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 February 14, 2006 Richard W. Small, Ph.D. Executive Director Walker Home and School 1968 Central Avenue Needham, MA 02492 Re: Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan Verification and Mid-cycle Review for the Day and Intensive Residential Program (Needham Campus) Dear Dr. Small: 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 April 7, 2004. 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 July 14, 2006. The reasons for the “Provisional Approval” are clearly indicated on the attached Corrective Action Plan Implementation Checklist. In areas where the private school has failed to implement fully its approved Corrective Action Plan, the Department views these findings to be serious. 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 Kevin Bobetich by February 28, 2006. The private school must demonstrate the specific steps to be taken to come into substantial compliance with all identified areas requiring corrective action by March 22, 2006. 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’s intake are necessary at that time. 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 Kevin Bobetich at 781-338-3746. Sincerely, Kevin Bobetich, Program Review Follow-up Chairperson Program Quality Assurance Services John D. Stager, Administrator Program Quality Assurance Services c: David P. Driscoll, Commissioner of Education Encl.: Follow-up Monitoring Report 2 MASSACHUSETTS DEPARTMENT OF EDUCATION MID-CYCLE PROGRAM REVIEW Walker Home and School Day and Intensive Residential (Needham Campus) ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION Action Plan Submitted on May 28, 2004 Progress Reports Submitted on May 28, December 3, 2004 and January 24, 2005 Onsite Visit Conducted on November 17-18, 2005 Date of this Report: February 14, 2006 Criterion Number and Topic 1.2 Program and Student Description 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 Documentation review and Interviews The Walker Home and School closed the Regular Residential Program on July 1, 2005. Walker now has one approved Residential Program that is referred to as the Intensive Residential Program. Students in the Day and Intensive Residential Program are “mixed” together during the school day. Walker states that the ratios are the same for both programs for the school portion of the day. 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 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 1.3 Program’s Curriculum 28.09(9) Documentation review and interviews The Walker Home and School has a description of the program’s curriculum, and a written plan that describes opportunities for students to participate in daily and recreational activities that are appropriate to their ages, interests, and needs. 2 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 The Walker Home and School submitted evidence of their curriculum in the area of English Language Arts after the Mid-Cycle Review. The Walker Home and School must develop a written plan that describes steps that will be taken to create a comprehensive curriculum that is consistently implemented throughout the entire 12-month school year by March 1, 2006. Essential learning opportunities that are offered to students to reach the state graduation requirements must be included. Interviews and documentation revealed that the school utilizes a different curriculum during the summer, which is not implemented during the school year. For example, the curriculum utilized during the summer months does not consistently address all of the areas appropriate to students’ specific grade level and the content areas as outlined in each student’s IEP. The School must provide written evidence of monthly progress towards a comprehensive curriculum to the Department through September of 2006. 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 2.2 Approvals, Licenses, Certificates of Inspection 28.09 (2)(b)4-5 28.09(5) 28.09(6) 18.04(1) Documentation review and interviews The Walker Home and School has an updated lead paint inspection. Documentation review and interviews The Department of Early Education & Care is currently updating the Walker Home and School’s approval status. The school will submit the updated approval status to the Department after the Department of Early Education and Care complete the licensing study. 102 CMR 3.06 (4)(b) 2.3 DEEC Licensure (Not Applicable to Day Schools) 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 The Walker Home and School has not provided the Department with the asbestos and PCB inspections as cited in the Program Review. The Walker Home and School must provide the Department with a plan to inspect for asbestos and PCB’s or provide certificates of inspection by March 1, 2006. 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 Documentation review The Walker Home and School has developed policies and procedures for items 1i, 1k, 1m, and 2b, 2c, 2d, 2f, 2h, 2m, and 2n. The school provides written notice to parents that the policies and procedures manual is available upon request on a yearly basis. The school maintains their policies on an electronic database. 3.1 Policies and Procedures Manual 28.09(11)(b) 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 The school’s policy and procedure manual did not contain 1d, 2i, and 2k. The school has placed all of its policies on an online database, but the database is not yet accessible to parents. The Department will review the policies that were submitted after the review. If not submitted already the school must submit the policies and procedures for 1d, 2i, and 2k to the Department for approval by March 1, 2006. Once approved by the Department the Walker Home and School mist retrain all staff on the new policies and procedures by April 1, 2006. The school must develop a procedure for making the complete policy and procedure manual available to parents upon request by March 1, 2006. 4 The school must have a hard copy of the policy and procedure manual on-site for each program by March 1, 2006. 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 3.2 Health Care Manual 18.05 (9)(d) Documentation review The Walker Home and School has submitted a Health Care Manual. 4.2 Documentation review and interviews The Walker Home and School posts first aid and medical emergency procedures, the location of the nearest telephones within each building, and emergency phone numbers in each building. The school has evacuation routes posted in some areas. Public Information and Postings 28.09(6)(a,b,c, d,e) 28.09(2)(b)(4) 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 The Walker Home and School was missing some policies and procedures from the Health Care Manual at the time of the Mid-Cycle Review. The school was in the final stages of completing an electronic database of all the policies. Most of the missing policies were found and submitted after the date of the review. Refer to criterion 3.1. The Department determined that the Walker Home and School did not post enough evacuation routes in order for students to evacuate the school building safely. Specifically, the school building does not have clear lines of sight, which make it difficult to locate the exit in case of an emergency. The Walker Home and School must collaborate with the Department to determine the areas of the education building that will need additional evacuation routes posted by April 1, 2006. 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 Documentation review 4.4 Advanced Notice of Program/ Facility Change 28.09(5)(c) 4.5 Immediate Notification 18.03(10) 18.05(7) 28.09(12) Documentation review The Walker Home and School has notified the Department of some substantial changes through the required Form 1 procedures. The Walker Home and School consistently notifies the parent, the public school district special education administrator, any state agency involved in the student care or placement, and the Department of Education of all required incidents that require immediate notification. 6 Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance The Walker Home and School has not given the Department advanced notice of program/facility changes. Specifically, the school did not seek prior written approval before closing the Regular Residential Program. Further Corrective Action Ordered by the Department of Education and Timelines for Implementation and Further Progress Reporting The school must update their policy on immediate notification to include prior approval from the Department for all form 1 requests by March 1, 2006. The school must retrain all administrative staff on the updated policy and procedure by April 1, 2006. 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 Documentation review and interviews The Walker Home and School’s policy states that the policies and procedures manual is available to parents prior to admission. Students are now required to have documentation from a licensed physician of a complete physical examination not more than (12) months prior to admission. 5.1 Student Admissions 28.09(11) 18.05(1) and (2) 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 Documentation review indicated that not all consent forms have been completed prior to student admission. The Walker Home and School must retrain all admissions staff on the student admissions policy to ensure that students are admitted to the program with all required consents. A copy of the agenda and sign in sheet from the training must be sent to the Department by April 1, 2006. See criterion15.5. . The Walker Home and School must review all student records and update any records that do not have all required consents by March 1, 2006. The Department will conduct an on-site visit to review student records prior to the end of the school year. 7 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 Documentation review and interviews The Walker Home and School has contracts signed by both parties and include all required elements. Items c, d, k, and l are included in the documentation submitted 5.2 Policies and Procedures for Coordination/ Collaboration with Public School Districts & Content requirements policies/procedures for Coordination/ Collaboration with Public School Districts 28.06(2-3) 28.09(9)(c)&(d) 28.09(2)(b)7 Federal Regulations: 300.349 and 300.400-.401 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 Education and Timelines for Implementation and Further Progress Reporting The Walker Home and School was missing some policies and procedures at the time of the Mid-Cycle Review. The school was in the final stages of completing an electronic database that maintains all the policies. The Walker Home and School must revise its’ policy and procedure for Coordination and Collaboration with Public School Districts to meet state and federal laws and regulations and submit them to the Department for review by April 1, 2006. Most of the missing policies were found and submitted after the date of the Mid-Cycle Review. One section of the policies and procedures that was submitted after the review was complete policies and procedure specific to the Coordination and Collaboration with Public School Districts. Once approved by the Department the school must retrain all educational staff on the updated policies and procedures. An agenda and sign-in sheet for the training must be submitted to the Department by May 1, 2006. 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 Documentation review and interviews 6.1 Daily Instructional Hours 603 C.M.R. 27.00 The Walker Home and School has provided the Department with a schedule of the instructional hours for both the day and residential programs. 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 The school offers activities that are counted as instructional time which are not specified on student’s IEP’s. The Walker Home and School must revise its’ schedule for daily instructional hours by April 1, 2006. The schedule must demonstrate how both the day and residential program’s average instructional hours are based upon student’s IEP’s. A review of the school schedule for the summer months and student’s IEP’s revealed that not all IEP goals are addressed during the summer months and the 12 -month program service delivery page does not match the services provided. 6.2 School-to-work (Instructional hours) 603 CMR 27.02, 27.04 Not Applicable 9 The school must provide a revised summer schedule that meets the minimum daily instructional hours and are based on the services that are specified on the student’s IEP’s by May 1 2006. Criterion Number and Topic 6.3 Kindergarten (Instructional hours) 603 CMR 27.03(5) 6.4 School Days per Year 28.09(9) 6.5 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 Not Applicable 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 Documentation review and interviews The Walker Home and School has provided the Department with a schedule, which includes the required number of school days per year. Not Applicable Early Release of High School Seniors 603 CMR 27.05 10 The Walker Home and School operates a twelvemonth day program and a twelve-month residential program. The school has developed a different schedule for the summer months. Refer to criterion 6.1. Criterion Number and Topic 7.1 Curriculum Frameworks 28.09(9)(b) 7.2 Staff Training 28.09(9)(b) Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented 7.3 State/District Wide Assessments 28.09(9)(d) 8.4 Current IEP & Student Roster 28.09 Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documentation review and interviews The Walker Home and School provides Curriculum Frameworks training to all staff. Documentation review and interviews All staff receive training and have an understanding of the Curriculum Frameworks. Documentation review and interviews The Walker Home and School ensures that all enrolled students participate in all required State and/or District wide assessments. The Walker Home and School has a written procedure outlining how the school will ensure that all students participate in State and/or District wide assessments. The Walker Home and School has provided the Department with a current IEP and student roster. 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 The school has not provided a list of initials of students participating in MCAS testing, either with or without accommodations as required. The school must provide a list of initials of the students participating in MCAS testing, either with or without accommodations by April 1, 2006. Documentation review and interviews 11 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 8.7 IEP-Progress Reports 28.07(3) 20 U.S.C. Chapter 33, Section 1414(d)(1)(A)(v iii) Documentation review and interviews A review of the Walker Home and School’s progress reports showed that the school consistently documents the quarter during which the progress report was written. 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 A review of student records indicated that not all of Walker Home and School’s progress reports include information on the extent to which a student’s progress is sufficient to achieve the goals by the end of the year. The school must retrain all staff on the policies and procedures for IEP Progress Reports to ensure that the progress reports document the extent to which such progress is sufficient to enable the child to achieve the goals by the end of the year. The school must submit an agenda and sign in sheet to the Department by April 1, 2006. Some progress reports were written based upon rejected or unsigned IEP’s. IDEA Regulations: 300.347 Some progress report summaries, particularly those issued in the summer-months, do not report on the IEP goals as required. 12 The school must revise its’ policy on IEP progress reports to meet state and federal laws and procedures by April 1, 2006. The school must retrain all educational staff on the updated policy and procedure and submit an agenda and sign-in sheet to the Department by May 1, 2006 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 8.9 IEP Revisions and Changes 34 CFR 300 Documentation review and interviews The Walker Home and School has a policy and procedure for IEP revisions and changes. 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 Some school districts have requested that the Walker Home and School conduct team meetings without the presence of an administrative representative from the responsible school district. The Walker Home and School must submit a complete policy for IEP revisions and changes by April 1, 2006. The school must retrain all educational staff on the new policy and procedure and submit an agenda and sign-in sheet to the Department by May 1, 2006. 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 Documentation review and interviews 8.10 IEP- Less Restrictive Placement 28.09(9(c) 9.1 Policies and Procedures 18.05(5) Documentation review The Walker Home and School coordinates with the sending school district to transition students to the least restrictive environment. The Walker Home and School has developed a comprehensive set of policies and procedures dealing with discipline and behavior management and the staff consistently utilize these policies and procedures. 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 The Walker Home and School does not have a complete policy for IEPless restrictive placement. Interviews with staff revealed that the school had a student who attended a public school part-time while transitioning back to a less restrictive placement, yet there was no policy or procedure. The Walker Home and School must submit an updated policy on IEP-less restrictive placement to meet state and federal laws and procedures by April 1, 2006. The school must retrain all educational staff on the new policy and procedure and submit an agenda and sign-in sheet to the Department by May 1, 2006. Criterion Number and Topic 9.3 Runaway Students 18.03(10) Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented 9.5 3-5 Day Suspensions 18.05(6) 9.6 10+ Day Suspensions Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Interviews Interviews with staff revealed that all staff are aware of the definition of a runaway and are familiar with the policy and procedure for a runaway student. Documentation review The Walker Home and School has a complete policy and procedure for 3-5 Day Suspensions. Documentation review The Walker Home and School has a complete policy and procedure for 10+ Day Suspensions. Joint responsibilities of the private School and the Sending School District 34 CFR 300.519-529 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 9.7 Terminations 18.05(7) 28.09(12)(b) 10.1 Student: Teacher Ratios 28.06(6)(d)&(g) 28.09(7)(e) 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 Education and Timelines for Implementation and Further Progress Reporting The Walker Home and School is approved as a 12-month program for the Day and Intensive Residential Programs. Documentation review, personnel records, and interviews revealed that the student: teacher ratios are not the same for the summer months as during the school year. Some instructional groupings do not have teachers during the summer months. The school must develop a plan to ensure that the student: teacher ratios are the same throughout the entire school year and are approved by the Department by April 1, 2006. Documentation review The Walker Home and School has a complete policy and procedure for Terminations. Documentation review and interviews The Walker Home and School has on average a 3:1 ratio during school hours. Classes are composed of approximately 8-10 students with at least one teacher, an assistant teacher, a child-care worker, and occasionally an additional intern or volunteer. 16 Criterion Number and Topic 10.4 Student: Child Care Ratios 28.09(7) 18.01(2) 11.1 Personnel Policies 28.09(7) 28.09(11)(a) 18.05(11) 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 Documentation review and interviews The childcare ratios for the Intensive Residential Program are 8 students to 3 staff in the afternoon, in which supervisors and float staff are not included in the ratio. The overnight staff ratio is approximately 8 students to 2 staff. (See 10.1 for Day program ratios) Documentation review and interviews The Walker Home and School has a set of written personnel policies and procedures. The Walker Home and School recently revised its’ written plan for using volunteers and/or intern services. 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 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 11.3 Educational Administrator Qualifications 28.09(7)(a) 603 CMR 44.00 and 44.04 11.4 Teachers Special Education Teachers and Regular Education Teachers 28.09(7)(b)(c) 18.05(11)(f) Documentation review and interviews Documentation review and interviews 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 The Educational Administrator does not meet the required qualifications to serve in this role. Documentation must be submitted by March 1, 2006 that shows evidence that the person serving in the role of Educational Administrator is qualified to serve in this role. Not all teaching staff at the Walker Home and School have a license or an approved waiver issued by the Department. The Walker Home and School must ensure that all teaching staff are appropriately licensed or on an approved waiver by submitting an updated teacher roster that specifies the requirements as listed in this criterion by March 1, 2006. For teachers who do not hold the appropriate license and/or waiver by March 1, 2006, a plan specific to coming into compliance is required to be submitted as well. 18 Criterion Number and Topic 11.4(a) Professional Development Plans 28.09(7)(b)(c) 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 Documentation review and interviews The Walker Home and School develops and approves professional development plans for staff holding a professional license. 18.05(11)(f) 11.5 Related Services Staff 28.09(7)(d) Documentation review and interviews All Walker Home and School’s related service staff hold an appropriate license. 11.6 Master Staff Roster 28.09(7) Documentation review The Walker Home and School has provided the Department with an updated Master Staff Roster for both the Day and Intensive Residential Programs. 11.7 Job Descriptions 18.05(11)(d) Documentation review The Walker Home and School maintains job descriptions for all staff positions. 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 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 11.8 Salary Ranges 18.05(11)(e) Documentation review 11.9 Organizational Structure 28.09(7) 28.07(c) 11.11 Supervision of Students 28.09(7) Documentation review The Walker Home and School has provided the Department with a current organizational chart. Documentation review and interviews The Walker Home and School has a detailed plan for the supervision of students. 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 The Walker Home and School has not provided the Department with a list of the salary ranges for all staff positions. The Walker Home and School must provide the Department with a list of the salary ranges for all staff by March 1, 2006. See criterion 4.4 See criterion 4.4. Criterion Number and Topic 11.12 Accessibility of Extracurricular Activities Title VI: 42 U.S.C. 2000d; 34 CFR 100.3(a), (b); Title IX: 20 U.S.C. 1681; 34 CFR 106.31, 106.41; Section 504: 29 U.S.C. 794; 34 CFR 104.4,104.37(a) , (c); Title II: 42 U.S.C. 12132; 28 CFR 35.130; NCLB: Title X, Part C, Sec. 721; Mass. Const. amend. art 114; M.G.L. c. 76, s. 5; 603 CMR 26.06 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 Documentation review and interviews The Walker Home and School’s extracurricular activities are accessible to all students. 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 12.1 Staff Orientation Training 18.05 (11)(g) 12.2 Annual InService Training Plan and Calendar 28.09(7)(f) 18.05(11)(h) 12.2 (a) Behavior Management and Restraint Training 28.09(11) 18.05(5) 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 Documentation review The Walker Home and School provides all required orientation trainings to new staff prior to working directly with students. Documentation review The Walker Home and School provides annual trainings to all staff, which, is documented in personnel records. Documentation review Documentation and staff interviews revealed that there are procedures for obtaining and recording data regarding student discipline and behavior along with a description of how such data is integrated into IEP team discussions. 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 12.2(b) Child Abuse Reporting 18.05(9)(j) 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 Documentation review and interviews All staff have now received training in reporting child abuse and neglect to both the Department of Social Services and/or the Disabled Persons Protection Committee. 12.2 (d) Medication Training 18.05(9)(f)(3)© Documentation review and interviews All staff providing direct care to students, who receive medication, now receive training that includes the nature of the medication, potential side effects and any special precautions or requirements. 12.2(i) Staff Evaluations 18.05(110©1 Documentation review and interviews All written performance evaluations are maintained on staff and personnel are evaluated annually. 23 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 13.3 Comparability of Facilities 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 Observations and interviews The Walker Home and School has co-ed residences, which are comparable in size for all students. Title VI: 42 U.S.C. 2000d; 34 CFR 100.3(b)(2); Title IX: 20 U.S.C. 1681; 34 CFR 106.33,106.40( b)(3); Section 504: 29 U.S.C. 794; 34 CFR 104.34(c); Mass. Const. amend. art. 114; 603 CMR 28.03(1)(b) 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 15.1 Parental Involvement and Parents’ Advisory Group 18.05(4)(a) 15.2 Orientation Procedures 28.09(11) 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 Documentation review and interviews The Walker Home and School’s Parents Advisory Group meets monthly and advises the schools on matters that pertain to the education, health and safety of the students. Documentation review and interviews The Walker Home and School has developed a more formal process for orientation procedures for parents and students. The school has an Admissions Coordinator who is responsible for providing orientation to parents. 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 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 15.3 Information to be translated into Languages other than English Documentation review The Walker Home and School has recently developed an updated policy and procedure for information to be translated into languages other than English. Title VI; EEOA: 20 U.S.C. 1703(f); M.G.L. c. 76, s. 5; 603 CMR 26.02(2) 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 The Walker Home and School’s submitted a new policy and procedure for Information to be Translated into Languages other than English after the review. All staff must be trained on the new policy and a copy of the training agenda and sign-in sheet must be submitted to the Department by May 1, 2006. The school must submit to the Department a sample of a document that has been translated into another language by May 1, 2006. 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 Documentation review and interviews Consents for IEP related matters and restraint procedures were consistently found in the Walker Home and School’s student files. 15.5 Parent Consent 28.07(1)(b) 27 Findings Regarding Incomplete Implementation of Approved Corrective Action Plan or Identification of Additional Issues of Noncompliance Consents for human sexuality training were not found in the Walker Home and School’s student records. Further Corrective Action Ordered by the Department of Education and Timelines for Implementation and Further Progress Reporting See criterion 5.1. Criterion Number and Topic 15.8 Registering Complaints 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 Documentation review The Walker Home and School has a policy and procedure for registering complaints. Documentation review The Walker Home and School now has emergency first aid procedures that include all required elements. 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; NCLB: Title X, Part C, Sec. 722(g)(1)(J)(ii) 16.4 Emergency First Aid 18.05(9)(e) 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 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 16.5 Administration of Medication Documentation review and interviews The Walker Home and School has a policy and procedure for administration of medication. 18.05(9)(f) 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 The policy and procedure for administration of medication does not meet all of the Department’s requirements. The Walker Home and School must submit an updated policy and procedure on administration of medication to meet state and federal laws and procedures by March 1, 2006. Walker Home and School must train all staff on the new policy and procedure by April 1, 2006. A copy of the agenda and sign in sheet must be submitted to the Department by May 1, 2006. 29 Criterion Number and Topic 16.6 Administration of Antipsychotic Medication 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 Documentation review and interviews The Walker Home and School has developed a policy and procedure for administration of antipsychotic medication. 18.05(9)(f)(9) 30 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 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 Documentation review and interviews The Walker Home and School recently submitted a complete policy for preventive health care. 16.7 Preventive Health Care 18.05(9)(f)(9)(h) 31 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 The Walker Home and School’s submitted a complete policy for preventive health care after the program review. All staff must be retrained on the new policy and procedure and a copy of the training agenda and sign-in sheet must be submitted to the Department by April 1, 2006. Criterion Number and Topic 16.9 Students with Comfort Care/Do Not Resuscitate Orders 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 Documentation review The Walker Home and School has a policy and procedure for students with comfort care/do not resuscitate orders. 32 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 16.10 Meningococcal Disease and Vaccination Implementation Status of Requirements or Corrective Action Plan Determined to be Substantially Implemented Not Applicable Method(s) of Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified The Walker Home and School does not have students in grades 9-12 and therefore is not required to have a policy for Meningococcal-Disease and Vaccination. MGL, Chapter 76, s.15D 105 CMR 220.700 33 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 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 18.2 Student Records 28.09(10) Documentation review The Walker Home and School has a recent picture of each student in the student records. MGL c. 71, s. 34H 603 CMR 23.00 Family Educational Rights and Privacy Act (FERPA) 34 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 The Walker Home and School has stored all of the student’s information from the face sheets on an electronic database. During the review, a hard copy of the Walker Home and School’s face sheets did not include all of the required items. The school was able to update the hard copy of all of the face sheets shortly after the on-site visit. The Walker Home and School must develop a policy to ensure that all face sheets are updated annually and include all required elements and submit it to the Department by April 1, 2006. The Department will conduct an on-site visit to ensure that there is a hard copy on the face sheet in each student’s file.