November 4, 2008
Dr. Roya Ostovar
75 Pleasant Street, Malden, Massachusetts 02148-4906 Telephone: (781) 338-3700
TTY: N.E.T. Relay 1-800-439-2370
McLean Hospital
CNS/Pathways
115 Mill Street
Belmont, MA 02478
Re: Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan Verification and
Mid-cycle Review
Dear Dr. Ostovar:
Enclosed is the Department's Program Review Follow-up Monitoring Report together with findings regarding your private school’s Mid-cycle 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 June 12, 2006. 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 Elementary and Secondary 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 30, 2009
. The reasons for the “Provisional Approval” are clearly indicated on the attached
Corrective Action Plan Implementation Checklist.
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 November 17, 2008 .
Page 1 of 2

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 781-338-3723.
Sincerely,
Mary Howard, Program Review Follow-up Chairperson
Program Quality Assurance Services
Darlene Lynch, Director
Program Quality Assurance Services c: Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education
Scott Rauch, MD, Chairperson, Board of Directors
Cynthia Kaplan, Vice President, McLean Hospital
Encl.: Follow-up Monitoring Report
Provisional Private School Approval Certificate, Expiration Date: April 30, 2009
Page 2 of 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

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
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November 4, 2008
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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
M.G.L. c.
71A; Title VI
Implementation
Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented


Not applicable

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation review
The Center for
Neurointegrative Services
(CNS) has current approvals, licenses, and certificates of inspection as required.
Documentation review
CNS has a policy for
Program Modifications and
Support Services for Limited
English Proficient Students that contains all required elements.
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
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November 4, 2008
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Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting

Criterion
Number and
Topic
8.5 Current
IEP &
Student
Roster
28.09(5)(a)
Implementation
Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented

Method(s) of
Verification
Documentation review; and
Student record review
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
Six of the twenty-four students currently at CNS do not have a current and/or signed IEPS.
Progress Reporting
Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
CNS must submit an updated student roster that shows that all students have a current, signed IEP by December 19,
2008.
The student roster must include:
 Each student’s initials;

The school district responsible for preparing the student’s IEP;

The agency(ies) supporting any part of the student’s tuition;

The portion of tuition supported by such agency(ies);

The implementation date of the current IEP;

The date of expiration for the student’s current IEP;

The date of parental signature;

The name of the school district contact person for each student; and
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November 4, 2008
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Criterion
Number and
Topic
11.3
Educational
Administrator
Qualifications
28.09(5)(a);
28.09(7)(a);
603 CMR
44.00
11.4 Teachers
(Special
Education
Teachers and
Regular
Education
Teachers)
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

For each unsigned IEP, evidence/documentation of efforts and/or steps taken for the public school district to obtain a signed IEP.
Documentation review
CNS has a designated
Educational Administrator who has appropriate qualifications.

Documentation review
As of the date of this report,
3 teachers had applied for waivers and are awaiting response from ESE.

At the time of document submission, not all teachers were appropriately licensed or on approved ESE waivers as special educators as required.
CNS must submit updated licensure documentation for 3 teachers who have applied for waivers (DE, KS, PL) by
December 19, 2008.
The teaching roster must include following information: o The name, title and role of each teacher in the program;
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Criterion
Number and
Topic
18.05(11)(f);
28.09(5)(a);
28.09(7)(b, c);
34 CFR
300.321
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 o Grade level being taught; o Subject(s) being taught; o Massachusetts teaching license title, type, grade level, number and expiration date; o Copy of ESE license or most current ELAR activity sheet; o In instances where teachers do not hold Massachusetts licensure for the area in which they are employed, a copy of a current certification waiver is provided or ELAR activity sheet; o In instances when general education teaching staff are providing special education services, the name and license of the special educator providing supervision; and
Most recent date of
Professional Development
Plan for teachers with
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Criterion
Number and
Topic
11.5 Related
Services Staff
28.09(7)(d)
11.6 Master
Staff Roster
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
Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting
Documentation review

CNS did not submit licensing documentation for 2 Social Workers listed as UFR#125
(LSCW).
Documentation review
Interviews at the time of the
Program Review revealed that the Registered Nurse only dispensed medications at noon, was on call, and the
Master Staff Roster listed her as 1.0 FTE.

It is not clear when a
Registered Nurse is onsite at CNS and the extent of the responsibilities of the person serving in this role.
Several other positions listed on the submitted
Master Staff Roster do not correspond with the submitted ESE approved
2002 budget which is based on sixteen students.
CNS is approved for:
1 FTE under UFR #111
(OT) and
1 FTE under UFR #113
(Sp/L). Based on the
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Page 6 of 12 professional level licensure
CNS must submit documentation that the Social
Workers listed under UFR#
125 are appropriately Licensed
Certified Social Workers by
December 19, 2008.
CNS must submit the current schedule of the Registered
Nurse and a written narrative or job description specific to the responsibilities of the person serving in this role by
December 19, 2008. Also include an explanation of how the current 0.50 vacancy is being covered.
CNS must submit a detailed narrative explaining all discrepancies between the
Master Staff Roster and the most recently approved ESE budget by December 19, 2008 .

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 increase in the number of students CNS should now have 1.5 FTE for each of these positions.
The following additional positions were added to the Master Staff Roster but not requested to ESE or approved by ESE:
2 FTEs under UFR #125
6 FTEs under UFR #135

Documentation Given the needs of students
1.2 review and space constraints, ESE
Program & set the operational capacity at
Student
Description,
Program
Capacity thirty-two students. The current enrollment at CNS is twenty-four.
5.2
Granting of

Documentation review
CNS now has a policy regarding transition planning
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November 4, 2008
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Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting

Criterion
Number and
Topic
HS diplomas
(now 7.4)
Transition planning
(now 8.11)
6.1
Daily
Instructional
Hours
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
Documentation review;
Observations; and
Interviews which is comprehensive and specifies when transition planning begins.
CNS now has a policy for the granting of High School diplomas that that is clear and comprehensive.
At the time of the Program
Review, observations revealed that some school district vehicles dropped students off late and some left early, which reduced instructional time for some students. During this onsite
Mid-cycle Review, students were observed to be dropped off at appropriate times for instructional time to begin.

Documentation, observations and interviews revealed that students often use
“Sensory Integration
Rooms” (SI) for sleeping.
Several of the classrooms observed did not have students engaged in direct instruction, despite the presence of sufficient staff and appropriate curriculum.
CNS must submit a detailed plan that includes supervision of teachers during instructional time, communication with teachers regarding instructional time, appropriate implementation of IEPS, detailed notes of observations and feedback given by
December 19, 2008.
Based on the clinical needs of some students, resting or taking breaks in SI rooms may be appropriate; however, students must be supervised at all times.
CNS must submit written documentation of staff monitoring SI rooms including,
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Criterion
Number and
Topic
7.1
Curriculum frameworks
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
Documentation review; and
Observations
CNS now has a comprehensive policy and training plan to assure that teaching staff are able to develop lesson plans that provide students with essential learning opportunities to prepare students to reach the state graduation standards.

Observations revealed that while some classes were being conducted in accordance with the curriculum frameworks, several classes with more than one student were reviewing information for the sake of a particular student and the student(s) who already mastered the material were not provided instruction nor expected to participate in
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Page 9 of 12 supervision of students, specific time and activities while any student was in this room, attempts made to engage students to attend class, and clinical rationale for students’ use of the SI rooms for the given days as listed below.
CNS must submit logs and documentation of supervision of SI rooms for November 10 th ,
14 th and 19 th by November 26,
2008.
CNS must develop and submit a plan which demonstrates how it will assure that IEP goals are being addressed for each student, during each period throughout the school day.
Please submit lesson plans for all academic classes conducted on November 21st, with a detailed narrative which explains how individual IEP goals are being addressed and assures that there is oversight

Criterion
Number and
Topic
8.8 IEP-
Progress
Reports
11.9
Organizationa l Structure
12.1
New Staff
Orientation and Training
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 class.
Student record review
Documentation review
Review of student records indicated that progress reports now address the extent to which the students’ progress is sufficient to achieve the goals by the end of the year.
At the time of the Program
Review, the Clinical Director and the Psychiatrist at CNS were listed as more than 1.0
FTE and were the same person. This issue has been resolved.

The narrative description of the organizational chart and job descriptions for
Program Director, Special
Education Administrator and ESE Liaison for
McLean-Based Schools do not correspond with lines of supervision indicated on the organizational chart.
Documentation review; and
Interviews
CNS now properly documents all of the trainings that staff receive in orientation and have developed a plan for assuring
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Page 10 of 12 on student participation in instructional time. Submit by
November 26, 2008.
CNS must submit an updated organizational chart and narrative that clearly explains the lines of supervision and organizational responsibility.
The chart must include each
UFR, FTE, program position title and specific name of person serving in each role at this time by December 19,
2008.

Criterion
Number and
Topic
12.2 In-
Service
Training Plan and Calendar
12.2cRequire
d Training-
CPR
Certification
15.5
Parent
Consent and
Required
Notification
15.8
Registering
Complaints and
Grievances-
Parents,
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
Documentation review
Documentation review
Student record review that staff hired after orientation receive training in required areas.
CNS now has a training plan and calendar which includes staff attendance sheets.
CNS now has documentation of all staff who have received
CPR training and certification.

Not all student records contained the required annual consents including permission for emergency medical treatment, physical restraint and medication administration.
Documentation review
CNS now has a specific policy for registering complaints and grievances which describes how the school provides for prompt and equitable treatment of

Observation and interviews at this Midcycle Review revealed that
CNS Policies and
Procedure Manual were not readily available for
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Page 11 of 12
CNS must review all student records for required annual consents and document the person responsible for this review, the results of the review, rate of compliance and any further follow-up steps taken, by December 19, 2008.
CNS must submit written documentation, including the name of person responsible for oversight of the policies and procedures manual, where the manuals are currently located

Students and
Employees
18.1
Confidential- ity of student records
18.2
Implementation
Status of
Requirements or
Corrective
Action Plan
Determined to be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation complaints by parents, students and staff.
See 18.2
Student record review
At the time of Program
Review, not all consents were signed annually. In addition, use of behavior management interventions including restraint and time-out procedure and copies of all incident reports were not maintained in student records as required.
Criterion
Number and
Topic
Corrective
Action Plan
Determined to be Not
Fully
Implemented or
Additional
Issues
Identified


Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Not all student records reviewed contained all required annual consents, copies of correspondence or documents related to behavioral interventions.
Further Corrective Action
Ordered by the
Department of Elementary and Secondary Education and Timelines for
Implementation and Further
Progress Reporting staff, parents and visitors. and that they are available for review upon request by
December 19. 2008.
CNS must review all student records to assure that current information is included and document the person responsible for this review, the results of the review, rate of compliance and any further follow up steps to be taken, by
December 19, 2008.
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