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 2, 2009
Denis Grandbois
Executive Director
St. Ann’s Home & School
100A Haverhill Street
Methuen, MA 01844
Re:
Mid-cycle Review and Verification of previous Program Review Corrective Action Plan
Dear Mr. Grandbois:
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 28, 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 December
21, 2009.
Page 1 of 2
Your staff's cooperation throughout these follow-up monitoring activities is appreciated. Should
you require additional clarification of information included in our report, please do not hesitate
to contact the Onsite Team Chairperson at 781-338-3713.
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
James Santangelo, Chairperson, Board of Directors, St. Ann’s Home & School
Teresa Jones, Director of Education, St. Ann’s Home & School
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
ST. ANN”S HOME & SCHOOL, INC.
DAY AND RESIDENTIAL PROGRAM
MID-CYCLE REVIEW REPORT
Previous Program Review Corrective Action Plan Submitted on June 28, 2007
Progress Reports Submitted on August 17. 2007, January 11, 2008 and May 30. 2008
Mid-cycle Onsite Visit Conducted on November 5 and 6, 2009
Date of this Report December 2, 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
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 1 of 12
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
18.04(1);
28.09(2)(b)(5);
28.09(5) (b);
28.09(6) (b, c)
2.3 EEC
Licensure
102 CMR
3.00
(Residential
Schools only)
8.4 Program
Modifications
and Support
Services for
Limited
English
Proficient
Students
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation


Documentation
St. Ann’s Home submitted
all current approvals,
licenses, and certificates of
inspection.

Documentation
The EEC licensures are
current for the residential
program.

Documentation
St. Ann’s Home submitted a
written policy on how they
will implement necessary
program modifications and
support services for limited
English proficient students
that meets all the
requirements stated in the
criterion.
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified

M.G.L. c.
71A; Title VI
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 2 of 12
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
8.5 Current
IEP &
Student
Roster
28.09(5)(a)
11.3
Educational
Administrator
Qualifications
28.09(5)(a);
28.09(7)(a);
603 CMR
44.00
11.4 Teachers
(Special
Education
Teachers and
Regular
Education
Teachers)
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation


Documentation
The current IEP and student
roster is complete and
contains all required
elements.

Documentation
The Educational
Administrator meets the
required qualifications to
serve in this position.
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
The 2007 Program
Review found St. Ann’s
School in
noncompliance for
having
paraprofessionals
design and implement
lesson plans instead of
having licensed or
waivered teachers write
lesson plans and
supervise
By January 6, 2010, St. Ann’s
Home must provide a written
plan for the process licensed or
waivered teachers will follow
to design instruction for all
subject areas being taught to
students by paraprofessionals
and the method of oversight by
the Educational Administrator.

Personnel
Records
Documentation

Personnel
Records
Interviews
Observations
28.09(7)(b)(c)
18.05(11(f)
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 3 of 12
By March 3, 2010, St. Ann’s
Home must submit copies of
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

11.5 Related
Services Staff
28.09(7)(d)
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
paraprofessional in
implementing these
lesson plans as required.
Interviews and
observations from this
Mid-cycle Review
indicate that St.Ann’s
remains in
noncompliance as
paraprofessionals
continue to design and
provide small group
instruction in the areas
of Mathematics and
English Language Arts
and one
paraprofessional is
designing and providing
large group instruction
in the area of science.
lesson plans led by
paraprofessionals showing that
the lesson plans were written
and signed by a licensed or
waivered educator who
supervises paraprofessionals as
required for the time period of
January and February 2010.

Documentation

Personnel
Records
The related service roster is
complete and all related
service providers are now
currently licensed or certified
in their respective areas.
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 4 of 12
Criterion
Number
and
Topic
11.6 Master
Staff Roster
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation
The master staff roster is
complete and contains all the
required elements.
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance

28.09(7)
Identified Areas of Non-Compliance During the 2007 Program Review or Other Areas of Concern
4.2 Public
Information
and Postings

Observations
Observations indicate that
emergency evacuation routes
are now posted throughout
the school and residences.

Documentation
St. Ann’s Home’s
admissions policies and
procedures now state that the
admissions policies and
procedures are made
available to parents and
students at any time upon
request as required. The
policies and procedures now
also state that students must
have documentation from a
licensed physician of a
28.09(6)(a, b,
c, d, e);
28.09(2)(b)(4)
5.1 Student
Admissions
28.09(11);
18.05(1)(b)(117); 18.05(2);
18.05(3)(c)
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 5 of 12
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

complete examination not
more that twelve (12) months
before admission, or in the
event of an emergency
placement, the school shall
make provisions for a
complete examination of the
student within thirty (30)
days of admissions as
required.
8.8 IEP –
Progress
Reports

Documentation
Interviews
28.07(3);
34 CFR
300.320(a)(3)(
i, ii)
9.4 Physical
Restraint
(Day
programs
only)
18.05(5); 603
CMR 46.00

Documentation
St. Ann’s Home now
contacts sending school
districts requesting for the
student’s IEP Team to
reconvene when it is
determined that the student is
not making progress towards
meeting annual goals.
St. Ann’s Home’s restraint
policy now includes the
requirements of 603 CMR
46.00, which describes how
physical restraint procedures
are implemented by the day
program staff for the day
students.
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 6 of 12
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
9.5
3-5 Day
Suspensions
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation
St. Ann’s Home now
reconvenes students’ IEP
Teams when suspensions for
three (3) consecutive school
days or five (5) nonconsecutive school days in a
school year occur to explore
all possible program
modifications within the
school in an attempt to
prevent more lengthy
suspension of the student
from the program.

Interviews
18.05(6)
9.6 10+ Day
Suspensions

Documentation
Interviews
34 CFR
300.530 – 537
18.05(7)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified
St. Ann’s Home now
reconvenes students’ IEP
Teams when suspensions
exceed 10 consecutive school
days or a pattern has
developed for exclusions to
the student support center
exceeding 10 cumulative
days. St. Ann’s Home now
requests the student's
responsible school district to
convene an IEP Team
meeting prior to a suspension
that constitutes a change in
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 7 of 12
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

placement of a student with
disabilities. Students who are
excluded from the classroom
now receive their educational
program with the assistance
of a teaching assistant.
11.1 Personnel
Policies and
Procedures
Manual

Documentation
St. Ann’s Home personnel
policies and procedures now
includes using volunteer
and/or intern services and
states how often Criminal
Offender Record Information
(CORI) checks are
completed on all staff as
required.

Documentation
St. Ann’s Home now
conducts all mandated
trainings to all staff
including, reporting abuse
and neglect of students to the
Department of Children and
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
12.2 InService
Training Plan
and Calendar
28.09(7)(f);
Personnel
Records
Interviews
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 8 of 12
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

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;
34 CFR
100.3; EEOA:
20 U.S.C.
1703(f); Title
IX: 20 U.S.C.
1681; 34 CFR
106.31106.42;
M.G.L. c. 76,
§ 5; 603 CMR
26.00, esp.
26.07(2, 3)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified

Families and/or the Disabled
Persons Protection
Commission and emergency
procedures including
evacuation and emergency
drills as required.
St. Ann’s Home now
conducts additional required
in-service training topics to
all teaching staff as required,
including how the learning
standards of the
Massachusetts Curriculum
Frameworks are incorporated
into the program’s
instruction procedures for the
inclusion of all students in
MCAS testing and/or
alternate assessments and
student record policies and
confidentiality. St.Ann’s
Home training plan now
includes provisions for the
training of interns, volunteers
or others who work at the
program.
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 9 of 12
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
12.2(c)
Required
TrainingCPR
Certification
18.05(9)(e)
13.7 Library/
Resource
Room
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation
Interviews
St. Ann’s Home’s policy
regarding basic/emergency
first aid training now states
that all staff are trained
annually as required.
Interviews
Observations
18.04(6)(b)
15.3
Information
to be
Translated
into
Languages
Other than
English
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
St. Ann’s Home
translates documents
such as IEPs to parents
or guardians with
limited English
language skills;
however, progress
reports were not
translated as required.
St. Ann’s Home must submit a
sample of three translated
progress reports to the
Department by February 1,
2010.

Personnel
Records

Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified
Interviews
St Ann’s library services are
now fully integrated into the
curriculum of the educational
program and provide a
variety of materials
appropriate to the age and
abilities of the students as
required.

Student
Records
Title VI;
EEOA: 20
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 10 of 12
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

U.S.C.
1703(f);
M.G.L. c. 76,
§ 5; 603 CMR
26.02(2)
15.8
Registering
Complaints
and
Grievances –
Parents,
Students and
Employees
18.05(1)(b)(16
)
Title IX: 20
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

Documentation
St. Ann’s Home has a policy
regarding the filing of
complaints by parents and
students which is now
communicated to parents and
students through the
dissemination of an
information packet mailed at
the beginning of each school
year.
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 11 of 12
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
16.4
Emergency
First Aid and
Medical
Treatment
Implementation
Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Documentation
St. Ann’s Home policies and
procedures regarding
emergency first aid now
contains procedures to be
followed in the case of
illness or emergency if
parents cannot be reached
and as required.

Interviews
18.05(9)(e, f)
16.5
Administratio
n of
Medication
18.05(9)(f)(8)
16.6
Administratio
n of
Antipsychotic
Medication

Corrective
Action Plan
Determined
to be Not
Fully
Implemented
or
Additional
Issues
Identified
Documentation
Interviews
St. Ann’s Home policies and
procedures on the
Administration of
Medication now contain all
required elements.
St. Ann’s Home policies and
procedures on the
Administration of
Antipsychotic Medication
now contain all required
elements.
18.05(9)(f)(9)
St. Ann’s Home and School Mid-cycle Review Report
December 2, 2009
Page 12 of 12
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