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
December 30, 2009
Catherine Loeffler
Catholic Charities of the Diocese of Worcester
10 Hammond Street
Worcester, MA 01610
Re:
Mid-cycle Review and Verification of Previous Program Review Corrective Action Plan
Dear Ms. Loeffler:
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 June 11, 2007. This report also includes a report on the status
of implementation for new state or federal special education requirements enacted since your
program’s last Program Review.
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 March 31, 2010. The reasons for the “Provisional
Approval” are clearly indicated on the attached Mid-cycle Review Report.
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 these requirements 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 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 program within the timelines specified. Your
statement of assurance must be submitted to the Department's Onsite Chairperson by January 15,
2010.
Page 1 of 2
Please be advised that the attached Department of Elementary and Secondary Education
Approval Certificate must be conspicuously posted in a public place within the program as
required by 603 CMR 28.09.
Your staff's cooperation throughout these follow-up monitoring activities is appreciated. Should
you require additional clarification of information included in our report, please do not hesitate to
contact the Onsite Team Chairperson at 781-338-3719.
Sincerely,
Diane Chadwell, 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
Patricia Stepanski Plouffe, Chairperson, Board of Directors
Doreen Donovan-Barbera, Local Program Review Coordinator
Encl.: Mid-cycle Review Report
Provisional Private School Approval Certificate, Expiration Date: March 31, 2010
Page 2 of 2
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
PRIVATE SCHOOL MID-CYCLE REVIEW
Catholic Charities of the Diocese of Worcester County
Mercy Centre
MID-CYCLE REVIEW REPORT
Previous Program Review Corrective Action Plan Submitted on July 20, 2007
Mid-cycle Onsite Visit Conducted on December 1, 2009
Date of this Report December 30, 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

Selected Approved Private School Program Mid-cycle Review Criteria
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 1 of 17
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
2.2 Approvals,
Licenses,
Certificates of
Inspection
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification

Documentation
Review
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

18.04(1);
28.09(2)(b)(5);
28.09(5) (b);
28.09(6) (b, c)
2.3 EEC
Licensure
Comments Regarding
Corrective Action Plan
Implementation
NA
Mercy Centre submitted
current copies of all
appropriate approvals,
licenses, and certificates of
inspection for the school
building.
Mercy Centre is a day school.
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

Documentation
Review
Mercy Centre submitted a
written plan that addresses
how the program will
effectively serve limited
English proficient (LEP)
students. The written plan
includes all required elements.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 2 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification

Documentation
Review
Mercy Centre submitted a
current IEP and student roster
for all publicly funded
Massachusetts students
enrolled in the program that
contains all the required
elements for this criterion.

Documentation
Review
The person designated by
Mercy Centre to serve as the
Educational Administrator is
appropriately qualified and
licensed.
8.5 Current
IEP & Student
Roster
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
A review of
documentation indicates
that one of the four
teachers at Mercy Centre
is not currently licensed as
a special education teacher
nor has an approved
waiver to be serving in the
position of special
Mercy Centre must submit to
the Department by February 5,
2010 evidence that all teachers
are appropriately licensed or
waivered.

28.09(5)(a)
11.3
Educational
Administrator
Qualifications
Comments Regarding
Corrective Action Plan
Implementation
28.09(5)(a);
28.09(7)(a);
603 CMR
44.00

11.4 Teachers
(Special
Education
Teachers and
Regular
Education
Teachers)
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 3 of 17
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
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting

education teacher.
Additionally, the program
has one teacher who is
licensed as a physical
education teacher but does
not have a license as a
special education teacher.
This teacher has been
reported under UFR 115
as a special education
teacher.
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
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance

Documentation
Review
Mercy Centre submitted a
Master Staff Roster including
all required elements.
28.09(7)
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 4 of 17
A review of
documentation indicates
that the speech language
pathologist assistant at
Mercy Centre is not
licensed.
.
Mercy Centre must submit to
the Department by February 5,
2010 evidence that the speech
language pathologist assistant
is appropriately licensed.
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

Identified Areas of Non-Compliance During the 2007 Program Review or Other Areas of Concern
3.1
Policies &
Procedures
Manual Table
of Contents
28.09(11)(b)
(Includes
elements from
former
Criterion 3.1(a)
and 5.1)
3.1(a)
Contents
Section 504: 29
U.S.C. 794; 34
CFR 104.11104.14; Title
II: 42 U.S.C.
12132; 28 CFR
35.140; Mass.
Const. amend.
art 114
*As of the 2009-2010
academic year, the
Department is no longer
monitoring this criterion.
*As of the 2007-2008
academic year, the
requirements regarding the
contents of the policy and
procedures manual are
incorporated into Criterion
3.1. Additionally, as of the
2009-2010 academic year, the
Department is no longer
monitoring Criterion 3.1.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 5 of 17
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

3.2
Health Care
Manual
18.05(9)
*As of the 2009-2010
academic year, the
Department is no longer
monitoring this criterion.
4.5
Immediate
Notification
18.03(10);
18.05(7);
28.09(12) (a,
b)

Documentation
Review
Mercy Centre submitted a
copy of the written procedures
describing how it notifies all
appropriate parties of serious
incidents within the program
that now includes written
notification to the Department
of Elementary and Secondary
Education in the event of a
motor vehicle accident.
5.1
Student
Admissions
28.09(11);
18.05(1)(b)(117); 18.05(2);
18.05(3)(c)

Documentation
Review
Mercy Centre submitted a
copy of the written admissions
policy that now includes the
policy and procedures
describing how copies of its
policies and procedures are
provided to the student (if
applicable), parents, and the
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 6 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

placing school district prior to
admission of the student.
6.1(a)
Physical
Education
Requirements
M.G.L. c. 71, §3
7.2
Staff Training
28.09 (9)(b)
8.7
IEP
Implementatio
n
28.09

Documentation
Review and
Interview
Mercy Centre submitted
evidence that indicates all
students are now receiving
adaptive physical education as
required on their IEPs.
*As of the 2007-2008
academic year, Criterion 7.2
is reserved and the content of
the criterion has been edited
and moved to Criterion 12.2,
Staff Training.
*As of the 2007-2008
academic year, Criterion 8.7
is reserved and the content of
the criterion has been deleted.
Information regarding
physical education services is
incorporated into Criterion
6.1a.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 7 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
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
Mercy Centre submitted a
copy of its means of
documenting the use of
the time-out space. This
documentation does not
include all of the elements
required. Information
relative to who approved
the procedure was not
included in the
documentation.
Mercy Centre must submit to
the Department by February 5,
2010 a copy of its new
documentation forms, which
include all required elements.

9.1
Polices and
Procedure for
Behavior
Management
18.03(7)(b)(2);
18.05(5, 6, 7);
28.09(11); 603
CMR 46.00;
ESE Advisory
on Restraint in
Special
Education
Programs
dated 12/20/05
9.1(a)
Student
Separation
Resulting from
Behavior
Management
18.05(5)(i);
18.05(6, 7);
46.02(5)(b)
Comments Regarding
Corrective Action Plan
Implementation
*As of the 2007-2008
academic year, the
requirements regarding staff
training related to discipline
and behavior management
policy and procedures are
incorporated into Criterion
12.2, In-service Training Plan
and Calendar.

Observation
and
Documentation
Review
Observation of the time-out
room at Mercy Centre
indicates that the space used
for time-out no longer has
safety hazards.

Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 8 of 17
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

9.3
Runaway
Students
18.03(10)
*As of the 2007-2008
academic year, the
requirements regarding staff
training related to the
runaway policy and
procedures are incorporated
into Criterion 12.2, In-service
Training Plan and Calendar.
Additionally as of the 20092010 academic yea the
Department is no longer
monitoring Criterion 9.3.
10.2
Age Range
28.06(6)(f, g)

Documentation
Review
Mercy Centre submitted block
schedules for each classroom
and every period indicating
that now the ages of the
youngest and oldest child in
any instructional grouping
does not differ by more that
forty-eight months.
11.1
Personnel
Policies and
Procedures

Documentation
Review and
Personnel
Record Review
Mercy Centre submitted its
Personnel Policy and
Procedures Manual that now
includes all required elements
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 9 of 17
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
Manual
18.05(11);
18.05(11)(c)(1);
28.09(7);
28.09(11)(a);
M.G.L. c. 71, §
38R; ESE
Advisory on
CORI revised
5/7/07
(Includes
former
Criterion 12.2i)
11.13
Plan for Staff
Coverage
18.03(1)(b)4
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

of this criterion. The school’s
CORI policy has been updated
to include all required
elements. A plan for using
volunteer and interns has been
added, and all staff have
current annual evaluations.
*As of the 2007-2008
academic year, the
requirements of Criterion
11.13 are incorporated into
11.11. Additionally, as of the
2009-2010 academic year, the
Department is no longer
monitoring Criterion 11.11.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 10 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
12.1
New Staff
Orientation
and Training
18.05(11)(g, i);
28.09(7)(f)
Documentation
Review and
Personnel
Record Review
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;
Documentation
Review and
Personnel
Record Review
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified



Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 11 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Review of in-service
training records for new
staff indicates that the
school does not provide
Civil Rights training for
staff. The program’s
current practice is to have
staff read the program’s
policies related to Civil
Rights and to sign a
declaration that they have
read the assigned
materials.
Mercy Centre must submit
evidence to the Department by
February 5, 2010 that it has
provided a Civil Rights training
for all new staff relative to
discrimination and harassment.
Mercy Centre submitted
its training calendar,
attendance sign-in sheets,
and a list of trainings
attended by each staff
person indicating that all
required trainings except
Civil Rights training have
been provided. A copy of
the school’s policy and
tracking of trainings for
volunteers and interns was
provided. The training
Mercy Centre must submit
evidence to the Department by
February 5, 2010 that it has
provided a Civil Rights training
for all staff relative to
discrimination and harassment.
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

calendar indicates that
currently the school does
not provide Civil Rights
training for staff. Instead,
staff are directed to read
the program’s policies
related to Civil Rights and
to sign a declaration that
they have read the
assigned materials.
34 CFR 100.3;
EEOA: 20
U.S.C. 1703(f);
Title IX: 20
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)
(Includes
Criterion 12.2a, 12.2-b, 12.2d, and 12.2-e)
12.2 (a)
Details
Behavior
Management
and Restraint
Training
28.09(11),
18.05(5)
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
*As of the 2007-2008
academic year, the
Department is no longer
monitoring the requirements
of Criterion 12.2a. The
training requirement of this
criterion is incorporated into
Criterion 12.2.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 12 of 17
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
12.2 (b)
Child Abuse
Reporting
18.05(9)(j)
12.2(g)
Interns and
Volunteers
Training
18.05(11)(i)
12.2 (i)
Staff
Evaluations
18.05(11)(c)1
13.8
Indoor Space
18.04(7)(a)
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

*As of the 2007-2008
academic year, the details
about training regarding
Child Abuse Reporting has
been incorporated into
Criterion 12.2. See 3.1(c) for
policy requirements in this
regard.
*As of the 2007-2008
academic year, the training
requirements of interns and
volunteers are incorporated
into 12.1 and 12.2.
*As of the 2007-2008
academic year, the elements of
Criterion 12.2(i) are
incorporated into Criterion
11.1.
*As of the 2007-2008
academic year, the elements of
Criterion 13.8 are
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 13 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

incorporated into Criterion
13.2. Requirements regarding
time out rooms has been
incorporated into Criterion
9.1(a).
14.3
Toileting
Procedures
and Individual
Plans
18.03(8)
*As of the 2007-2008
academic year, the
Department is no longer
monitoring this criterion.
15.2
Orientation
Procedures
28.09(11)
15.8
Registering
Complaints
and
Grievances –
Parents,
Students and
Employees
18.05(1)(b)(16)
Title IX: 20
*As of the 2007-2008
academic year, Criterion
number 15.2 has been deleted.

Documentation
Review
Mercy Centre submitted
written procedures for
registering complaints and
grievances for parents,
students, and employees that
now includes all required
elements of this criterion.
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 14 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

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
16.1
Health care
Policy and
Procedure
Manual
18.05(9)(d)
18.05(9)(c)
16.4
Emergency
First Aid and
Medical
Treatment
18.05(9)(e, f)
16.5
Administration
of Medication
Comments Regarding
Corrective Action Plan
Implementation
*As of the 2007-2008
academic year, the elements of
Criterion 16.1 are
incorporated into Criterion
3.2. Additionally, as of the
2009-2010 academic year, the
Department is no longer
monitoring Criterion 3.2.

Documentation
Review

Documentation
Review
Mercy Centre submitted its
policy and procedures for
emergency first aid and
medical treatment that now
includes all required elements
of this criterion.
Mercy Centre submitted its
policy and procedures for the
administration of medication
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 15 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation

that now includes all required
elements of this criterion.
18.05(9)(f)(8)
16.6
Administration
of
Antipsychotic
Medication
18.05(9)(f)(9)

Documentation
Review
Mercy Centre submitted its
policy and procedures for the
administration of antipsychotic
medication that now includes
all required elements of this
criterion.
16.7
Preventive
Health Care
18.05(9)(g)
M.G.L. c. 71, §
57
M.G.L. c. 111,
§ 111.

Documentation
Review
Mercy Centre submitted its
plan for the preventive health
care of students that now
includes appropriate
procedures for communicable
disease notification and
prevention.
17.1
Transportation
Safety
28.09(11)(b)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
*As of the 2007-2008
academic year, the
requirements regarding the
training of staff persons have
been incorporated into
Criterion 12.2. The
requirements regarding the
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 16 of 17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

notification of accidents to the
Department are incorporated
into Criterion 4.5
Mercy Centre Mid-cycle Review Report
December 30, 2009
Page 17 of 17
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