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