January 5, 2010
75 Pleasant Street, Malden, Massachusetts 02148-4906 Telephone: (781) 338-3700
TTY: N.E.T. Relay 1-800-439-2370
Neil Berger, Ph.D., Administrative Director
Kolburne School
343 New Marlborough Southfield Rd.
New Marlborough, MA 01230
Re: Mid-cycle Review and Verification of previous Program Review Corrective Action Plan
Dear Dr. Berger:
Enclosed are the Department’s findings regarding your private school program’s recent onsite
Mid-cycle Review. This Mid-cycle Review Report contains the Department's findings regarding the implementation status and effectiveness of corrective steps taken in response to your previous
Program Review Report issued on September 25, 2007. This report also includes the status of the program’s implementation of new state or federal special education requirements enacted since your program’s last Program Review.
While the Department of Elementary and Secondary Education found one previous area of noncompliance to be only partially corrected, we are pleased to indicate that the Department has found your program’s overall 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. Therefore, your program will 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 findings of the Department are included in the attached Mid-cycle Review Report. You and your entire staff are to be congratulated for your efforts in implementing all necessary improvements.
As the Department previously informed you, in cases where a program fails to fully and effectively implement a Corrective Action Plan which was proposed by your program and approved by the Department, the Department must then prepare a Corrective Action Plan for the program which must be implemented without further delay. You will find this requirement for corrective action and further progress reporting included in the attached report, together with any steps that must be taken by the program to fully implement the special education requirements.
Please provide the Department with your written assurance that the Department's requirements for corrective action will be implemented by your program within the timelines specified. Your statement of assurance must be submitted to the Department's Onsite Chairperson by January
15, 2010 .
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 Department's next routine monitoring visit to occur sometime during the FY 2013, 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 the Onsite Team Chairperson at 413-858-4591.
Sincerely,
Sandra K. Hanig, 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
Dominick Ferrusi, Local Program Review Coordinator, Kolburne School
Jeane Weinstein, Chairperson, Board of Directors, Kolburne School
Encl.: Mid-cycle Review Report
Full Private School Approval Certificate, Expiration Date: August 31, 2013
Criterion
Number and
Topic
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
PRIVATE SCHOOL MID-CYCLE REVIEW
MID-CYCLE REVIEW REPORT
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Previous Program Review Corrective Action Plan Submitted on November 14, 2007
Progress Reports Submitted on April 15, 2008
Mid-cycle Onsite Visit Conducted on November 19, 2009
Date of this Report January 5, 2010
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
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 1 of 14
Criterion
Number and
Topic
2.2
Approvals,
Licenses,
Certificates of
Inspection
18.04(1);
28.09(2)(b)(5);
28.09(5) (b);
28.09(6) (b, c)
2.3
EEC Licensure
102 CMR 3.00
(Residential
Schools only)
8.4
Program
Modifications and Support
Services for
Limited
English
Proficient
Students
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
Documentation
Review
Documentation
Review
Comments Regarding
Corrective Action Plan
Implementation
Kolburne School submitted current copies of all appropriate approvals, licenses, and certificates of inspection for all school and residential buildings.
Kolburne School submitted a current EEC license for each of its residential buildings.
Kolburne School has a plan to implement necessary program modifications and support services to identify and effectively service limited
English proficient (LEP) students.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 2 of 14
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
M.G.L. c. 71A;
Title VI
8.5
Current IEP &
Student Roster
28.09(5)(a)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
11.3
Educational
Administrator
Qualifications
28.09(5)(a);
28.09(7)(a);
603 CMR
44.00
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation
Review
Documentation
Review
Kolburne School has on file a current Individualized
Educational Program (IEP) for each Massachusetts student that has been issued by the responsible school district and consented to and dated by the student’s parent or guardian or has documented its repeated efforts to obtain a signed copy from the sending public school district.
The person designated by
Kolburne School to serve as the Educational Administrator holds a current Massachusetts license as a Special Education
Administrator (All Levels) and therefore, meets the requirements to serve in this role.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 3 of 14
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
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
11.5
Related
Services Staff
28.09(7)(d)
11.6
Master Staff
Roster
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
Comments Regarding
Corrective Action Plan
Implementation
Kolburne School submitted documentation verifying that all teaching staff are appropriately licensed or hold a current waiver.
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
Review
Documentation
Review
All staff providing or supervising the provision of related services for Kolburne
School are appropriately certified, licensed or registered in their professional area.
Kolburne School submitted a
Master Staff Roster that contains the name, program job title, corresponding UFR
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 4 of 14
Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number and
Topic
28.09(7)
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 title number, licensure and/or certification if appropriate, full-time equivalent (FTE), and qualifications for current staff.
The Master Staff Roster accurately corresponds to the last approved ESE Program
Budget as required.
Identified Areas of Non-Compliance During the 2007 Program Review or Other Areas of Concern
Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting
1.2
Program and
Student
Description
28.09(2)(a)(2);
28.09(2)(b)(2, 3,
7)
4.4
Advanced
Notice of
Proposed
Documentation
Review
Kolburne School provided a written narrative that now fully describes the program’s philosophy, goals, objectives, student population, educational services, and related services.
Documentation
Review
Kolburne School now has written procedures regarding how it notifies and/or obtains approval from the Department
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 5 of 14
Criterion
Number and
Topic
Program/
Facility Change
28.09 (5)(c)
5.1
Admissions
28.09(11);
18.05(1)(b)(1-
17); 18.05(2);
18.05(3)(c)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
5.2(a)
Contracts
28.06(3)(f)
6.1
Daily
Instructional
Hours
603 CMR 27.04
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation prior to changes in the program as required by the current Form 1.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Review
Student Record
Review
Documentation and Student
Record Review
Kolburne School’s written admissions policy no longer contains language that is discriminatory or provides for the acceptance of students who do not meet the school’s admissions criteria.
Contracts for all
Massachusetts students were reviewed when on site and found to be current and signed.
Kolburne School offers students an educational program of 1296 instructional hours per year. Each school day includes 30 minutes of transition time (15 minutes at the beginning and end of each day) and a 35 minute lunch
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 6 of 14
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
6.1(a)
Physical
Education
M.G.L. c. 71 ,
§ 3
6.4
School Days Per
Year
603 CMR
27.05(2);
28.09(9)(a)
8.8
IEP – Progress
Reports
28.07(3);
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 period as instructional learning time. IEP goals and objectives for transition and lunch periods were found in every IEP reviewed when on site.
Kolburne School submitted a written description of the physical education program offered to students.
Documentation
Review
Kolburne School has revised its schedule in summer months to ensure instruction is led by a licensed educator.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Student Record
Review
The finding at the time of the
Program Review was that the format for progress reports on pre-vocational classes consisted of a checklist of
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 7 of 14
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
34 CFR
300.320(a)(3)(i, ii)
9.6
10+ Day
Suspensions
34 CFR 300.530
– 537
18.05(7)
11.9
Organizational
Structure
28.09(7)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
Documentation
Review
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
activities that did not specifically address the student’s progress on IEP goals.
The same format for
Individualized Educational
Program (IEP) progress reports is now used for prevocational and academic classes. Progress reports now address student’s progress on
IEP goals as required.
Kolburne School has a policy on 10+ day suspensions that now includes all state and federal regulations as required, including procedures to conduct a manifestation determination.
Kolburne School submitted a copy of its current organizational chart that now includes lines of supervision.
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 8 of 14
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
12.1
New Staff
Orientation and
Training
18.05(11)(g, i);
28.09(7)(f)
12.2
In-Service
Training Plan and Calendar
28.09(7)(f);
28.09(9)(b);
28.09(10);
18.03(3);
18.05(9)(e)(1);
18.05(10);
18.05(11)(h)
Title VI: 42
U.S.C. 2000d;
34 CFR 100.3;
EEOA: 20
U.S.C. 1703(f);
Title IX: 20
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
Documentation
Review and
Interview
Comments Regarding
Corrective Action Plan
Implementation
Kolburne School’s orientation program for new staff members now includes training in civil rights responsibilities as required.
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
Kolburne School has developed a system to maintain the status of each individual staff member’s participation in required trainings in a database.
Review of this document indicates that a number of staff members have not participated in required annual trainings in the previous 12 months as required.
Kolburne School must submit a narrative description of procedures to monitor and track staff member participation in required trainings to ensure each attends required annual trainings within a 12 month period. This narrative must include the title of each staff person who has a role in these revised procedures.
Kolburne School must submit a copy of the memo sent to all staff members informing them of their role in these revised procedures to monitor and track staff attendance at
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 9 of 14
Criterion
Number and
Topic
U.S.C. 1681; 34
CFR 106.31-
106.42; M.G.L.
c. 76, § 5; 603
CMR 26.00, esp. 26.07(2, 3)
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 required annual trainings.
Kolburne School must submit a copy of the database print-out of staff trainings for the previous 12 months that clearly shows the names of all staff, lists the required trainings as found under this criterion and indicates if each staff has participated in the required training in the past 12 months.
If this document indicates staff members have not participated in a training or is overdue for a training, Kolburne School must submit a statement indicating the date each staff member is scheduled to attend the training.
These documents must be received at the Department by
February 12, 2010 .
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 10 of 14
Criterion
Number and
Topic
13.4
Physical
Facility/
Architectural
Barriers
18.04(8);
Section 504:
29 U.S.C. 794;
34 CFR
104.21,104.22;
Title II: 42
U.S.C. 12132;
28 CFR 35.149,
35.150; Mass.
Const. amend. art.
13.7
Library
18.04(6)(b)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
Documentation
Review
Comments Regarding
Corrective Action Plan
Implementation
Kolburne School submitted a written plan to assign a student’s residence to the accessible dormitory on campus if handicap accessibility is necessary.
Since the dormitory currently houses both male and female students, this is an appropriate plan available to all students at Kolburne
School.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Kolburne School submitted a schedule indicating times individual classes are regularly scheduled to access the library and receipts for purchase of updated materials appropriate to service the needs of students enrolled.
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 11 of 14
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
15.8
Registering
Complaints and
Grievances
18.05(1)(b)(16);
Title IX: 20
U.S.C. 1681; 34
CFR 106.8;
Section 504: 29
U.S.C. 794; 34
CFR 104.7;
Title II: 42
U.S.C. 12132;
28 CFR 35.107
16.4
Emergency
First Aid and
Medical
Treatment
18.05(9)(e, f)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation and Student
Record Review
Documentation
Review
Comments Regarding
Corrective Action Plan
Implementation
Kolburne submitted a written policy and procedures for parents or students to file a grievance based on discrimination. Copies of these forms completed by parents and students were found in student records.
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Kolburne School submitted a written policy and procedures for Emergency First Aid and
Medical Treatment that now contains all required elements of this criterion, including procedures to be followed in the event a parent or guardian cannot be reached.
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 12 of 14
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
16.5
Administration of Medication
18.05(9)(f)(8)
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Documentation
Review
16.6
Administration of Antipsychotic
Medication
18.05(9)(f)(9)
16.7
Preventive
Health Care
18.05(9)(g)
M.G.L. c. 71, §
Comments Regarding
Corrective Action Plan
Implementation
Documentation
Review
The policy on administration of medication now contains all required elements, including procedures to obtain written authorization from a parent/guardian before medication can be administered and that this authorization will be renewed annually.
Kolburne School submitted a written policy and procedures for the administration of antipsychotic medication that now contains all required elements of this criterion.
Documentation
Review
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified
Kolburne School submitted a written policy and procedures for providing students with preventive health care that contains all required elements, including
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 13 of 14
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
57
M.G.L. c. 111, §
111
Implementation Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation conducting annual medical and dental examinations as well as vision, hearing and postural screenings.
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
Kolburne School Mid-cycle Review Report
January 5, 2010
Page 14 of 14