The Commonwealth of Massachusetts
Department of Education
350 Main Street, Malden, Massachusetts 02148-5023
Telephone: (781) 338-3700
TTY: N.E.T. Relay 1-800-439-2370
January 5, 2005
Mr. John T. Weldon, M.S.W.
Executive Director
St. Vincent’s Home
2425 Highland Avenue
Fall River, MA
Re:
Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan
Verification and Mid-cycle Review
Dear Mr. Weldon:
Enclosed is the Department's Program Review Follow-up Monitoring Report together with
findings regarding your private school’s Mid-Cycle Program Review. This report contains the
Department's findings based on the onsite activities conducted in your school to verify the
implementation status and effectiveness of corrective steps taken in response to your Program
Review Report issued on December 13, 2002. This report also includes a report on the status of
implementation for new state or federal special education requirements enacted since your
school’s last Program Review.
While the Department of 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 May 2, 2005. The reasons for the “Provisional Approval” are clearly
indicated on the attached Corrective Action Plan Implementation Checklist.
As the Department previously informed you, in cases where a private school fails to fully and
effectively implement a Corrective Action Plan which was proposed by your school and
approved by the Department, the Department must then prepare a Corrective Action Plan for the
school 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 school 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 private school within the timelines specified.
Your statement of assurance must be submitted to the Department's Onsite Chairperson by
January 25, 2005.
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 781-338-3711.
Sincerely,
Nina M. Marchese, M.Ed.
Program Review Follow-up Chairperson
Program Quality Assurance Services
John D. Stager, Administrator
Program Quality Assurance Services
c:
David P. Driscoll, Commissioner of Education
Most Rev. George W. Coleman, Chairperson, Board of Directors
Michelle Lorranger-Cruise, Local Program Review Coordinator
Encl.: Follow-up Monitoring Report
2
MASSACHUSETTS DEPARTMENT OF EDUCATION
PROGRAM REVIEW
St. Vincent’s Home
ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION
AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION
Onsite Visit Conducted on October 19 & 20, 2004
Date of this Report January 5, 2005
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting


1.2
Program &
Student
Description
1.3
Program’s
Curriculum
28.09(9)

Documentation

Documentation
Interviews
The program and student
description was updated
and includes all
requirements of this
criterion for the approved
program only.
The on site team found
that the school has
developed a recreation and
leisure activities
appropriate to meet the
needs of the students.

The description needs
to reflect the maximum
capacity of the
approved private school
program.
Documentation to be
submitted that reflects the
maximum capacity of the
approved private school
program only.
St. Vincent’s must
develop the curriculum
across all required areas
that is aligned with the
Massachusetts
Curriculum
Provide a specific timeline
on how the curriculum at St.
Vincent’s will be developed
so that it is fully aligned
with the Massachusetts
Curriculum Frameworks.
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting


Frameworks so that
there is a school-wide
curriculum.
2.2
Approvals,
Licenses,
Certificates of
Inspection
28.09 (2)(b)4-5
28.09(5)
28.09(6)
18.04(1)
Documentation

St. Vincent’s maintains
required licenses,
approvals and certificates
of inspection by state and
local agencies in a place
available for public and
employee view.
102 CMR 3.06
(4)(b)
2
Also include the name and
role of the staff person who
is responsible and how staff
will be trained on the
updated curriculum by
March 14, 2005
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


2.3
OCCS
Licensure (Not
Applicable to
Day Schools)
3.1
3.2
3.3
Policies and
Procedures
Manuals
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Documentation

Documentation
Interviews
St. Vincent’s has a current
full license from the Office
of Child Care Services
(OCCS).
St. Vincent’s has a policy
and procedure manual that
is online for all staff to
access, has a crosswalk of
all requirements from
regulatory agencies is
clearly written and
extremely thorough.
3
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


4.4
Advanced
Notice of
Program/
Facility Change
28.09(5)(c)

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
St. Vincent’s has provided
the Department with
written notification prior
to any substantial change.
St. Vincent’s consistently
maintains communication
with the private school
liaison, from the
Department of Education,
to provide updates the
status of form 1’s.
4
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


4.5
Immediate
Notification
18.03(10)
18.05(7)
28.09(12)

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Student
Records
St. Vincent’s provides
immediate notification to
the parent, the public
school district special
education administrator,
and any State Agency
involved in the student’s
care or placement and
Department of Education
through form 2
requirements. St.
Vincent’s staff provide
appropriate follow-up
when needed.
5
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
Although St. Vincent’s
has updated the student
admissions criteria
policies and procedures
to reflect the approved
residential education
program, consent forms
must be added to the
policy and procedure,
including the procedure
St. Vincent’s will
follow to ensure
consents are updated on
an annual basis.
St. Vincent’s must submit a
policy that specifies how
consents will be updated for
all students on an annual
basis by March 14, 2005.



Documentation
5.1
Student
Admissions
6
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
Although St. Vincent’s
has updated numerous
policies and procedures
that fall under this
criterion, a policy
specific to contents and
general arrangements
for executing contracts
with placing school
districts must include
language as required
under 603 CMR
28.06(3)(f).
St. Vincent’s must update its
policy specific to contents
and general arrangements
for executing contracts with
placing school districts must
include language as required
under 603 CMR 28.06(3)(f)
by March 14, 2005.



5.3
Contents of
Coordination
and
Collaboration
with Public
School Districts
28.06(2-3)
28.07(5)
28.09(9)(c)&(d)
28.09(2)(b)7
Federal
Regulations:
300.349
and
300.400-401

5.4
Training
Documentation
Interviews
St. Vincent’s trains staff
with school district
responsibility regarding
their roles.
7
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
St. Vincent’s is meeting
the required number of
instructional hours per
school day for
elementary and
secondary age students
during the school year
but must increase the
daily instructional hours
to maintain the
requirements over the
summer months. St.
Vincent’s is approved
by the Department as a
12-month program, so
the average hours must
meet the average of 5
hours per school day for
elementary age students
and 5.5 hours per
school day for the
secondary age students.
St. Vincent’s must revise the
school hours that it is in
session from June through
August that meets the daily
instructional hours of 5
hours per day for elementary
age students and 5.5 hours
per day for secondary age
students. In addition to
providing an updated
calendar, provide meeting
notes from staff meetings
that address this and how
others will be notified. This
schedule must be
implemented for the summer
of 2005. The plan is due to
the Department no later than
March 14, 2005.


6.1
Daily
Instructional
Hours
603 C.M.R.
27.00

Documentation
Interviews
Observations of the on-site
team determined that when
students are removed from
the classrooms during the
school day they are
primarily working on IEP
related goals.
8

Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
St. Vincent’s needs to
add 5 extra calendar
days to account for
unforeseen
circumstances.
St. Vincent’s must provide
an updated calendar to the
Department that includes 5
extra calendar days to
account for unforeseen
circumstances by March 14,
2005.
St. Vincent’s must
continue to work with
teaching staff on how to
align the curriculum
and use Curriculum
frameworks when
designing and
implementing
instruction to students.
Please refer to criterion
1.3.
Please refer to criterion 1.3.


6.4
School Days per
Year
28.09(9)
Documentation

7.1
Curriculum
Frameworks
28.09(9)(b)
Documentation
Interviews

9
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


7.2
Staff Training

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Interviews
St. Vincent’s ensures that
all staff responsible for
implementing services as
specified on students’
Individualized Education
Programs have an
understanding and
knowledge of the general
curriculum expectations
and learning standards of
the Massachusetts
Curriculum Frameworks
and shall incorporate such
knowledge into the
school’s educational
program.
10
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
Although St. Vincent’s
has specified how all
required educational
services are
implemented for the
described population.
St. Vincent’s must hire a
Physical Education teacher
whose responsibility it is to
conduct physical education
classes and work with
teachers to ensure all
students are receiving
appropriate physical activity.
Provide a detailed plan to
the Department by March
14, 2005 that addresses this
mandate.


8.1
Implementation
Educational
Services

Documentation
Interviews
Observations
Students are not
receiving appropriate
physical education
requirements.
11
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
St. Vincent’s is not
providing the
appropriate
occupational therapy
services as required on
student IEP’s.
St. Vincent’s must hire an
Occupational Therapist who
will work directly with
students to ensure their IEP
goals are being
implemented. Provide a
detailed plan to the
Department by March 14,
2005 that addresses this
mandate.


8.2
Implementatio
n – Related
Services
8.3
Implementation on
Supplementary
Aids/Services

Documentation
Student
Records
Interviews

Documentation
St. Vincent’s provided a
list of the supplementary
aids and services that are
available for students in
the program.
12
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


8.4
Current IEP &
Student Roster
28.09


8.5
Education
Case Manager
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Student
Records
Interviews
St. Vincent’s has on file a
current IEP for each
enrolled Massachusetts
student that has been issue
by the responsible school
district and consented to
by the student’s parent(s)
(or student in applicable
situations) for each student
enrolled ion the program.
Documentation
Student
Records
St. Vincent’s assigns an
educational case manager
to each student.
13
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


8.6
IEP
Implementation

Documentation
Interviews
Observations
St. Vincent’s implements
all services on the
students’ with the
exception of Occupational
Therapy. Please refer to
criterion 8.2.
8.7
IEP Progress
Reports

Documentation
Student Record
In IEP Progress Reports,
St. Vincent’s includes
written information on the
student’s progress toward
the annual goals in the
IEP, including information
on the extent to which
such progress is sufficient
to enable the child to
achieve the goals by the
end of the year. Progress
reports are thorough and
well written.
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 Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


8.8
IEP Revisions
and Changes

Documentation
Student Record
St. Vincent’s has identified
the person responsible for
notifying the public school
and parents whenever an
IEP needs to be revised
and has a written
procedure that outlines this
practice.
8.9
IEP- Less
Restrictive
Placement
28.09(9(c)

Documentation
St. Vincent’s has
developed and
implemented procedures to
ensure opportunities for
students to return to a less
restrictive educational
program.
15
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation



9.1
Policies and
Procedures
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Interviews
St. Vincent’s has a
comprehensive set of
policies and procedures
dealing with discipline and
behavior management that
meet all federal special
education requirements as
well as all applicable state
and federal requirements
pertaining to the use of
restraint that are
consistently implemented
by staff. Staff have
received training and
supervision on policies
and procedures to ensure
appropriate
implementation.
16
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


9.3
Runaway
Students

Documentation
Interviews
St. Vincent’s has a policy
and procedure on the use
of runaway students that
distinguishes between “out
of location” from “run
away.”
10.1
Student:
Teacher Ratios
28.06(6)(d)&(g)
28.09(7)(e)

Documentation
School
schedules
The student: teacher ratios
in the school at St.
Vincent’s are 1:4 which
exceeds the requirements
of the student: teacher
ratios.
17
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


10.4

Documentation
Work
Schedules

Documentation
Student: Child
Care Ratios
28.09(7)
18.01(2)
11.1
Personnel
Policies
28.09(7)
28.09(11)(a)
18.05(11)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
The student: Child Care
ratios at St. Vincent’s are
not lower that 4:1 nor
greater that 6:1 during non
“school-day” waking hours
and not lower than 6:1 or
greater than 8:1 during
sleeping hours.
St. Vincent’s has written
personnel policies and
procedures that meet the
requirements of criterion
11.1.
18
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


11.4
Teachers
Special
Education
Teachers and
Regular
Education
Teachers
28.09(7)(b)(c)
18.05(11)(f)

Documentation
Interviews
St. Vincent’s ensures that
all teaching staff have
teaching licenses
appropriate to meet the
needs of the population
being served or who are on
an approved waiver issued
from the Department of
Education.
11.5
Related
Services Staff
28.09(7)(d)

Documentation
Interviews
St. Vincent’s is currently
filling the position of
Speech and Language. An
Occupational Therapist is
not included as part of the
approved program. Please
refer to criterion 8.2.
19
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


11.6
Master Staff
Roster
28.09(7)

Documentation
St. Vincent’s maintains a
master list of all staff for
every position within the
program that includes job
titles together with
corresponding UFR title
numbers and full-time
equivalencies.
11.9
Organizational
Structure
28.09(7)
28.07(c)

Documentation
Interviews
St. Vincent has an
organizational structure
that is clearly understood
by staff and staff
implementing IEP services
are consistently supervised
by appropriately licensed
and qualified educators.
20
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation



11.10
Supervision of
Child Care
Workers
(Direct Care
Staff)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Interviews
St. Vincent’s provides
ongoing and regular
supervision by a
professional staff person
who has supervisory and
administrative
responsibility within the
school and consistently
provides this support to
child care workers.
21
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


11.11
Supervision of
Students

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Interviews
St. Vincent’s implements a
detailed plan that describes
how appropriate
supervision is provided to
students while they are
engaged in any schoolrelated activity on and off
school grounds. In
addition, St. Vincent’s has
a plan to deal with crisis
situations that may arise.
22
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
St. Vincent’s is not
ensuring that newly
hired staff receive all
mandated trainings
prior to providing direct
care duties with
students.
St. Vincent’s must provide a
detailed policy that specifies
how newly hired staff will
receive all mandated
trainings before they have
direct care duties with
students. The plan must also
include provisions if a staff
member is absent for part of
the training as well as the
staff member who is
responsible for overseeing
this by March 14, 2005.


12.1
Staff
Orientation
Training

Documentation
Interviews
Personnel
Records
23
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified


12.2
Annual InService
Training Plan
and Calendar
28.09(7)(f)
18.05(11)(h)

Documentation
Interviews
Personnel
Records
12.2(a)
Behavior
Management
and Restraint
Training
28.09(11)
18.05(5)

Documentation
St. Vincent’s has a written
plan for staff training that
is consistent with the
needs of the student
population, appropriate to
meet the role of each staff
member and provides, on
average, at least two (2)
hours per month of
relevant training for all
staff including nonprofessional staff.
St. Vincent’s maintains all
requirements of behavior
management and restraint
training as outlined under
this criterion.
24
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation



Documentation
St. Vincent’s has a policy
that includes reporting to
the Disabled Persons
Protection Commission
(DPPC).

Personnel
records
Staff receive evaluations
according to the policy
outlined by St. Vincent’s.
12.2(b)
Child Abuse
Reporting
12.2 (i)
Staff
Evaluations
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
25
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


13.1
Educational
Facilities and
Materials

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Interviews
Observations
St. Vincent’s provides the
facilities, textbooks,
equipment, technology,
materials and supplies
needed to provide the
special education and
related services specified
on the IEP’s of the
enrolled students. St.
Vincent’s now has a
computer lab for students
use.
26
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation


15.1
Parental
Involvement
and Parents’
Advisory
Group
18.05(4)(a)
15.6
Consent at Age
of Majority
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Documentation

Documentation
Student
Records
Interviews
St. Vincent’s now provides
numerous opportunities for
parents to be involved in
the program. St. Vincent’s
has a Parents’ Advisory
Group that provides the
school with feedback that
addresses the education,
health and safety of the
students.
St. Vincent’s works
collaboratively with the
responsible school district
to ensure consent is
obtained from the student
to continue the special
education program upon
turning age eighteen or to
ensure that another
mechanism is in place to
obtain consent.
27
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
Comments Regarding
Corrective Action Plan
Implementation



16.1
HealthCare
Policy and
Procedure
Manual
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
St. Vincent’s has a
comprehensive health care
policy and procedure
manual that clearly
describes the provisions
made for medical, nursing
and infirmary care of
students and that is
approved by a licensed
physician.
28
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirement
s
or
Corrective
Action Plan
Determined
to be
Substantially
Implemented
Method(s) of
Verifica-tion
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 Education
and Timelines for
Implementation and Further
Progress Reporting
St. Vincent’s does not
maintain all required
elements of the face
sheets on student
records, specifically:
The name of the
education case
manager, the starting
and expiration dates of
the current IEP and the
most recent special
education evaluation.
Provide a random sample of
the face sheets from 10
student records with all
required information by
March 14, 2005.


18.2
Student Records
28.09(10)

Student
Records
Interviews
MGL c. 71, s.
34H
603 CMR 23.00
Family
Educational
Rights and
Privacy Act
(FERPA)
29