Massachusetts Department of Elementary and Secondary Education

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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 1, 2013
Edward Kelley
Executive Director
Robert F. Kennedy Children’s Action Corps, Inc.
11 Beacon Street, Suite 325
Boston, MA 02108
Re:
Mid-cycle Review and Verification of previous Program Review Corrective Action Plan
A - Experiment With Travel Day Program
B - Lancaster Residential Program
C - Lancaster Day Program
Dear Mr. Kelley:
Enclosed is the Department of Elementary and Secondary Education’s (“Department”) Midcycle Review Report based upon the Mid-cycle Review conducted in your private school
programs in September 2013. Because the Department determined that not all requirements were
found to be fully implemented during the 2011 Program Review, this Mid-cycle Review Report
includes the Department's findings regarding the implementation status and effectiveness of
corrective steps taken in response to your previous Program Review Report, as well as a report
on the status of selected Mid-cycle Review criteria and the implementation of new state or
federal special education requirements enacted since your programs’ 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 the Experiment With Travel Day Program
“Provisional Approval” status effective from the date of this letter and indicated on your
approval certificates. Your “Provisional Approval” will expire on March 28, 2014. The reasons
for the “Provisional Approval” are clearly indicated on the attached Mid-cycle Review Report.
At this time the Department is unable to issue any approval status for the Lancaster Residential
Program and the Lancaster Day Program based on the Department having previously issued the
programs provisional approvals, which expired in April, 2013. The Department cannot exceed
six months in issuing a provisional approval based on 603 CMR 28.09(3). The program must
demonstrate the specific steps to be taken to come into substantial compliance by November 18,
2013. Pending the outcome of review of these steps, the Department will determine whether or
not sanctions in the form of “Probationary Approval” status and/or a closing of the private school
program’s intake are necessary at that time.
You will find the 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 programs
within the timelines specified. Your statement of assurance must be submitted to the
Department's Onsite Chairperson by October 11, 2013.
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.
Sincerely,
Amy Krukonis, 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
Encl.: Mid-cycle Review Report
Provisional Approval Certificate, Expiration Date: March 28, 2014
Experiment With Travel Day Program
Page 2 of 2
MID-CYCLE REVIEW REPORT
Robert F. Kennedy Children’s Action Corps, Inc.
MCR Onsite Dates: 09/09/2013 - 09/10/2013
Programs under review for the agency:
A - Experiment With Travel Day Program
B - Lancaster Residential Program
C - Lancaster Day Program
Mitchell D. Chester, Ed.D.
Commissioner of Elementary and Secondary Education
MID-CYCLE REVIEW REPORT
PS Criterion #2.2 - Approvals, Licenses, Certificates of Inspection
Rating:
Implemented
Applies To:
All
Basis for Findings:
A review of documentation indicated that there were current approvals, licenses and
certificates for all building used by the students.
PS Criterion #2.3 - EEC Licensure (Residential Programs Only)
Rating:
Not Applicable
Applies To:
A - Experiment With Travel Day Program, C - Lancaster Day Program
Basis for Findings:
These programs are day programs, therefore this criterion is not applicable.
PS Criterion #2.3 - EEC Licensure (Residential Programs Only)
Rating:
Implemented
Applies To:
B - Lancaster Residential Program
Basis for Findings:
A review of documentation indicated there was a current license from the Department of Early
Education and Care for all residential facilities.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 2 of 19
PS Criterion #4.4 - Advance Notice of Proposed Program/Facility Change
Rating:
Not Implemented
Applies To:
All
Basis for Findings:
Interviews indicated that Experiment with Travel Day Program has current vacancies in the
clinical coordinator, consulting nurse and Science teacher position. The program did not notify
the Department of these vacancies using the required Form 1.
A review of documentation and interviews indicated that Lancaster Day Program is operating
with at least a 10% increase in enrollment and prior approval from the Department has not
been obtained prior to this change as required.
A review of documentation and interviews indicated that Lancaster Residential Program is
operating with at least a 10% decrease in enrollment and notification 15 working days prior to
such a change was not provided to the Department as required.
Department Order of Corrective Action:
The Educational Administrator at Experiment with Travel Day Program must ensure the
required written notification to the Department is made for any sudden and/or unexpected
changes that may impact the overall health or safety of students and/or the delivery of
services required by IEPs. The program must immediately address the submission of any
necessary Form 1.
The Educational Administrator at both Lancaster Day Program and Lancaster Residential
Program must ensure that the required prior approval of the Department is obtained for
proposed changes that effect the educational programs. The programs must immediately
address the submission of any necessary Form 1's.
Required Elements of Progress Reports:
Experiment with Travel Day Program must submit a Form 1 and all of the related Form 1
required documentation for the Science teacher, the consulting nurse and the clinical
coordinator positions.
Lancaster Day Program and Residential Program must submit Form 1s and all of the related
Form 1 required documentation for the 10% increase in the day program and the 10%
decrease in the residential program.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 3 of 19
PS Criterion #6.1 - Daily Instructional Hours
Rating:
Implemented
Applies To:
All
Basis for Findings:
A review of documentation indicated that all students were scheduled to receive the required
number of instructional hours at all programs.
PS Criterion #6.4 - School Days Per Year
Rating:
Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of documentation indicated that the required number of school days were offered to
all students.
PS Criterion #6.4 - School Days Per Year
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
A review of documentation indicated that the school calendar for the program did not reflect
five additional days for unforeseen circumstances and the last day for seniors.
Department Order of Corrective Action:
The program must ensure that before the beginning of each school year, the program sets a
school schedule that includes all required elements.
Required Elements of Progress Reports:
The program must submit a revised copy of the school calendar for this school year, clearly
indicating the number of scheduled days that includes five additional days for unforeseen
circumstances and the last day for seniors. The program must also provide evidence of
having shared the revised school calendar with parents/guardians, school districts and other
purchasers.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 4 of 19
PS Criterion #8.5 - Current IEP & Student Roster
Rating:
Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of documentation and student records indicated that there was a current IEP for
each enrolled Massachusetts student that had been issued by the responsible public school
district and consented to by the student's parent or student, when applicable, or
documentation indicating the program's efforts to obtain such.
PS Criterion #8.5 - Current IEP & Student Roster
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
While student record review indicated the students had current IEPs, a review of
documentation indicated that the IEP and student roster did not include all required elements
and it did not reflect the current Massachusetts student enrollment; therefore the Department
was unable to verify that the program had a current IEP for each enrolled Massachusetts
student issued by the responsible public school district and consented to by the student's
parent or student, when applicable.
Department Order of Corrective Action:
The Educational Administrator must ensure that all IEP's for Massachusetts students enrolled
are current and accurately reflected on the IEP and student roster.
Required Elements of Progress Reports:
Submit a revised, current IEP and student roster that includes all required elements and
reflects the current number of Massachusetts students enrolled.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 5 of 19
PS Criterion #8.8 - IEP - Progress Reports
Rating:
Implemented
Applies To:
A - Experiment With Travel Day Program, B - Lancaster Residential Program
Basis for Findings:
At the time of the 2011 Program Review, a review of student records at Experiment with
Travel Day Program indicated that IEP progress reports did not always correspond with the
last consented to IEP.
In the Mid-cycle Review, a review of student records at the Experiment with Travel Day
Program indicated that IEP progress reports are now written to correspond to the last
consented to IEP.
At the time of the 2011 Program Review, a review of student records at Lancaster Residential
Program indicated that IEP progress reports were not sent to parents as often as parents of
students without disabilities.
In the Mid-cycle Review, a review of student records at the Lancaster Residential Program
indicated that parents receive reports on the student's progress towards reaching the goals
set in the IEP at least as often as parents are informed of the progress of students without
disabilities.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 6 of 19
PS Criterion #9.4 - Physical Restraint (Day programs only)
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
At the time of the 2011 Program Review, the program was unable to produce documentation
that verified the intensive training required for the staff member who serves as the restraint
resource for the program and interviews indicated that not all staff who participated in
restraints received annual refresher training.
In the Mid-cycle Review, a review of documentation indicated that evidence of the restraint
resource's intensive training was not submitted as requested; therefore the Department was
unable to verify the effectiveness of the corrective action plan from the Program Review.
Department Order of Corrective Action:
The Program Director must ensure that there are staff identified to serve as restraint
resources within the program and evidence of their intensive training must be provided to the
Department.
Required Elements of Progress Reports:
The program must submit the name of staff who serve as restraint resources within the
program and evidence of their intensive training.
Progress Report Due Date(s):
11/18/2013
PS Criterion #11.3 - Educational Administrator Qualifications
Rating:
Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of documentation indicated that the Educational Administrator for each program
possessed the required qualifications to serve in this position.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 7 of 19
PS Criterion #11.3 - Educational Administrator Qualifications
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
While interviews demonstrated that the person designated as the Educational Administrator
had a current special education administrator license, a review of documentation indicated
that the license was not current.
Department Order of Corrective Action:
The Educational Administrator must possess licensure as a special education administrator or
possess all of the following: license as a special educator; a minimum of a master's degree in
special education or a related field; and a minimum of one year administrative experience.
Required Elements of Progress Reports:
The program must submit a current copy of the Educational Administrator's special education
administrator license or evidence that this person meets all of the other three required
qualifications.
Progress Report Due Date(s):
11/18/2013
PS Criterion #11.4 - Teachers (Special Education Teachers and Regular
Education Teachers)
Rating:
Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
A review of documentation indicated that the teaching staff were appropriately licensed or had
been granted an appropriate waiver for the 2013-14 school year.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 8 of 19
PS Criterion #11.4 - Teachers (Special Education Teachers and Regular
Education Teachers)
Rating:
Partially Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of documentation and interviews indicated that not all staff are appropriately licensed
or on an approved waiver for the grade level(s) and subject area(s) in which they are
teaching.
Department Order of Corrective Action:
The Educational Administrator must ensure that all teaching staff are appropriately licensed or
on approved waivers for the grade level (s) and subject area (s) in which they are teaching.
Required Elements of Progress Reports:
The Lancaster Day Program and Lancaster Residential Program must submit current
teaching rosters that include all required elements and copies of current licenses and/or
approved waivers must be submitted for each teacher listed on each roster.
Progress Report Due Date(s):
11/18/2013
PS Criterion #11.5 - Related Services Staff
Rating:
Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
A review of documentation indicated that the staff providing or supervising the provision of
related services were appropriately certified, licensed or registered in their professional areas.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 9 of 19
PS Criterion #11.5 - Related Services Staff
Rating:
Partially Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of documentation and interviews indicated that both programs currently utilize a
consulting psychologist, but a current Massachusetts State Board of Registration was not
submitted; therefore the Department was unable to verify that all staff providing or supervising
the provision of related services are appropriately certified,licensed or registered in their
professional areas.
Department Order of Corrective Action:
The program must ensure that the staff providing or supervising the provision of related
services, including consultants, are appropriately certified, licensed or registered in their
professional areas.
Required Elements of Progress Reports:
The programs must submit the Massachusetts State Board of Registration for the current
consulting psychologist.
Progress Report Due Date(s):
11/18/2013
PS Criterion #11.6 - Master Staff Roster
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program, B - Lancaster Residential Program
Basis for Findings:
A review of documentation indicated the following: the list of all staff for every position within
the program did not correspond to other rosters; it did not correspond to the last Departmentapproved program budget; and evidence of justification for any discrepancy from the last
approved budget was not provided.
Department Order of Corrective Action:
The program must ensure that the master staff roster includes each staff person and the
following: corresponding UFR#s; UFR titles; full time equivalents (FTEs); position title;
vacancies and justification for any discrepancies from the last approved budget.
Required Elements of Progress Reports:
The programs must submit a revised master staff roster that includes all required elements,
all staff positions and provides justification for any discrepancy from the last approved budget.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 10 of 19
PS Criterion #11.6 - Master Staff Roster
Rating:
Not Implemented
Applies To:
C - Lancaster Day Program
Basis for Findings:
A review of documentation indicated that the program did not submit a master staff roster as
requested.
Department Order of Corrective Action:
The program must ensure that there is a master staff roster that includes each staff person
and the following: corresponding UFR#s; UFR titles; full time equivalents (FTEs); position title;
vacancies and justification for any discrepancies from the last approved budget.
Required Elements of Progress Reports:
The program must submit a revised master staff roster that includes all required elements, all
staff positions and provides justification for any discrepancy from the last approved budget.
Progress Report Due Date(s):
11/18/2013
PS Criterion #11.12 - Equal Access
Rating:
Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
A review of staff records and interviews indicated that all students were provided with equal
access to services, facilities, activities and benefits regardless of race, color, sex, gender
identity, religion, national origin, sexual orientation, disability or homelessness.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 11 of 19
PS Criterion #11.12 - Equal Access
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
While interviews indicated that all students were provided with equal access to services,
facilities, activities and benefits regardless of race, color, sex, gender identity, religion,
national origin, sexual orientation, disability or homelessness, a review of documentation
indicated that the description of the program's practices to ensure that extracurricular
activities are accessible to all students did not include gender identity.
Department Order of Corrective Action:
The program must ensure that its policy is current and includes that the program provides all
students with equal access to services, facilities, activities and benefits regardless of race,
color, sex, gender identity, religion national origin, sexual orientation, disability or
homelessness.
Required Elements of Progress Reports:
The program must submit the description of the program's practices to ensure that
extracurricular activities are accessible to all students.
Progress Report Due Date(s):
11/18/2013
PS Criterion #12.1 - New Staff Orientation and Training
Rating:
Implemented
Applies To:
A - Experiment With Travel Day Program, B - Lancaster Residential Program
Basis for Findings:
A review of staff records indicated that new staff participated in an orientation-training
program that included the program's philosophy, organization, program, practices, goals and
all mandated trainings listed under criterion 12.2a-e.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 12 of 19
PS Criterion #12.1 - New Staff Orientation and Training
Rating:
Partially Implemented
Applies To:
C - Lancaster Day Program
Basis for Findings:
A review of staff records at Lancaster Day Program indicated that not all new staff
participated in all mandated training listed under criterion 12.2 a-e during new staff orientation
training prior to their assignment of direct care duties with students.
Department Order of Corrective Action:
The program must ensure that all new staff participate in all mandated training prior to their
assignment of direct care duties with students.
Required Elements of Progress Reports:
The program must submit the name of person responsible for coordination and
implementation of orientation training and a copy of the written orientation and training
program for new staff. The program must also submit evidence of completed orientation
training for any new staff hired prior to this progress report submission. The program must
also submit a narrative describing how the program ensures that new staff receive all required
training prior to their assignment of direct care duties with students.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 13 of 19
PS Criterion #12.2 - In-Service Training Plan and Calendar
Rating:
Partially Implemented
Applies To:
B - Lancaster Residential Program
Basis for Findings:
At the time of the 2011 Program Review, a review of Lancaster Residential Program staff
records indicated that not all staff participated in annual in-service training on average at least
two hours per month and had not received training in the required in-service training topics.
In the Mid-cycle Review, the management staff records continued to indicate this same
problem and an interview of a related service staff also revealed the person had not
participated in annual in-service training at least two hours per month and had not received
training in the required in-service training topics.
Department Order of Corrective Action:
The staff person responsible for the development and implementation of the in-service
training program/calendar must ensure that all staff, including new employees, interns and
volunteers, participate in annual required in-service training topics and participate in in-service
training on average at least two hours per month.
Required Elements of Progress Reports:
The program must submit an annual in-service training plan that reflects a minimum of 24
hours and that includes all required elements. The program must also submit evidence of
how the program tracks and records individual staff attendance at training. The program must
also submit a plan of how it intends to ensure that all staff receive the required training and
when a staff is unable to attend a required and/or annual training, how the program will
ensure the staff will receive it and/or participate in the training.
Progress Report Due Date(s):
11/18/2013
PS Criterion #15.5 - Parent Consent and Required Notification
Rating:
Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
At the time of the 2011 Program Review, a review of student records indicated all consents
were obtained at the time of admission into the program, but not always obtained thereafter
as required.
In the Mid-cycle Review, a review of student records indicated that all required consents are
now obtained annually.
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 14 of 19
PS Criterion #16.7 - Preventive Health Care
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
At the time of the 2011 Program Review, a review of student records indicated physical and
dental examinations, hearing, vision and postural screenings were not documented.
In the Mid-cycle Review, a review of student records indicated there was not evidence of
dental examinations for all students.
Department Order of Corrective Action:
The nurse must ensure that evidence of dental examinations are obtained and maintained in
the student records.
Required Elements of Progress Reports:
The program must submit evidence indicating current dental examinations for all currently
enrolled Massachusetts students and the dates of efforts to obtain such examinations.
Progress Report Due Date(s):
11/18/2013
PS Criterion #19 - Anti-Hazing
Rating:
Partially Implemented
Applies To:
All
Basis for Findings:
While a review of student records indicated student receipt of a copy of the school program's
anti-hazing disciplinary policy approved by the Board of Director's, a review of documentation
indicated a copy of student handbooks or disciplinary code that is distributed to students was
not submitted for all programs.
Department Order of Corrective Action:
The Educational Administrator for all programs must ensure that the anti-hazing policy has
been included in the student handbook or in other means of communicating school program
policies to students.
Required Elements of Progress Reports:
All programs must submit copies of student handbooks or the disciplinary code that is
distributed to students.
In addition, if the student handbooks or disciplinary codes do not currently contain the antihazing policy, also submit a plan to revise the policy and a plan to disseminate to all students
by the progress report date of 11/18/2013.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 15 of 19
PS Criterion #20 - Bullying Prevention and Intervention
Rating:
Partially Implemented
Applies To:
A - Experiment With Travel Day Program
Basis for Findings:
While interviews indicated staff participated in professional development and understood the
program's procedures to follow regarding bullying, a review of documentation indicated that
the program did not submit the professional development plan developed by the program for
all staff for the school year and did not submit evidence of its implementation, including the
dates, format(s) used and agenda(s).
Department Order of Corrective Action:
The program must ensure that a professional development plan has been developed for all
staff and that it has been implemented.
Required Elements of Progress Reports:
The program must submit the professional development plan developed by the program for all
staff for the school year and evidence of its implementation, including the dates, format(s)
used and agenda(s).
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 16 of 19
PS Criterion #20 - Bullying Prevention and Intervention
Rating:
Partially Implemented
Applies To:
B - Lancaster Residential Program, C - Lancaster Day Program
Basis for Findings:
Interviews indicated that not all staff participated in professional development and the
programs do not provide annual written notice to all staff of the Plan. A review of
documentation also indicated that the following were not submitted as requested: a
description of the process the program followed to amend its student admission
material/handbook to include an age appropriate summary of their Bullying Prevention and
Intervention Plan; a description of how the Plan information was distributed; a description of
the professional development plan developed by the program for all staff for the school year;
and evidence of its implementation, including the dates, format(s) used and agenda(s).
Department Order of Corrective Action:
The Program Director must ensure that all requirements of the Bullying Prevention and
Intervention Plan are implemented in both programs.
Required Elements of Progress Reports:
The programs must submit a description of the process followed to amend the student
admission material/handbook to include an age appropriate summary of their Bullying
Prevention and Intervention Plan; a description of how the Plan information was distributed; a
description of the professional development plan developed by the programs for all staff for
the school year; and evidence of its implementation, including dates, format(s) used and
agenda(s). The programs must also submit a narrative of how the programs intend to provide
annual written notice to all staff of the Plan.
Progress Report Due Date(s):
11/18/2013
Massachusetts Department of Elementary & Secondary Education – Program Quality Assurance Services
Robert F. Kennedy Children’s Action Corps, Inc. Mid-cycle Review Report
Page 17 of 19
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