has developed a written policy on immediate notification of serious incidents that contains all required elements. Incident reports were found in student records. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 9 of 25 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 5.1 Student Admissions 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 and student record review Hillcrest Educational Centers, Inc. submitted its admissions policy that contains all required elements. A current medical examination was found in all student records reviewed. Hillcrest Educational Center also submitted a narrative clarifying student admissions and waiting list procedures. In February 2004 the Department approved the agency’s proposal to expand the approved Hillcrest Center School to also include the (separately approved) Brookside and Highpoint Programs. The Department approved what had formerly been three separate approved residential programs as one expanded residential Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 10 of 25 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 program. With that approval, the Department agreed that Hillcrest Educational Centers would serve a different population on each of the three campuses. 6.1 Documentation review Hillcrest Educational Centers, Inc. has developed block schedules for its approved residential programs that include all core content and elective subject areas taught as well as beginning and ending times for each instructional period. Documentation review Hillcrest Educational Centers has developed written guidelines that describe how the private school verifies hours students spend in School-to-Work opportunities. Daily Instructional Hours 6.2 School-to-Work Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 11 of 25 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 7.1 7.3 State/District Wide Assessments Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Documentation review and interview Hillcrest Educational Center, Inc. has a written description of how the learning standards of the Massachusetts Curriculum Frameworks are incorporated into the private school’s instruction and describes techniques used to make teachers and students aware of the framework addressed in each class lesson. The policy indicates that teachers keep a copy of Massachusetts Curriculum Frameworks in the classroom and the learning standard being addressed in a class lesson is posted throughout the classroom. Documentation review Hillcrest Educational Centers, Inc. has developed written procedures for ensuring participation in state and district-wide assessments that contains all required elements. Curriculum Frameworks Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 12 of 25 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 7.4 Documentation review Hillcrest Educational Centers has developed written procedures regarding issuing diplomas and certificates of attendance that meets Department requirements. Documentation and student record review Hillcrest Educational Centers, Inc. submitted a written description of how the private school documents parents, sending school districts and /or agencies receive copies of progress reports. It indicates that a copy of a cover letter mailed with each IEP progress report is placed in the student’s record. These were found in student records. Documentation review Hillcrest Educational Centers, Inc. submitted a written plan that describes opportunities for enrolled students to gain the capacity IEP – Progress Reports 8.10 IEP - Least Restrictive Placement Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance High School Diplomas and Certificates of Attendance 8.8 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 13 of 25 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 return to a less restrictive educational program. 8.11 Documentation and student record review The private school’s written transition plan meets the requirements. Transition Planning Forms were found in student records. Documentation and student record review Hillcrest Educational Center’s written transition plan for students approaching graduation or age 22 meets requirements and is included in the Policy and Procedures Manual. A copy of a 688 referral was found in student records. Documentation review and interview Hillcrest Educational Center has developed a written description of its behavior management policies and procedures that are IEPTransition Planning 8.12 IEPTransition Services 9.1 Discipline and Behavior Management Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 14 of 25 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 implemented at all campuses included in its residential programs. Runaway Students 9.5 3-5 Day Suspensions Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Policies and Procedures 9.3 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation and student record review Hillcrest Educational Center has developed a Runaway Policy that contains all required elements. Incident reports of runaways were found in student records. Documentation review and interview Hillcrest Educational Centers writes that it does not suspend students. The private school’s suspension policy describes behavior management procedures that will be implemented if a student has behaviors that preclude him or her from being allowed to participate in assigned classroom activities with other students because of behavior or safety concerns. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 15 of 25 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 9.6 Documentation review Hillcrest Educational Centers, Inc. has developed written procedures to ensure that it follows federal regulations if a student is refused participation in classroom activities by Hillcrest Educational Centers for 10 consecutive school days or a pattern of need for exclusion from classes has developed that exceeds 10 cumulative days. Documentation review Hillcrest Educational Centers’ policy on termination of students includes all required elements and is found in the Policy and Procedures Manual. Documentation review Hillcrest submitted job description that indicates the corresponding UFR number and qualifications required of staff for each position match Terminations 11.7 Job Descriptions Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Suspensions 10+ Day Suspensions 9.7 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 16 of 25 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 At the time of the Midcyle Review, Hillcrest Educational Centers Inc. was in the process of requesting changes to its two approved residential programs. The private school did not submit organizational charts with accompanying narrative for its agency or two residential programs. For a progress report, submit the following documents: what was approved with the Special Circumstances for ITU in 2007 and Center Schools expansion in 2004. 11.9 Organizational Structure Documentation review and interview The concern at the time of the previous program review was that the Education Director did not supervise principals, which led to a lack of unification of procedures. Principals were supervised by Program Directors who did not have an Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 17 of 25 Organizational chart for agency Organizational chart for each of the two approved residential programs For each approved program, include a narrative description of lines of supervision of staff and students and explain how this organizational and supervision structure promotes an educational program that best serves students and teachers. Note that organizational charts must include the UFR 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 educational background. Teacher assistants reported to a day supervisor who had no educational background. 11.11 Documentation review Hillcrest Educational Centers has developed a written plan that describes arrangements for individual and group recreational programs appropriate to the age, interests, and needs of each student with assigned staff as appropriate. Documentation review Hillcrest Educational Centers, Inc. submitted a list of sports offerings, extracurricular activities and clubs offered to all students enrolled in the approved Hillcrest Residential Program that is located on three campuses. Supervision of Students 11.12 Accessibility of Extracurricular Activities Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 18 of 25 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting number for each position. These documents must be received by May 29, 2009. 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 12.2 Training 12.2 (f) Description of Physical Facilities 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 See contents of finding for criterion 4.4 See details of progress report required for criterion 4.4. Documentation review and interview Hillcrest Educational Centers, Inc. submitted a narrative description of the agency’s procedures to monitor and document that staff members participate in all trainings required for their job duties. Review of the private school’s system for tracking staff attendance at mandated trainings indicates that all staff members participate in trainings as required. Documentation review The private school submitted documentation of 2 fire drills per building per shift in the previous 12 months. Emergency Procedures 13.2 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation review and observation Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 19 of 25 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification 13.4 Physical Facility Architectural Barriers 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 Observation indicates that neither the approved Residential Programs nor the Intensive Residential Treatment Program are fully handicapped accessible. Submit a specific plan that details steps to be taken to comply with Section 504 of the Rehabilitation Act of 1973 for the approved Residential Program and another for the approved Intensive Residential Treatment Program. Documentation review observation and interview Hillcrest Educational Center did not submit a specific plan to provide all residential and educational program services at an equivalent alternate location in handicapped accessible buildings. If the private school’s plan includes building renovations, submit expected timelines for completion of each stage of the project(s.) If the private school’s plan is to move the location of a student’s education and residential services to accessible buildings, please note that Hillcrest must submit two written plans, one each for the Residential Program and one for the Intensive Residential Treatment Program. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 20 of 25 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 Attach floor plans. Documentation must be received at the Department by May 29, 2009. 13.7 Library/ Resource Room Observation and interview Hillcrest Educational Centers, Inc. submitted a written narrative to describe the library/resource area at each campus. At the time of the onsite visit, the private school did not have a plan for separate library space in the renovated school building on the Brookside campus. Submit a written description of the location and variety of materials available in the separate library or resource room on the Brookside campus. This narrative must address how the location was chosen to facilitate use of the library. Include a statement of when and how often students access the library. Final approval of compliance with this criterion is subject to onsite verification by Department staff. Documentation must be received at the Department by May 29, 2009. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 21 of 25 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 15.3 Documentation review Hillcrest Educational Centers, Inc. submitted a description of how the private school will respond promptly to parent/guardian requests to have important school information translated on demand, either orally or in writing. Documentation review and student records. Written procedures to ensure all appropriate personnel receive information about a change in a student’s legal status and results of judicial and administrative proceedings meet Department requirements. The private school’s “Legal Status Change Notification” form was found in student records. Documentation and student record review Hillcrest Educational Centers submitted a copy of its consent form for permission to take or publish a student’s Change of Student’s Legal Status 15.5 Parent Consent Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Information to be Translated into Languages Other Than English 15.4 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 22 of 25 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 photograph, sound recording, film or name for purposes of staff and parent training, observation and public relations. The private school also submitted a statement on when this consent would be required. Consents were found in student records reviewed. 16.5 Documentation review Documentation review Administration of Medication 16.6 Administration of Antipsychotic Medication Hillcrest Educational Centers, Inc. has developed written policy and procedures for administration of medication that contains all required information and is placed in the Health Care Manual. Hillcrest Educational Centers, Inc. has developed written policy and procedures for administration of antipsychotic medication that contains all required information and is placed in the Health Care Manual. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 23 of 25 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 16.7 17.1 Documentation review Transportation Safety Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting At the time of the onsite visit, Hillcrest Educational Centers, Inc. was in the process of reviewing and revising the wording of written procedures for medical treatment on the grounds of sincere religious belief. Submit a statement of medical treatment on the grounds of sincere religious belief that is included in the Health Care Manual. Hillcrest Educational Centers, Inc. submitted a written plan for providing students with preventative health care that meets requirements. Documentation review and interview Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Preventive Health care 16.8 Medical Treatment – Religious Beliefs Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation review Hillcrest Educational Centers, Inc. has developed detailed written transportation safety procedures to ensure vehicles are safe and students are transported in a safe manner. A selection of personnel records of staff members who Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 24 of 25 Documentation must be received by May 29, 2009. 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 transport students was reviewed. Each contained a copy of a current driver’s license. Hillcrest Educational Centers, Inc. Residential Program and Intensive Treatment Resident Program Review Mid-cycle Report April 15, 2009 Page 25 of 25 Further Corrective Action Ordered by the Department of Elementary and Secondary Education and Timelines for Implementation and Further Progress Reporting