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
February 24, 2010
Dr. Rhonda Taft-Farrell
Head of School
Willow Hill School
98 Haynes Road
Sudbury, MA 01776
Re:
Mid-cycle Review and Verification of Previous Program Review Corrective Action Plan
Dear Dr. Taft-Farrell:
Enclosed are the Department’s findings regarding your private school program’s recent onsite
Mid-cycle Review. This Mid-cycle Review Report contains the Department's findings regarding
the implementation status and effectiveness of corrective steps taken in response to your previous
Program Review Report issued on April 10, 2007. This report also includes a report on the status
of implementation for new state or federal special education requirements enacted since your
program’s last Program Review.
While the Department of Elementary and Secondary Education found certain noncompliance
issues to be resolved, others were partially corrected, not addressed at all and/or new issues were
identified by the Department’s onsite team. Therefore, the Department is issuing a “Provisional
Approval” status effective from the date of this letter and indicated on your approval certificate.
Your “Provisional Approval” will expire on May 24, 2010. The reasons for the “Provisional
Approval” are clearly indicated on the attached Mid-cycle Review Report.
As the Department previously informed you, in cases where a program fails to fully and
effectively implement a Corrective Action Plan which was proposed by your program and
approved by the Department, the Department must then prepare a Corrective Action Plan for the
program which must be implemented without further delay. You will find these requirements for
corrective action and further progress reporting included in the attached report, together with any
steps that must be taken by the program to fully implement new special education requirements.
Please provide the Department with your written assurance that the Department's requirements
for corrective action will be implemented by your program within the timelines specified. Your
statement of assurance must be submitted to the Department's Onsite Chairperson by March 10,
2010.
Page 1 of 2
Your staff's cooperation throughout these follow-up monitoring activities is appreciated. Should
you require additional clarification of information included in our report, please do not hesitate to
contact the Onsite Team Chairperson at 781-338-3713.
Sincerely,
Helen M. Murgida, Mid-cycle Review Chairperson
Program Quality Assurance Services
Darlene Lynch, Director
Program Quality Assurance Services
c:
Mitchell D. Chester, Ed.D., Commissioner of Elementary and Secondary Education
Philip A. Mason, Chairperson, Board of Directors, Willow Hill School
Encl.: Mid-cycle Review Report
Provisional Private School Approval Certificate, Expiration Date: May 24, 2010
Page 2 of 2
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
PRIVATE SCHOOL MID-CYCLE REVIEW
WILLOW HILL SCHOOL
MID-CYCLE REVIEW REPORT
Previous Program Review Corrective Action Plan Submitted on May 25, 2007 and July 6, 2007
Progress Reports Submitted on October 5, 2007, November 16, 2007, November 26, 2007 and December 24, 2007
Mid-cycle Onsite Visit Conducted on November 12, 2009
Date of this Report February 24, 2010
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented

Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Selected Approved Private School Program Mid-cycle Review Criteria
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 1 of 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
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

Documentation
Willow Hill has current
approvals, licenses, and
certificates of inspection by
state and local agencies as
required.
Not applicable
Willow Hill is a Day School.
Documentation
Willow Hill submitted a written
policy on how they will
implement necessary program
modifications and support
services for limited English
proficient students that meets
all the requirements stated in
18.04(1);
28.09(2)(b)(5);
28.09(5) (b);
28.09(6) (b, c)
2.3 EEC
Licensure
Not applicable
102 CMR 3.00
(Residential
Schools only)
8.4 Program
Modifications and
Support Services
for Limited
English Proficient
Students
M.G.L. c. 71A;

Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 2 of 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
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


the criterion.
Title VI
8.5 Current IEP
& Student Roster

Documentation
Student Record
Review
28.09(5)(a)
11.3 Educational
Administrator
Qualifications
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Documentation
Willow Hill has a current IEP
and student roster that shows
that the school 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).
The Educational Administrator
meets the required
qualifications to serve in this
position.
28.09(5)(a);
28.09(7)(a);
603 CMR 44.00
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 3 of 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
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
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

Documentation
Personnel
Record Review
Interviews
The Teacher Roster submitted
is complete and all special
education and regular education
teachers are currently licensed
or on approved waivers as
required.
18.05(11)(f);
28.09(5)(a);
28.09(7)(b, c); 34
CFR 300.321
11.5 Related
Services Staff

Personnel
Record Review
28.09(7)(d)
11.6 Master Staff
Roster
28.09(7)
Documentation

Documentation
The related service staff roster
is complete and all related
services staff providers are
currently licensed or certified in
their respective areas.
Willow Hill School has a
master list of all staff for every
position within the program, the
staff positions correspond to the
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 4 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
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

last ESE approved Program
Budget, and the list includes
job titles along with their
corresponding UFR title
numbers and full-time
equivalents (FTE’s) as required.
Identified Areas of Non-Compliance During the 2007 Program Review or Other Areas of Concern
1.2 Program &
Student
Description,
Program Capacity
Documentation
Willow Hill’s description of
their program, students and
capacity now contains all
required elements as indicated
in this criterion.
Observation
Willow Hill now posts first aid
and emergency procedures
within each building as required
and also posts the location of
the nearest phones.

28.09(2)(a)(2);
28.09(2)(b)(2, 3, 7)
4.2 Public
Information and
Postings
28.09(6)(a, b, c,
d, e);

Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 5 of 16
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

28.09(2)(b)(4)
4.4 Advance
Notice of
Proposed
Program/
Facility Change

Documentation
Willow Hill is now aware that
they must provide written
notification or obtain prior
approval from the Department
depending on the proposed
changes within their program as
indicated on the current Form 1.
The documentation submitted
by Willow Hill now includes
written procedures for notifying
or obtaining prior approval
from the Department.

Documentation
Willow Hill’s Crisis
Management Manual now
contains an explanation when a
Form 2 (incident report) is
required to be submitted to the
Department, and the “Accident
/Incident Reports” statement in
the Health Manual now states
that a Form 2 (not a Form 1)
28.09 (5)(c)
4.5 Immediate
Notification
18.03(10);
18.05(7);
28.09(12) (a, b)
Student Record
Review
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 6 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

must be submitted when
reporting a serious incident.
The school now has a policy
and procedure that includes all
serious incidents that are
required to be reported to the
Department.
5.1 Student
Admissions

Documentation
Willow Hill has a Policy and
Procedure for student
admissions that now include
copies of the school’s
application/intake form, a
sample letter to parents
regarding the acceptance of a
student and the admission
process as required.

Documentation
Willow Hill has policies and
procedures regarding discipline
and behavior management
included in its parent, student,
and faculty handbooks. The
policy and procedure pertaining
28.09(11);
18.05(1)(b)(1-17);
18.05(2);
18.05(3)(c)
9.1 Polices and
Procedure for
Behavior
Management
18.03(7)(b)(2);
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 7 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification
Comments Regarding
Corrective Action Plan
Implementation

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified
Further Corrective
Action
Ordered by the
Department of
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Willow Hill’s restraint
policy now includes all
the requirements of 603
CMR 46.00 and is
included in their Policies
and Procedures Manual;
however, Student Record
Reviews did not contain
Consent to Restraint
forms signed yearly by
parents as required.
Willow Hill must
submit a list of all
students on the Student
Roster and the most
recent date of parent
signature for the
Consent to Restrain
form by April 5, 2010.

to the use of restraints now
includes all Department
requirements and is included in
the school’s Policies and
Procedures Manual.
18.05(5, 6, 7);
28.09(11); 603
CMR 46.00; ESE
Advisory on
Restraint in
Special Education
Programs dated
12/20/05

Documentation
9.4 Physical
Restraint
(Day programs
only)
Student Record
Review
18.05(5); 603
CMR 46.00
9.5
3-5 Day
Suspensions
Findings Regarding
Incomplete
Implementation of
Approved Corrective
Action Plan or
Identification of
Additional Issues of
Noncompliance

Documentation
The 3-5 Day Suspension Policy
is now included in the Policies
and Procedures Manual.
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 8 of 16
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

18.05(6)
9.6
10+ Day
Suspensions

Documentation
Willow Hill’s Policy and
Procedure for 10+ Day
Suspensions now includes all
elements as required.

Documentation
Willow Hill’s Termination
Policy is now included in the
Policies and Procedures
Manual.

Documentation
Willow Hill is approved to have
instructional groupings of up to
8 students to one Licensed
Educator. Willow Hill provides
instruction in smaller groupings
depending on the class taught
and observation revealed six
students in the woodshop class
with a teacher and an assistant.
34 CFR 300.530 –
537
18.05(7)
9.7 Terminations
18.05(7);
28.09(12)(b)
10.1
Staffing for
Instructional
Groupings
28.06(6)(d);
28 09(7)(e)
Observations
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 9 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
11.1 Personnel
Policies and
Procedures
Manual
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented
Method(s) of
Verification


Documentation
Willow Hill now has written
personnel policies and
procedures which includes a
plan for using volunteer and/or
intern services, a statement of
equal employment/educational
opportunities/affirmative action
statement, and a Criminal
Offender Record Information
(CORI) policy that is consistent
with state law.

Documentation
Willow Hill’s organization
chart now includes the lines of
supervision that are reflected in
the job descriptions and the
school provided a narrative that
illustrates and describes the
lines of supervision for staff
and students.
28.09(7)
Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

18.05(11);
18.05(11)(c)(1);
28.09(7);
28.09(11)(a);
M.G.L. c. 71, §
38R; ESE
Advisory on
CORI revised
5/7/07
11.9
Organizational
Structure
Comments Regarding
Corrective Action Plan
Implementation
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 10 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
12.1 New Staff
Orientation and
Training
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


28.09(7)(f);
28.09(9)(b);
28.09(10);
18.03(3);
18.05(9)(e)(1);
Documentation
Interviews

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

Personnel
Record Review
18.05(11)(g, i);
28.09(7)(f)
12.2 In-Service
Training Plan and
Calendar
Method(s) of
Verification
Documentation
Willow Hill has a plan for staff
orientation for all new staff
which now includes all
required elements of this
criterion including
a description of how newly
hired staff are provided training
on all required topics at the
time of hire if the required
topics have already been
covered with existing staff, and
the name of the person
responsible for coordination
and implementation of
orientation training.

Personnel
Record Review
Interviews
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 11 of 16
Willow Hill’s In-service
Training Plan and
Calendar includes all
mandated training topics
offered annually to all
staff providing direct
care services to students
and now includes that all
required trainings will be
Willow Hill must
submit documentation
that medication
administration
(including but not
limited to
administration of
antipsychotic
medication and
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
provided, including
medication
administration and side
effects, student records
and confidentiality, and
the name and job
description for the staff
person responsible for
the development and
implementation of the inservice training
program/calendar.
discussions of
medications students
are currently taking and
their possible side
effects) is provided
annually to appropriate
staff based on their job
responsibilities for all
students by April 5,
2010.

18.05(10);
18.05(11)(h)
Title VI: 42 U.S.C.
2000d; 34 CFR
100.3; EEOA: 20
U.S.C. 1703(f);
Title IX: 20 U.S.C.
1681; 34 CFR
106.31-106.42;
M.G.L. c. 76, § 5;
603 CMR 26.00,
esp. 26.07(2, 3)
Upon parental request,
the Willow Hill school
nurse has an agreement
that the student’s
medications and possible
side effects are kept in a
separate location in the
nurse’s office and are not
shared with appropriate
staff based on their job
responsibilities.
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 12 of 16
Criterion
Number
and
Topic
15.8 Registering
Complaints and
Grievances –
Parents, Students
and Employees
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Documentation
Personnel
Record Review
Interviews

Corrective
Action Plan
Determined
to be Not
Fully
Implemented or
Additional
Issues
Identified

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
16.4 Emergency
First Aid and
Medical
Treatment
Comments Regarding
Corrective Action Plan
Implementation
Documentation
Willow Hill has a policy and
procedure for staff regarding
resolution of complaints
alleging discrimination based
on legally protected categories,
timelines to ensure prompt
resolution, and that when
reporting the grievance to the
head of school, steps to appeal
to another level and associated
timelines. The parent and
student handbooks now include
a grievance and complaint
process.
Willow Hill now has a policy
on emergency first aid and
medical treatment.
18.05(9)(e, f)
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 13 of 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
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting
Criterion
Number
and
Topic
16.5
Administration of
Medication
18.05(9)(f)(8)
16.6
Administration of
Antipsychotic
Medication
Implementation Status of
Requirements
or
Corrective
Action Plan
Determined to
be Substantially
Implemented


Method(s) of
Verification
Documentation
Documentation
18.05(9)(f)(9)
16.7 Preventive
Health Care
18.05(9)(g)
M.G.L. c. 71, § 57
M.G.L. c. 111, §
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
Willow Hill School has a
policy and procedure for
preventive health care
that now includes
medications and medical
supplies are kept in a
Willow Hill must
submit a list of the five
students who did not
have proof of a yearly
vision exam and the
eight students who did

Interviews

Comments Regarding
Corrective Action Plan
Implementation
Documentation
Willow Hill has a policy
regarding the administration of
medication which now includes
that the school disposes of or
returns to parents any unused
medication, and that a review of
medication administered to the
student is incorporated into all
progress reviews conducted for
the student as required.
The policies and procedures
submitted by Willow Hill now
include a policy regarding the
administration of antipsychotic
medication that includes all
required elements.

Student Record
Review
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 14 of 16
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

cabinet separate from
other toxic substances,
toxic substances are
labeled with contents and
antidote, the phone
number for the nearest
poison center is posted
clearly, the provisions of
family planning
information, subject to
any applicable state of
federal legislation, and
the procedures for
protecting students to
foods chemicals, or other
materials to which they
are allergic.
111.
Review of Student
Records revealed that
five students had no
evidence of vision
screening and eight
students had no evidence
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 15 of 16
not have proof of a
yearly hearing exam
which includes date of
exam or Willow Hill’s
plan to ensure those
screenings occur,
including associated
timelines, by April 5,
2010.
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

of hearing screening as
required.
Willow Hill School Mid-cycle Review Report
February 24, 2010
Page 16 of 16
Further Corrective
Action
Ordered by the
Department of
Elementary and
Secondary Education
and Timelines for
Implementation and
Further Progress
Reporting