The Commonwealth of Massachusetts
Department of Education
350 Main Street, Malden, Massachusetts 02148-5023
Telephone: (781) 338-3700
TTY: N.E.T. Relay 1-800-439-2370
January 7, 2005
Heidi Bettencourt
Kennedy-Donovan Center School
19 Hawthorne St.
New Bedford, MA 02740
Re:
Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan
Verification and Mid-cycle Review
Dear Ms. Bettencourt:
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 May 1, 2002. 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.
While the Department of Education 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 April 4, 2005. The reasons for the “Provisional Approval” are clearly
indicated on the attached Corrective Action Plan Implementation Checklist. In areas where the
private school has failed to implement fully its approved Corrective Action Plan, the Department
views these findings to be serious.
As the Department previously informed you, in cases where a private school fails to fully and
effectively implement a Corrective Action Plan which was proposed by your school and
approved by the Department, the Department must then prepare a Corrective Action Plan for the
school 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 school 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 private school within the timelines specified.
Your statement of assurance must be submitted to the Department's Onsite Chairperson by
January 25, 2005.
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 781-338-3746.
Sincerely,
Kevin Bobetich, Program Review Follow-up Chairperson
Program Quality Assurance Services
John D. Stager, Administrator
Program Quality Assurance Services
c:
David P. Driscoll, Commissioner of Education
Mary Graham, Chairperson, Board of Directors
Encl.: Follow-up Monitoring Report
2
MASSACHUSETTS DEPARTMENT OF EDUCATION
MID-CYCLE PROGRAM REVIEW
Kennedy Donovan-Center School
ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION
AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION
Action Plan Submitted on June 19, 2002
Progress Reports Submitted on September 30, 2002
Onsite Visit Conducted on December 15, 2004
Date of this Report January 7, 2005
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification

1.3
Program’s
Curriculum
28.09(9)
Documentation
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 Education
and Timelines for
Implementation and Further
Progress Reporting
The Department review of
the Kennedy Donovan
Center’s documentation
revealed that the school
does not have a
curriculum aligned with
the Massachusetts
Curriculum Frameworks
that addresses the wide
range of ages and
disabilities served within
the school.
The Kennedy Donovan Center
must align its curriculum with
the Massachusetts Curriculum
Frameworks, and /or take steps
to provide students with
essential learning opportunities
that address the wide range of
ages and disabilities served
within the school. The updated
curriculum must be submitted
to the Department by October
15, 2005. In addition, the
school must provide the
Department with monthly
written updates on the
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 Education
and Timelines for
Implementation and Further
Progress Reporting

development of this
curriculum.
2.2
Approvals,
Licenses,
Certificates of
Inspection
28.09 (2)(b)4-5
28.09(5)
28.09(6)
18.04(1)

Documentation
Observations
The Kennedy Donovan Center
has submitted to the Department
all required Approvals,
Licenses, and Certificates of
Inspection.
102 CMR 3.06
(4)(b)
2.3
OCCS
Licensure (Not
Applicable to
Day Schools)
N/A
2
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

4.4
Advanced
Notice of
Program/
Facility Change
28.09(5)(c)


Documentation
Interviews
3
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
The Kennedy Donovan
Center does not have a
written policy for
notification to the
Department of any
substantial changes to the
program. Staff interviews
and documentation review
indicated that the staff
does not utilize the Form
1 for Notification of
Substantial Changes
within a Private Special
Education School
Program.
The Kennedy Donovan Center
must submit an updated policy
for notification to the
Department of any substantial
changes to the program by
March 1, 2005. In addition,
administrative staff must
receive training from the
Department on this policy and
procedure by June 1, 2005.
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

4.5
Immediate
Notification
18.03(10)
18.05(7)
28.09(12)

Additional
Issues
Identified
Documentation
Interviews
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Staff interviews revealed
that Kennedy Donovan
Center does not have a
procedure to ensure that
all required parties are
notified of the serious
incidents outlined on the
Form 2, Private Day and
Residential School
program Incident Report.
The Kennedy Donovan Center
must submit an updated policy
on immediate notification to
include a complete listing of all
serious incidents the program is
required to provide notification.
In addition, all staff must
receive training on this policy
and procedure by June 1, 2005.
The updated policy along with
the staff training agenda and
sign-in sheets must be
submitted to the Department by
June 1, 2005.
4
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

5.2
Contents of
Coordination
and
Collaboration
with Public
School Districts
28.06(2-3)
28.07(5)
28.09(9)(c)&(d)
28.09(2)(b)7
Federal
Regulations:
300.349
And
300.400-401
6.1
Daily
Instructional
Hours
603 C.M.R.
27.00


Documentation
Interviews

Documentation
Observations
The Kennedy Donovan Center
provides the required minimum
number of daily instructional
hours.
5
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
A review of
documentation and staff
interviews revealed that
the Kennedy Donovan
Center does not have a
written policy and
procedure for coordination
and collaboration with
public school districts
containing all the required
elements.
The Kennedy Donovan Center
must submit a policy and
procedure for the coordination
and collaboration with public
school districts to the
Department by March 1, 2005.
In addition, all staff must
receive training on the new
policy and procedure by June
1, 2005. The staff training
agenda and attendance sheets
for this training must be
submitted to the Department by
June 15, 2005.
Criterion
Number
and
Topic
6.2
School-to-Work
603 CMR
27.02, 27.04
6.3
Kindergarten
6.4
School Days per
Year
28.09(9)
6.5
Early Release of
High School
Seniors
603 CMR 27.05
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

N/A


Documentation
Interviews

Documentation
The Kennedy Donovan Center
does not set a separate school
year and school day for
kindergarten programs.
The Kennedy Donovan Center
exceeds the required school days
per year.
N/A
6
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of 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

7.1
Curriculum
Frameworks
28.09(9)(b)
7.3
State/District
Wide
Assessments
28.09(9)(d)


Documentation
Interviews

Documentation
Interviews
The Kennedy Donovan Center
has a written procedure outlining
how the school will ensure that
all enrolled students participate
in state and/or district wide
assessments in accordance with
the assessment participation
information provided on the
student’s IEP.
7
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Staff interviews and
review of documentation
indicated that Kennedy
Donovan Center Staff do
not have a full
understanding of
Massachusetts Curriculum
Frameworks.
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
All staff need to receive
training that reflects a full
understanding (p.30 #1)
Massachusetts Curriculum
Frameworks. The submission
of an attendance sheet and
agenda as well as the trainer’s
qualifications, must be
submitted by March 1, 2005.
Criterion
Number
and
Topic
8.4
Current IEP &
Student Roster
28.09
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 Education
and Timelines for
Implementation and Further
Progress Reporting
A review of student
records found that not all
IEP’s were consented to
by the parent or guardian.
The Kennedy Donovan Center
must develop a written
procedure for the coordination
and collaboration with school
districts to ensure that all IEP’s
are consented to by the parent
or guardian before they are
implemented. The School must
document the efforts they have
made to contact the sending
school district for updated IEP
information following an IEP
Team meeting. The School
must assure the Department of
Education that they will no
longer implement drafts of
IEP’s. Upon the Department’s
approval of the new
procedures, the new policy and
procedure will need to be
included in the Policies and
Procedures Manual and staff
will need to complete training
in this update policy. The
submission of an attendance
sheet and agenda as well as the
trainer’s qualifications, must be
submitted by June 1, 2005.

Documentation,
Student
records
The Kennedy Donovan Center
has provided the Department
with a current list of IEP’s for
all students enrolled in the
program.
8

Criterion
Number
and
Topic
8.8
IEP Progress
Reports
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
Documentation
Interviews,
Student
records
The Kennedy Donovan Center
sends copies, at least quarterly,
of education progress reports to
the parents and public 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 Education
and Timelines for
Implementation and Further
Progress Reporting
A review of student
records found that student
progress reports are
written based upon IEP
goals that have not been
consented to by the parent
or guardian.
Although, the Kennedy
Donovan Center does send
quarterly progress reports to
parents and the public school
districts, the school has not
developed a written policy and
procedure for the completion of
quarterly progress reports that
is included in the Policy and
Procedure Manual. This policy
must clearly state that IEP
progress reports are based upon
the student’s current signed
IEP.
The new policy and procedure
must be submitted for
Department of Education
approval by March 1, 2005.
9
All staff must receive training
on this new policy by June 1,
2005. A copy of the training
agenda and staff sign in sheets
must be submitted by June 15,
2005.
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

8.9
IEP- Less
Restrictive
Placement
28.09(9(c)


Documentation
Interviews
10
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
A review of
documentation and staff
interviews indicated that
the Kennedy Donovan
Center has not developed
a policy and procedure to
ensure that students have
access to a less restrictive
educational program
Some community based
instruction)
The Kennedy Donovan Center
must submit an updated policy
on the IEP-Less Restrictive
Placement, which reflects the
student’s options for
community programs and less
restrictive educational
programs to be included in the
Policy and Procedure Manual
by March 1, 2005. Once the
Department has approved the
new policy and procedure the
staff need to complete training
in the new procedure. The
submission of an attendance
sheet and agenda as well as the
trainer’s qualifications, must be
submitted by June 15, 2005.
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

9.6
10+ Day
Suspensions


Documentation
11
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
The Department found no
written policy from the
Kennedy Donovan Center
on 10+ Day Suspensions.
The Kennedy Donovan Center
must submit an updated policy
on 10+ Day Suspensions by
March 1, 2005. In addition, all
staff must receive training on
this new policy by June 1,
2005. A copy of the training
agenda and staff sign in sheets
must be submitted to the
Department by June 15, 2005.
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

10.1
Student:
Teacher Ratios
28.06(6)(d)&(g)
28.09(7)(e)


Documentation
Interviews
Observations
12
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
The Department observed
three licensed teachers to
forty-five students, which
is a ratio of one teacher to
fifteen students. The
student teacher ratios for
instructional groupings
cannot exceed eight
students to one licensed
teacher without an aide or
twelve students to one
licensed teacher with an
aide.
The Kennedy Donovan Center
must develop a plan for
ensuring that the student
teacher ratios for instructional
groupings do not exceed twelve
students to one licensed teacher
with an aide. This plan must
be submitted to the Department
by March 1, 2005. The
Kennedy Donovan Center must
submit written assurances
stating that the school will be in
compliance with the student
teacher ratio requirements by
the 2005-2006 school year.
The School must submit
written monthly progress
reports on the 15th of each
month documenting the efforts
to come into compliance with
the requirements for
instructional groupings.
Criterion
Number
and
Topic
11.1
Personnel
Policies
28.09(7)
28.09(11)(a)
18.05(11)
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


11.3
Educational
Administrator
Qualifications
28.09(7)(a)
603 CMR
44.00 and 44.04
11.4
Special
Education
Teachers and
Regular
Education
Teachers
28.09(7)(b)(c)
18.05(11)(f)

Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Personnel
records
The Kennedy Donovan Center
has developed written personnel
policies and procedures, which
meet the Department’s
requirements including a written
evaluation policy.
Documentation
Kennedy Donovan Center’s
educational administrator meets
the criteria to qualify as an
educational administrator.
Documentation
Interviews
The Kennedy Donovan Center’s
current teaching staff are
licensed or on an approved
waiver in special education or
areas appropriate to the school.
(See findings under 10.1)

13
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
11.5
Related
Services Staff
28.09(7)(d)
11.6
Master Staff
Roster
28.09(7)
11.9
Organizational
Structure
28.09(7)
28.07(c)
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
Documentation
The Kennedy Donovan Center
has submitted to the Department
a roster of all staff providing or
supervising the provision of
related services appropriately
licensed by their respective state
boards or professional
associations.
Documentation
The Kennedy Donovan Center
submitted a roster of all staff for
every position within the
program, including UFR’s.
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
The Department has not
received documentation
from the Kennedy
Donovan Center on the
Organizational Structure
of the program.
The Kennedy Donovan Center
must submit an updated
organizational chart describing
the lines of supervision within
the school by March 1, 2005.


Documentation
14
Criterion
Number
and
Topic
11.11
Supervision of
Students
28.09(7)
18.03(1)
11.12
Accessibility of
Extracurricular
Activities
12.2
Annual InService
Training Plan
and Calendar
28.09(7)(f)
18.05(11)(h)
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





Interviews

Documentation
Interviews
The Kennedy Donovan Center
sponsors extracurricular
activities that are nondiscriminatory.
The Kennedy Donovan Center
has submitted a written calendar
for staff training includes all
mandated topics.
15

Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
The Department has not
received documentation
from the Kennedy
Donovan Center on the
Supervision of Students
while they are engaged in
any school-related activity
on and off school grounds.
The Kennedy Donovan Center
must submit an updated policy
on Supervision of Students by
March 1, 2005. In addition, all
staff must receive training on
this new policy by June 1,
2005. A copy of the training
agenda and staff sign in sheets
must be submitted to the
Department by June 15, 2005.
Staff interviews and
review of documentation
indicated that Kennedy
Donovan Center Staff do
not have a full
understanding of
Massachusetts Curriculum
Frameworks. (See 7.1)
See Criterion 7.1
Criterion
Number
and
Topic
12.2(a)
Behavior
Management
and Restraint
Training
28.09(11)
18.05(5)
12.2(i)
Staff
Evaluations
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 Education
and Timelines for
Implementation and Further
Progress Reporting
A review of Kennedy
Donovan Center’s
personnel files uncovered
inconsistencies between
their policy and procedure
for staff evaluations and
written performance
evaluations for all staff.
The Kennedy Donovan Center
must develop a plan for
ensuring that all personnel are
receiving evaluations according
to the timeline in the Policy and
Procedure Manual, and that all
evaluations are documented in
the staff member’s personnel
file. The Department of
Education will conduct an onsite review of personnel records
on or after October 1, 2005 to
ensure that all required
information is being maintained
in personnel records.

Documentation
The Kennedy Donovan Center
Behavior Management and
Restraint Training procedures
include all of the elements
required by the Department.

Documentation
Interviews
18.05(11)(c)1.
16
Criterion
Number
and
Topic
13.3
Comparability
of Facilities
15.1
Parental
Involvement
and Parents’
Advisory Group
18.05(4)(a)
15.3
Information to
be Translated
into Languages
other than
English
603 CMR
26.02(2)
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification

N/A

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 Education
and Timelines for
Implementation and Further
Progress Reporting

Document-ation
Interviews
The Kennedy Donovan Center
does not provide separate
facilities for members of a
specific group.
The Kennedy Donovan Center
has developed a written plan for
involving parents, which
includes a Parents’ Advisory
Group.


Documentati
on
17
The Department found no
written policy from the
Kennedy Donovan Center
on Information to be
Translated into Languages
other than English.
The Kennedy Donovan Center
will continue to submit
documentation for ongoing
Parent Advisory Group
Meetings, including attendance
sheets and an agenda by June
15, 2005.
The Kennedy Donovan Center
must submit a policy on
information to be Translated
into Languages other than
English by March1, 2005. In
addition, all staff must receive
training on this new policy by
June 1, 2005. A copy of the
training agenda and staff sign
in sheets must be submitted to
the Department by June 15,
2005.
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

15.8
Registering
Complaints
18.05(1)(b)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 Education
and Timelines for
Implementation and Further
Progress Reporting
The Department found no
written policy from the
Kennedy Donovan Center
on Registering
Complaints.
The Kennedy Donovan Center
must submit a policy on
Registering Complaints by
March 1, 2005. In addition, all
staff must receive training on
this new policy by June 1,
2005. A copy of the training
agenda and staff sign in sheets
must be submitted to the
Department by June 15, 2005.


Documentation
Interviews
In addition, all
parents/guardians must be
provided with a copy of this
written policy and procedure.
A copy of the letter notifying
parents of this change as well
as a list of parents/guardians
receiving this notification must
be made available to the
Department of Education on or
before October 1, 2005.
18
Criterion
Number
and
Topic
16.6
Administration
of
Antipsychotic
Medication
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

Documentation
The Kennedy Donovan Center
has developed a policy in the
Health Care and Policy
Procedure Manual for the
Administration of Antipsychotic
Medication including all of the
required elements.
19
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
18.2
Student Records
28.09(10)
MGL c. 71, s.
34H
603 CMR 23.00
Family
Educational
Rights and
Privacy Act
(FERPA)
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 Education
and Timelines for
Implementation and Further
Progress Reporting
A review of student
records found that
Kennedy Donovan Center
is not maintaining all
required parental consent
forms as well as contracts
with the sending school
districts. Specifically, the
school is not obtaining
annual consent from
parents or guardians for
physical restraint. In
addition, the private
school must ensure that
the contracts with sending
school districts contain all
required elements as
outlined in 603 CMR
28.06(3)(f)(1-5).
The Kennedy Donovan Center
must develop a written policy
for parental consents and a
policy on contracts to be
included in the Policy and
Procedure Manual. The
Department will review student
records on or after October 1,
2005 to ensure that all required
consents are signed, and all
contracts comply with 603
CMR 28.06(3)(f)(1-5).

Documentation
Interviews
The Kennedy Donovan Center
has student records that contain:
a log of access, face sheets, a
copy of the current IEP, copies
of quarterly progress reports and
any modification of the IEP,
copy of the student’s termination
or discharge plan, health
records, evaluations and
assessments, pertinent
correspondence, and copies of
all incident reports.
20
