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 7, 2005 Mr. Eric Masi Wayside Academy 75 Fountain Street Framingham, MA 01702 Re: Onsite Follow-up Monitoring Report: Program Review Corrective Action Plan Verification and Mid-cycle Review Dear Mr. Masi: 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 29, 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 April 29, 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 31, 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 781-338-3717. Sincerely, Betsy Holcombe, Program Review Follow-up Chairperson Program Quality Assurance Services John D. Stager, Administrator Program Quality Assurance Services c: David P. Driscoll, Commissioner of Education Donald S. Keller, Chairperson, Board of Directors Toby Peterson, Local Program Review Coordinator Encl.: Follow-up Monitoring Report 2 MASSACHUSETTS DEPARTMENT OF EDUCATION PROGRAM REVIEW Wayside Academy ONSITE VERIFICATION OF CORRECTIVE ACTION PLAN IMPLEMENTATION AND/OR IDENTIFICATION OF ADDITIONAL FINDINGS REQUIRING CORRECTIVE ACTION Action Plan Submitted June 2002 Progress Reports Submitted on August 2002, July 2003 Onsite Visit Conducted on November 30 & December 1, 2004 Date of this Report January 7, 2005 Criterion Number and Topic Implementation Status of Requirement s or Corrective Action Plan Determined to be Substantially Implemented Method(s) of Verification Comments Regarding Corrective Action Plan Implementation 1.2 Program and Student Description 1.3 Program’s Curriculum 28.09(9) Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified Documenta -tion, Interviews, Observation Documenta -tion The program has submitted a thorough description that clearly connects the education program and the residence for the approved residential program. The curriculum is aligned with the Massachusetts Curriculum Frameworks. 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 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 2.2 Approvals, Licenses, Certificates of Inspection 28.09 (2)(b)4-5 28.09(5) 28.09(6) 18.04(1) Documenta -tion, Interviews, Observation Most current licenses and certificates of inspection have been submitted. Documenta -tion The residence has a current OCCS license. 102 CMR 3.06 (4)(b) 2.3 OCCS Licensure (Not Applicable to Day Schools) 2 The school needs an updated fire safety inspection and the residence needs an updated building inspection. All current inspections must be submitted by January 28, 2005. Criterion Number and Topic Implementation Status of Requirement s 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 program is in the process of updating to ensure that all documents are current and address all elements. The complete and updated policies and procedures must be submitted by May 2, 2005. The residence does not consistently post evacuation routes in all rooms. All evacuation routes must be appropriately posted by May 2, 2005. 3.1 3.2 3.3 Policies and Procedures Manuals 4.2 Public Postings 4.4 Advanced Notice of Program/ Facility Change 28.09(5)(c) Documenta -tion, Interviews The policies and procedures are used consistently between the school and residence. Observation Interview The school has all required postings. Documenta -tion The staff understands that a Form 1 needs to be sent to the Department when there is a significant programmatic change, especially enrollment and staff changes, and there is a written policy. 3 Criterion Number and Topic Implementation Status of Requirement s 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 4.5 Immediate Notification 18.03(10) 18.05(7) 28.09(12) 5.1 Student Admissions Documenta -tion, Interview The staff understands that a Form 2 needs to be submitted when there is a significant incident, and there is a written policy. Documenta -tion, Interviews The student admissions documents are current and are consistently implemented by the principal and residence director. 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 Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified 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 6.1 Daily Instructional Hours 603 C.M.R. 27.00 Documenta -tion, Interviews There are written policies that address all elements included in the Policies and Procedures Manual. Documenta -tion The block schedule has been submitted that documents the required instructional hours for the 12 month program. 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 Verification Comments Regarding Corrective Action Plan Implementation Corrective Action Plan Determined to be Not Fully Implemented or Additional Issues Identified 6.2 School To Work 6.3 Kindergarten 6.4 School Days per Year 28.09(9) Not Applicable 6.5 Early Release of High School Seniors Not Applicable Documenta -tion A description of a student’s school-to-work program has been submitted. Documenta -tion The school calendar has been submitted, which includes five additional days for emergency closings. This calendar also reflects the days scheduled for July and August that indicates a 12 month program. 6 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 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 This continues to be an area that is not consistently addressed. Not all staff are attending the mandated annual training, especially residential staff. Please submit all attendance sheets and the agenda of MCAS training by May 2, 2005. 7.1 Curriculum Frameworks 28.09(9)(b) 7.2 Staff Training 8.1 Implementation – Educational Services Documenta -tion, Interviews The curriculum is aligned with the Massachusetts Curriculum Frameworks. Documenta -tion, Interviews Staff training in MCAS is offered. Documenta -tion, Student Files, Observation All educational services are being implemented, as required. 7 Criterion Number and Topic Implementation Status of Requirement s 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 8.4 Current IEP & Student Roster 28.09 8.8 IEP – Progress Reports 8.9 IEP- Less Restrictive Placement 28.09(9(c) Documenta -tion Interviews The current IEP and Student Roster has been submitted. Student Files The progress reports are issued quarterly. Documenta -tion, Interviews The less restrictive placement is considered and discussed in IEP meetings. 8 The reports are missing required elements, such as to whom they were sent, the dates, and student progress towards attaining each goal. A policy needs to address all requirements. See Criterion 18.2. All required information, including a policy, regarding progress reports must be submitted by May 2, 2005. On-site review of student records will be conducted on or after October 1, 2005. Criterion Number and Topic Implementation Status of Requirement s 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 9.1 Policies and Procedures 9.2 Discipline Code 9.3 Runaway Students 9.5 3-5 Day Suspensions 9.6 10+ Day Suspensions Documenta -tion, Interviews Documenta -tion, Interviews Documenta -tion, Interviews Documenta -tion, Interviews Documenta -tion, Interviews There are written policies and procedures that address behavior concerns, which are utilized in both the school and residence. There are written policies and procedures that address behavior concerns. There are written policies and procedures that address runaway students, and the Form 2 is consistently used for notification to the Department. There are written policies and procedures that address 3-5 day suspensions. There are written policies and procedures that address 10+ day suspensions. 9 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 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 program is in the process of updating to ensure that all documents are current and address all elements. The complete and updated policies and procedures must be submitted by May 2, 2005. 9.7 Terminations 10.1 Student: Teacher Ratios 28.06(6)(d)&(g) 28.09(7)(e) 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) Documenta -tion, Interviews Documenta -tion, Observation There are written policies and procedures that address terminations. The day program maintains appropriate student: teacher ratios. Documenta -tion, Observation Interviews The written schedule indicates that the residential program maintains appropriate student: child care ratios. Documenta -tion, Interviews The policies and procedures are used consistently between the school and residence. 10 Criterion Number and Topic Implementation Status of Requirement s 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 11.3 Educational Administrator Qualifications 11.4 Teachers Special Education Teachers and Regular Education Teachers 28.09(7)(b)(c) 18.05(11)(f) 11.5 Related Services Staff 28.09(7)(d) Documenta -tion, Interviews The Educational Administrator meets all requirements of the position. Documenta -tion, Interviews A review of documentation revealed that not all teaching staff at Wayside Academy are appropriately licensed or on an approved waiver. Documenta -tion, Interviews 11 Teachers need to be currently licensed or on an approved waiver in their subject area. Waivers are needed when required and the expiration dates and name of the supervisor need to be included in the Roster. Evidence that all teaching staff are appropriately licensed or waivered must be submitted by May 2, 2005. An updated roster must be included. No list of related services staff was submitted. A separate list is required for each approved program. An updated related services staff roster must be submitted for each approved program, by May 2, 2005. Criterion Number and Topic Implementation Status of Requirement s 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 list of staff needs to include UFRs, FTEs, and specific job titles. A separate list is required for each approved program. Specifically, this master staff roster must indicate the FTE for each staff member in each approved program. An updated Master Staff Roster must be submitted for each approved program, by May 2, 2005. No list of salary ranges was submitted. An updated list of salary ranges needs to be submitted by May 2, 2005. 11.6 Master Staff Roster 28.09(7) 11.7 Job Descriptions Documenta -tion, Interviews A master staff roster was submitted. Documenta -tion Job descriptions are maintained and were submitted. 11.8 Salary Ranges 12 Criterion Number and Topic Implementation Status of Requirement s 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 11.9 Organizational Structure 28.09(7) 28.07(c) 11.11 Supervision of Students 11.12 Accessibility of Extracurricular Activities Documenta -tion The Organizational Chart has been submitted and demonstrates a connection between the residence and school for the approved residential school. Documenta -tion, Interviews Interviews The written schedule indicates that students are supervised at all times. Staff indicated that there is no discrimination in accessibility. 13 No written policy was submitted. An updated and complete written policy must be submitted by May 2, 2005. Criterion Number and Topic Implementation Status of Requirement s 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 This on-going issue is that not all mandated annual trainings are being provided, such as Abuse and Neglect; Runaway Policy; Transportation Safety; and Civil Rights. The updated training schedule of all mandated areas of training must be submitted by May 2, 2005. Evidence of participation of staff in attendance sheets and agenda must be included. 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) Documenta -tion, Interviews Most mandated areas of training are provided at orientation. Documenta -tion, Interviews Annual trainings in behavior management and restraint are offered consistently. 14 Criterion Number and Topic Implementation Status of Requirement s 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 residence is not accessible to individuals with limited physical mobility. A written plan for the residence to accommodate physically disabled individuals is required, including access into the residential building, by May 2, 2005. 12.2(f) Emergency Procedures Training 12.2(i) Staff Evaluations 13.3 Physical Facility/ Architectural Barriers Documenta -tion, Interviews Documenta -tion, Interviews Observation, Interviews Annual trainings in emergency procedures are offered consistently. The school building and residence both maintain evacuation logs with all required information. Evaluations are consistently written, as per the written policy. The school building is physically accessible. 15 Criterion Number and Topic Implementation Status of Requirement s 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 13.6 Library/Resource Room Observation, Interviews There is a separate space available with materials appropriate for the level of the enrolled students. Documenta -tion, Interviews There are regularly scheduled parent meetings, and parents are given a needs assessment for their input. Documenta -tion 15.4 Change of Student’s Status Documenta -tion 15.8 Registering Complaints Documenta -tion There is an updated policy to address translated information. There is an updated policy to address a student’s change of legal status. There is an updated policy to address the process of registering complaints. 15.1 Parental Involvement and Parents’ Advisory Group 18.05(4)(a) 15.3 Translated Information 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 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 16.1 Health Care Manual Documenta -tion There is an updated Health Care Manual, which is used in both the day and residential program. 16.4 Emergency First Aid Documenta -tion There is a written policy on emergency first aid. 16.5 Administration of Medication Documenta -tion Documenta -tion A written policy for administration of medication has been included in the Health Care Manual. There is a written policy on the administration of antipsychotic medication, which includes all elements. 16.6 Administration of Antipsychotic Medication 17 Some current and additional documents are needed (see citations below). Approval by a licensed physician is required. The policy does not include notification to the Department, parents, and the LEA. The required elements of F, G, and H are missing. G and H are on-going concerns. Approval by a licensed physician, and an updated and complete Health Care Manual are needed by May 2, 2005. An updated and complete written policy, including notification to the Department, parents, and the LEA, must be submitted by May 2, 2005. An updated and complete written policy including F, G, and H must be submitted by May 2, 2005. Criterion Number and Topic Implementation Status of Requirement s 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 16.7 Preventative Health Care 16.8 Receipt of Medical Treatment – Religious Beliefs 17.1 Transportation Safety 18.1 Student Records Documenta -tion There is a written policy on preventative health care. Documenta -tion, Interviews There is a written policy on the receipt of medical treatment and religious beliefs. Documenta -tion, Interviews There is a written policy on transportation safety which states that staff is trained and tested. Student Records The student records were made available to the Department. 18 The required elements of B, D, E, and G are missing. B, D, F, and G are on-going concerns An updated and complete written policy including B, D, E, and G must be submitted by May 2, 2005. Not all staff receive annual training in transportation safety. The updated training in transportation safety must be completed by May 2, 2005. Evidence of participation of staff in attendance sheets and agenda must be included. Criterion Number and Topic Implementation Status of Requirement s 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 18.2 Student Records 28.09(10) MGL c. 71, s. 34H 603 CMR 23.00 Student Records The student records contain all required documents. The updated face sheet has the required information. Family Educational Rights and Privacy Act (FERPA) 19 The progress reports need to address all areas. See Criterion 8.8. All required information regarding progress reports must be submitted by May 2, 2005. On-site review of student records will be conducted on or after October 1, 2005.