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
June 11, 2009
Ms. Kathleen Lovenbury, Executive Director
Stetson School, Inc.
455 South Street
Barre, MA 01005
Re:
Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan
Verification and Mid-cycle Review
Dear Ms. Lovenbury:
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 August 17, 2006. 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 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 October 31, 2009. 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 June
Page 1 of 2
23, 2009.
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 781-338-3704.
Sincerely,
Kerri Zeldis, Program Review Follow-up Chairperson
Program Quality Assurance Services
Darlene Lynch, Director
Program Quality Assurance Services
c:
Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education
Rebecca Levya, Local Program Review Coordinator
Encl.: Follow-up Monitoring Report
Provisional Private School Approval Certificate, Expiration Date: October 31, 2009.
Mid-cycle Cover Letter 2008 - 2009.doc
Rev. 8/14/08
Page 2 of 2
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
PRIVATE SCHOOL MID-CYCLE PROGRAM REVIEW
Stetson School, Inc.
ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION
AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION
Action Plan Submitted on September 29, 2006
Progress Reports Submitted on April 9, 2007
Onsite Visit Conducted on November 7, 2008
Date of this Report June 11, 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 Mid-cycle Review Criteria
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 1
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
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

√
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Although Stetson School,
Inc. submitted a written
plan to implement
necessary program
modifications and support
services to identify and
effectively serve limited
English proficient (LEP)
students, the plan did not
contain all required
Stetson School, Inc. must
develop a written plan to
implement necessary program
modifications and support
services to identify and
effectively serve limited
English proficient (LEP)
students which contains all
required elements. Such written
plan must contain the following

Documentation
Review
Stetson School, Inc. has all
current and required licenses,
approvals and certificates of
inspection from state and local
agencies.
√
Documentation
Review
Stetson School, Inc. has a
current, full license from the
Department of Early Education
and Care (EEC).
√
Documentation
Review
Stetson School, Inc. provided a
written plan to implement
necessary program modifications
and support services to identify
and effectively serve limited
English proficient (LEP)
students.
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
M.G.L. c. 71A;
Title VI
√
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 2
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting

elements.
information:
∙Unless the student’s IEP
specifies otherwise, the student
must receive:
- sheltered content
instruction from a
trained and qualified
teacher; and
- additional instruction in
English as a Second
Language by a certified
ESL teacher.
This written plan must be
submitted to the Department by
September 30, 2009.
8.5 Current
IEP & Student
Roster
28.09(5)(a)
√
Documentation
Review
Student
Stetson School, Inc. has on file a
current IEP for each enrolled
Massachusetts student that has
been issued by the responsible
public school district and
consented to and dated by the
student’s parent(s) (or student,
when applicable). In addition,
Stetson School, Inc. provided
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 3
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

11.3
Educational
Administrator
Qualifications
28.09(5)(a);
28.09(7)(a);
603 CMR
44.00
√
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Documentation
Review
the Department with sufficient
evidence of its efforts to obtain
copies of signed IEP’s from the
responsible public school
district.
The current, interim educational
administrator has been granted a
waiver in Moderate Disabilities,
5-12 until June 30, 2009, and
meets the requirements for this
position.
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 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 Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Criterion
Number
and
Topic
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
Review
Stetson School, Inc. submitted a
current teaching staff roster
indicating the name, title, role of
each teacher in the program,
grade level being taught, subject
being taught, and copies of
ELAR activity sheets for each
teacher.
√
Documentation
Review
√
Documentation
Review
Stetson School, Inc. submitted a
current staff roster for all related
service providers indicating the
name, title, role in the program,
and a copy of the provider’s
license issued by the
Massachusetts State Board of
Registration.
Stetson School, Inc. submitted a
current master staff roster.
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 teaching staff roster
indicated that four
teachers are employed as
special education teachers,
but are not licensed or
waivered in special
education.
Stetson School, Inc. must
submit current licenses or
approved waivers for all
teaching staff and a current
teaching staff roster to the
Department by September 30,
2009.
√
The related services staff
roster indicated that four
related services providers
are not properly licensed.
Stetson School, Inc. must
submit current licenses and a
current staff roster for all
related service providers to the
Department by September 30,
2009.
√
Although Stetson School,
Inc. provided the
Department with a current
master staff roster, Stetson
School, Inc. did not
Stetson School, Inc. must
develop a program budget
based on the current number of
students and staff that coincides
with the current tuition rate and

√
18.05(11)(f);
28.09(5)(a);
28.09(7)(b, c);
34 CFR
300.321
11.5 Related
Services Staff
28.09(7)(d)
11.6 Master
Staff Roster
28.09(7)
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 5
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
provide the Department
with a copy of the last
approved program budget.
Stetson School, Inc. did,
however, submit a letter
indicating that the last
approved program budget
dates back to
approximately 1988 or
before and, therefore is
unable to locate a copy of
this budget.
submit it to the Department by
September 30, 2009.

Identified Areas of Non-Compliance During 2006 Program Review or Other Areas of Concern
3.2 Health
Care Manual
√
Documentation
Review
Stetson School, Inc. maintains a
written and current Health Care
Manual containing a table of
contents and required healthrelated policies and procedures.
Onsite verification indicates that
a licensed physician has
approved the policies and
procedures contained within the
Health Care Manual.
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 6
Criterion
Number
and
Topic
4.2 Public
Postings
5.1 Student
Admissions
8.8 IEPProgress
Reports
8.11 IEP Transition
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

√
√
√
√
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting
Although progress reports
are maintained in the
student records, not all
progress reports for each
quarter are documented in
the student records.
Stetson School, Inc. must
develop a written policy
addressing how the school will
ensure that progress reports for
each student are completed in a
timely manner and documented
in the student records.

Facility
Observation
Documentation
Review
Student Record
Review
Student Record
Review
Student Record
Review
Stetson School, Inc. maintains
onsite and makes available for
public review all required
information and postings.
Stetson School, Inc. maintains a
written admissions policy that
includes all required
documentation.
Stetson School, Inc. maintains
progress reports in the student
records. In addition, Stetson
School, Inc. provided the
Department with sufficient
evidence of staff training on
addressing annual goals from the
last agreed upon IEP, even if it
is expired, and not from a
proposed IEP.
√
Stetson School, Inc. has a
written plan that addresses
transition planning and working
with the responsible school
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 7
Stetson School, Inc. must
review ten (10) student records
to ensure that all progress
reports for all quarters are
consistently maintained in the
student records by September
30, 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

district to discuss a student’s
transition needs at the IEP Team
meeting.
11.1 Personnel
Policies and
Procedures
Manual
√
Documentation
Review
Personnel File
Review
12.1 New Staff
Orientation
and Training
√
12.2 In-Service
Training Plan
√
Documentation
Review
Personnel File
Review
Documentation
Review
Stetson School, Inc. now
documents the transition
planning process for students 15
years and older and maintains
this documentation in the
student’s individual student
record.
Stetson School, Inc. has
developed a written Personnel
Policies and Procedures Manual
that now contains updated
information regarding written
staff evaluations.
Evaluations are now found
consistently in individual
personnel files.
Stetson School, Inc. has ensured
that new staff are now receiving
all mandated training topics
during orientation.
Stetson School, Inc. provided a
copy of its written in-service
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 8
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

15.5 Parent
Consent and
Required
Notification
√
16.5
Administration
of Medication
√
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 written policies and
procedures for
administration of
medication submitted by
Stetson School, Inc. did
not contain all the
required elements.
Stetson School, Inc. must
develop written policies and
procedures for administration
of medication which contains
all the required elements. Such
written policies and procedures
must include the following
information:
 No medication is
administered to a
student without written
authorization from a
parent. Such
authorization shall be
renewed annually.

Personnel File
Review
and Calendar
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Documentation
Review
training plan.
Staff are now being trained
annually on all required topics
and are receiving at least two
hours per month of relevant inservice training.
Stetson School, Inc, obtains all
required parent consents.
Student Record
Review
Documentation
Review
Stetson School, Inc. submitted a
copy of its written policies and
procedures for administration of
medication.
√
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 9
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting




No prescription
medication shall be
administered to a
student without the
written order of the
physician prescribing
the medication to that
student.
The school shall
dispose of or return to
the parents any unused
medication.
A review of
medications
administered to a
student shall be
incorporated into all
case reviews conducted
at the school with staff
regarding the student.
These written policies and
procedures must be submitted
to the Department by
September 30, 2009.
16.7 Preventive
Health Care
√
Documentation
Review
Stetson School, Inc. has a
written plan for the preventive
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 10
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s)
of Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance
Further Corrective Action
Ordered by the
Department of Elementary
and Secondary Education
and Timelines for
Implementation and Further
Progress Reporting

Student Record
Review
health care of students that now
includes provision of family
planning information.
Private School Mid-cycle Cover Letter and Report Form 2008.doc
Rev. 8/14/08
Stetson School, Inc. Program Review Mid-cycle Report
June 11, 2009
Page 11