2 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 October 11, 2012 Maureen Vibert, Executive Director Nashoba Learning Group Day Program 10 Oak Park ‘Drive Bedford, MA 01730 Re: Mid-cycle Review and Verification of previous Program Review Corrective Action Plan Dear Ms. Vibert: Enclosed is the Department of Elementary and Secondary Education’s (“Department”) Midcycle Report based upon the Mid-cycle review conducted in your private school program in September 2012. 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 April 23, 2010. 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 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 December 5, 2012. 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 October 19, 2012. Page 1 of 2 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 next routine monitoring visit to occur sometime during the 2015-2016 school year, unless the Department determines that there is some reason to schedule this visit earlier. Please be advised that the attached Department 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 781-338-3713. Sincerely, Helen M. Murgida, 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 Elizabeth Martineau, Chairperson, Board of Directors Maureen Vibert, Local Program Review Coordinator Encl.: Mid-cycle Review Report Provisional Private School Approval Certificate, Expiration Date: December 5, 2012 Page 2 of 2 MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION PRIVATE SCHOOL MID-CYCLE REVIEW NASHOBA LEARNING GROUP DAY PROGRAM MID-CYCLE REVIEW REPORT Previous Program Review Corrective Action Plan Submitted on May 24, 2010 Progress Reports Submitted on September 27, 2010 and November 18, 2010 Mid-cycle Onsite Visit Conducted on September 14, 2012 Date of this Report: October 11, 2012 Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 1 of 14 Criterion Number and Topic Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Selected Approved Private School Program Mid-cycle Review Criteria 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 Programs only) Not Applicable Documentation Observation Nashoba Learning Group submitted all current approvals, licenses, and certificates of inspection by state and local agencies as required. Nashoba Learning Group is a Day Program. Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 2 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 6.1 Daily Instructional Hours 603 CMR 27.04 & 6.4 School Days Per Year Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation Nashoba Learning Group submitted the Learning Time Worksheet indicating that they provide the required instructional hours for a 12 month 216 day program by offering 1296 hours of instruction per year. Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Interviews 603 CMR 27.05(2); 28.09(9)(a) 8.5 Current IEP & Student Roster Documentation Student Record Reviews 28.09(5)(a) Interviews Nashoba Learning Group has on file a current IEP for each Massachusetts enrolled student that has been issued by the responsible public school district and consented to and dated by the student’s Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 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 Nashoba Learning Center has nine designees to the Educational Administrator who attend IEP Team meetings who have not submitted proof of the master’s degree in Special Education and a minimum of one year of administrative experience. Five of these teachers have current licenses as special educators. Nashoba Learning Group has applied for By November 20, 2012 Nashoba Learning Group must submit the names and proof of a master’s degree in Special Education or a related field for the nine teachers who attend IEP Team Meetings and serve as designees to the Educational Administrator and provide the name and a copy of the Special Education license or waiver for five of the teachers. parent(s) as required. 11.3 Educational Administrator Qualifications 28.09(5)(a); 28.09(7)(a); 603 CMR 44.00 Documentation Staff Record Reviews Interviews The assigned Educational Administrator meets the required qualifications to serve in this capacity and the names and qualifications of designees to the Educational Administrator who attend IEP Team Meetings were not submitted. Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 4 of 14 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 waivers for four teachers which have not yet been approved. Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 5 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 Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 11.4 Teachers (Special Education Teachers and Regular Education Teachers) Documentation Staff Record Reviews Nashoba Learning Group has applied for waivers for five teachers which have not yet been approved. Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Interviews 18.05(11)(f); 28.09(5)(a); 28.09(7)(b, c); 34 CFR 300.321 Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 Nashoba Learning Group has applied for waivers for five teachers which have not yet been approved. By November 20, 2012 Nashoba Learning Group must submit the following for the five teachers: Current teaching staff roster that includes all UFR 115’s special education teachers and UFR 116’s regular education teachers in the program that contains the following information: o UFR#; o Name; o Position title within the program; o Grade level(s) taught; o Subject(s) taught; 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 o o o Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 7 of 14 Massachusetts teaching license title, type, grade level, number and expiration date; Copy of license or most current ELAR activity sheet; and 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. Criterion Number and Topic 11.5 Related Services Staff Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Documentation All related service providers are currently certified, licensed or registered in their professional area as required. Interviews 28.09(7)(d) 11.6 Master Staff Roster Documentation Interviews 28.09(7) 19 Anti-Hazing M.G.L. c. 269, §§ 17 through 19 Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation Student Record Reviews Interviews Nashoba Learning Group submitted a Master Staff Roster for every position within the program that corresponds to the last approved Program Budget as required. Nashoba Learning Group provided evidence of distribution of the Anti-hazing policy as approved by the program’s Board of Directors to all secondary aged students, as well as documentation of Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 20 Bullying Prevention and Intervention M.G.L. c. 71, s. 37H, as amended by Chapter 92 of the Acts of 2010. M.G.L. c. 71, s. 37O (e)(1) & (2). M.G.L. c. 71, s. 370(d). Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation Interviews students’ receipt of the policy as required. Nashoba Learning Group has amended its handbook admission material to include an age-appropriate summary of their Bullying Prevention and Intervention Plan and included a description of how it is distributed. The program also submitted a description of the professional development plan for all staff for the 20122013 school year and provided evidence of its implementation including dates, format used, and sign-in sheets indicating staff attendance. Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 9 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 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 Identified Areas of Non-Compliance from the 2009-2010 Program Review or Other Areas of Concern 8.8 IEP – Progress Reports 28.07(3); 34 CFR 300.320(a) (3)(I, ii) Documentation Student Records Interviews At the time of the Program Review, while Nashoba Learning Group staff wrote progress reports for students that were thorough and specific, and interviews revealed that information about student progress was shared with parents at regularly occurring monthly meetings, a review of student records revealed that some progress reports were not dated, and there was no evidence that progress reports were sent to parents/guardians, Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 10 of 14 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 sending school districts and applicable human service agencies as required. During the Mid-cycle Review, review of student records indicated that all progress reports were dated and sent to parents/guardians, and sending school districts and applicable human service agencies as required. 12.2(c) Required TrainingCPR Certification Documentation Interviews At the time of the Program Review, while Nashoba Learning Group had developed a training plan for CPR certification, documentation and interviews indicated that not all appropriate staff had Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation received the required annual CPR training. 18.05(9)(e) 16.7 Preventive Health Care 18.05(9)(g) M.G.L. c. 71, § 57 M.G.L. c. 111, § 111. Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation Student Records Interviews During the Mid-cycle Review, review of documentation of the training plan and name and certification of the certified instructor providing CPR training, and staff interviews revealed that all staff have current CPR certification. At the time of the Program Review, student record review and interviews revealed that Nashoba Learning Group had not ensured that each student received an annual dental and physical examination. Additionally, the school had not developed a plan to ensure Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 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 that vision, hearing, and postural screenings (grades 59) had been completed as required. A review of Student Records revealed that all students now receive a yearly dental examination onsite and there are copies of physical examinations as required. The program has developed and implements vision, hearing, postural screenings (grades 59) as required. 18.1 Confidentiality of Student Documentation Student Records At the time of the Program Review, student records revealed that the log of access Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 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 Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Records Interviews 28.09(5)(a); 28.09(10); 23.07(1); M.G.L. c. 71, § 34H Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified kept by Nashoba Learning Group did not contain the name, position and signature of the person releasing the information as required. The log of access now contains all required elements. Nashoba Learning Group, Day Program Mid-cycle Review Report October 11, 2012 Page 14 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 Commonwealth of Massachusetts Department of Elementary and Secondary Education NASHOBA LEARNING GROUP DAY PROGRAM A PRIVATE SPECIAL EDUCATION PROGRAM OPERATED PURSUANT TO 603 CMR 18.00 AND 28.09 10 Oak Park Drive Bedford, MA 01730 Program Rate Based on: 70 Students Approved Enrollment: 90 Students Day Program Summer Program Residential Program 10 month program 11 month program 12 month program APPROVED STUDENT:LICENSED EDUCATOR RATIO: Not Applicable APPROVED STUDENT:LICENSED EDUCATOR:AIDE RATIO: 10:1:10 APPROVAL STATUS PROVISIONAL APPROVAL Expires on: December 5, 2012 The current approval is a result of a Mid-cycle Review conducted in the 2012-2013 school year and the next review is scheduled for the 2015-2016 school year. HELEN M. MURGIDA, EDUCATIONAL SPECIALIST, PROGRAM QUALITY ASSURANCE SERVICES NINA M. MARCHESE, SUPERVISOR, PROGRAM QUALITY ASSURANCE SERVICES DARLENE A. LYNCH, DIRECTOR, PROGRAM QUALITY ASSURANCE SERVICES DATE ISSUED: 10/11/12