Program Quality Assurance Services
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Special Education Agency: Eagleton, Inc.
Program Review Onsite Year: 2012-2013
Programs under review for the agency:
Intensive Residential Program
All corrective action must be fully implemented and all noncompliance corrected as soon as possible and no later than one year from the issuance of the Program Review Final Report dated 06/19/2013.
Mandatory One-Year Compliance Date: 06/19/2014
Summary of Required Corrective Action Plans in this Report
Criterion / Criterion Title / PR RatingPS 1.2 / Program & Student Description, Program Capacity / Partially Implemented
PS 4.4 / Advance Notice of Proposed Program/Facility Change / Partially Implemented
PS 5.1 / Student Admissions / Partially Implemented
PS 9.1(a) / Student Separation Resulting from Behavior Management / Not Implemented
PS 10.1 / Staffing for Instructional Groupings / Partially Implemented
PS 10.2 / Age Range / Partially Implemented
PS 11.1 / Personnel Policies and Procedures Manual / Partially Implemented
PS 11.4 / Teachers (Special Education Teachers and Regular Education Teachers) / Partially Implemented
PS 11.6 / Master Staff Roster / Partially Implemented
PS 11.9 / Organizational Structure / Partially Implemented
PS 12.1 / New Staff Orientation and Training / Partially Implemented
PS 12.2 / In-Service Training Plan and Calendar / Partially Implemented
PS 13.2 / Kitchen, Dining, Bathing/Toilet and Living Areas: / Partially Implemented
PS 20 / Bullying Prevention and Intervention / Partially Implemented
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Criterion & Topic:
PS 1.2 Program & Student Description, Program Capacity / PR Rating:
Partially Implemented
Department Program Review Findings:
While documentation addressed the program's description for this criteria, observations and interviews indicated that the educational services, philosophy, goals and objectives, and pre-vocational services were not understood by some staff. In addition, through observations and interviews, the Department was unable to determine how residential services and educational services are fully coordinated. Observations and interviews further indicated staff working with students diagnosed with Autism who have educational and behavioral characteristics requiring additional supports do not have the necessary training to effectively and adequately provide the services to that specific population.
Description of Corrective Action:
Eagleton will ensure that all staff receive training and will understand the Program and Student Description including the educational services, philosophy, goals and objectives and pre-vocational services. Eagleton will revise the narrative that describes the program and services so that all staff will be able to understand and articulate the Program and Student Description. The narrative will be in bullet format replicating the DESE legal standard for Criterion 1.2. Each new employee will receive a copy of the Program and Student Description at the time of hire and during orientation training. At the end of orientation, employees will receive a multiple choice test to determine their level of understanding of the Program and Student Description. Employees who do not score 100% on the test will receive additional training and re-take the test until 100% is achieved.
For existing employees, Eagleton will conduct a training introducing the newly drafted narrative, with emphasis on the educational services, philosophy, goals and objectives and pre-vocational services. Each employee will receive a copy of the Program and Student Description. At the end of the training, employees will take a multiple choice test to determine the employee’s level of understanding of the Program and Student Description. Employees who do not score 100% on the test will receive additional training and re-take the test until 100% is achieved.
Eagleton will ensure that residential services and educational services are fully coordinated and that staff will be able to articulate how these services are coordinated (team meetings that include residential and school staff. Communication notebooks that go from school to residence; clinical Team meetings with residential and school staff)
Eagleton will ensure that all staff will receive all necessary training to effectively and adequately provide services to students diagnosed with Autism. Eagleton has hired Shannon Kay, Ph.D., BCBA-D of Autism Intervention Specialists to provide consultation for the students diagnosed with Autism. Consultation from Shannon Kay will begin on July 1, 2013. Shannon Kay will provide 5 hours of consultation weekly that will include staff training, functional assessment of problem behaviors, behavior plan development and assistance with curriculum development. Additionally, Eagleton will provide any additional supports to staff as recommended by Shannon Kay.
Title/Role(s) of Responsible Persons:
Bruce Bona, Executive Director / Expected Date of Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
Revised narrative that describes the program and student services
Agenda of the training/orientation training for Program and Student Services, name and job title of the person conducting the training, the audience to whom the training was provided, the dates and time of the training and a list of all attendees of the training.
Copy of the Multiple Choice Test given to new employees during orientation and to existing employees during the training held between July and September of 2013
Policy regarding Team Meetings
Policy regarding clinical meetings
Schedule of Team Meetings/Clinical Meetings
Sample agenda for Team/Clinical Meetings
Policy regarding Communication Notebooks including the Daily Cross-Disciplinary Communication Sheet
Contract with Shannon Kay Ph.D., BCBA-D
List of Trainings provided by Shannon Kay
Agenda of the training, the audience to whom the training was provided, the dates and time of the training and a list of all attendees of the training for those trainings already provided by Shannon Kay.
List of any additional supports given to staff
Description of Internal Monitoring Procedures:
1) Department directors will directly supervise ongoing training. The Human Resources Director will maintain documentation of participation in all required trainings.
2) The Education Director and Quality of Life Coordinator will monitor and review on a quarterly basis the individual service delivery checklists from academic and residential settings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 1.2 Program & Student Description, Program Capacity / Corrective Action Plan Status: Approved
Status Date:07/26/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit the revised written narrative for the program and student description that addresses all elements to include educational services, philosophy, goals and objectives, pre-vocational services and how residential services and educational services are fully coordinated. Eagleton must also submit the agenda and attendance sheets for trainings conducted, including any training with staff specific to students diagnosed with Autism who have educational and behavioral characteristics requiring additional supports. Eagleton must also submit the policy regarding communication notebooks and a copy of the daily cross-disciplinary communication sheet. In the 01/06/2014 progress report, Eagleton must submit the quarterly review conducted by the Education Director and the Quality of Life Coordinator.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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MA Department of Elementary & Secondary Education,Program Quality Assurance Services
Eagleton, Inc. Corrective Action Plan
PROGRAM REVIEWCORRECTIVE ACTION PLAN
Criterion & Topic:
PS 4.4 Advance Notice of Proposed Program/Facility Change / PR Rating:
Partially Implemented
Department Program Review Findings:
A review of student records and interviews indicated Eagleton did not notify the Department through a Form 1 regarding a vacancy in a Speech and Language Pathologist position that was not filled by another appropriately credentialed Speech and Language Pathologist that had a direct impact on the service delivery to students. In addition, the program did not send a notification letter to funding public school district(s) of students affected by the vacancy.
Description of Corrective Action:
Eagleton will notify the Department of Elementary and Secondary Education through a Form 1, of all vacancies in approved staff positions not filled by another appropriately licensed or waivered staff person that have a direct impact on the service delivery to students; vacancies that result in students not receiving services as indicated on their IEPs. Eagleton will clearly describe its alternative methods for providing these services to students while attempting to fill any vacant positions. When the school is able to temporarily fill a vacant position with a substitute teacher, it will notify ESE if substitute teachers are being used and Eagleton will continue to document its efforts to fill the position with an appropriately licensed staff person. Eagleton will notify the sending public school districts of staff vacancies only for those students affected by the vacancy and not receiving services as indicated on their IEPs. At this time there are no vacancies.
Title/Role(s) of Responsible Persons:
Vickie Shufton, Education Director / Expected Date of Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
In the event that vacancies arise, Copies of all Form 1 submittals maintained by the Education Director, and such Forms 1 will be submitted to the Department per regulations. Copies of letters notifying school districts will be placed in files of students affected by the vacancy. A master staff roster addressing any changes made to staffing of the school due to such a vacancy will be submitted to ESE.
Description of Internal Monitoring Procedures:
Quarterly quality review of the processes and documents mentioned above conducted by the Education Director.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 4.4 Advance Notice of Proposed Program/Facility Change / Corrective Action Plan Status: Approved
Status Date:07/26/2013
Basis for Partial Approval or Disapproval:
Department Order of Corrective Action:
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must report the results of its internal monitoring to the Department, including whether records of notification to school districts were found in any effected students' files if such a vacancy occurred. In the 01/06/2014 progress report, Eagleton must submit the outcome of its quarterly review conducted by the Education Director.
Progress Report Due Date(s):
10/01/2013
01/06/2014
1
MA Department of Elementary & Secondary Education,Program Quality Assurance Services
Eagleton, Inc. Corrective Action Plan
PROGRAM REVIEWCORRECTIVE ACTION PLAN
Criterion & Topic:
PS 5.1 Student Admissions / PR Rating:
Partially Implemented
Department Program Review Findings:
While documentation indicates that the program has procedures to prepare staff and students in the living unit for a new student’s arrival, interviews indicate a lack of implementation of such procedures for those students with Autism who require toileting and personal care assistance, behavior plans, and charting of particular behaviors.
Description of Corrective Action:
Eagleton will ensure that all procedures to prepare staff for new student’s arrival will be implemented for those students who require toileting and personal care assistance, behavior plans and charting of particular behaviors. Prior to a student moving in, Eagleton will develop an individual checklist specific to the student’s needs, based on the student’s IEP. The individual checklist will include the Goal, Activity and Method of Instruction. Eagleton will implement Daily Service Delivery Log, which will document the progress of the goals, as identified on the individual checklist. Shannon Kay, Ph.D., BCBA-D, will provide targeted training to residential staff regarding toileting, personal care assistance, behavior plans and charting of particular behaviors.
Title/Role(s) of Responsible Persons:
Vickie Shufton, Education Director
Carla Duby, Residential Director / Expected Date of Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
A copy of the individual checklist
A copy of the Daily Service Delivery Log
List of Trainings provided by Shannon Kay
Agenda of the training, the audience to whom the training was provided, the dates and time of the training and a list of all attendees of the training for those trainings already provided by Shannon Kay.
Description of Internal Monitoring Procedures:
Training rosters will be monitored and maintained by the Human Resources Director; daily residential checklists will be monitored by the Quality of Life Coordinator and reviewed at quarterly at Individual Service Plan meetings and annually at Individualized Educational Program meetings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 5.1 Student Admissions / Corrective Action Plan Status: Partially Approved
Status Date:07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states procedures to prepare staff for new student's arrival will be implemented and training specific to residential staff will be conducted by a BCBA, the program did not address the internal monitoring process that will be used to determine whether this identified area of noncompliance has been corrected and how the program will ensure continued compliance by the Education and Residential Directors.
Department Order of Corrective Action:
Eagleton must submit a description of the internal monitoring process by the Education and Residential Directors that will be used to determine whether this identified area of noncompliance has been corrected and how the program will ensure continued compliance.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit a copy of written admissions criteria from the policies and procedures manual; a copy of the individual checklist specific to the student’s needs and the daily service delivery log that documents the progress of the student’s goals. Eagleton must also submit the agenda and attendance sheet to include all required elements conducted by Shannon Kay and delivered to all residential staff regarding toileting, personal care assistance, behavior plans and charting of particular behaviors. Eagleton must also submit a description of the internal monitoring process by the Education and Residential Directors that will be used to determine whether this identified area of noncompliance has been corrected and how the program will ensure continued compliance. In the 01/06/2014 progress report, Eagleton must submit the results of it's internal monitoring. Eagleton must also submit completed copies of individual checklists and daily service delivery logs for students requiring such plans.
Progress Report Due Date(s):
10/01/2013
01/06/2014
1
MA Department of Elementary & Secondary Education ,Program Quality Assurance Services
Eagleton, Inc. Corrective Action Plan
PROGRAM REVIEWCORRECTIVE ACTION PLAN
Criterion & Topic:
PS 9.1(a) Student Separation Resulting from Behavior Management / PR Rating:
Not Implemented
Department Program Review Findings:
While documentation and interviews of administrative staff indicated the program's behavior management policy and procedures do not result in a student being separated in a room apart from the group or program activities, observations and interviews of direct care staff indicated students are separated and documentation of separation is not maintained.
Description of Corrective Action:
Eagleton will ensure documentation is maintained for any students separated from their designated program activities for the purpose of behavioral management. The documentation will include length of time, reasons for the separation, who approved the separation, and who monitored the student during the separation. Eagleton will revise the policy and procedures regarding behavior management specific to student separation that will comply with criterion 9.1(a). Eagleton will provide training to all staff regarding the revised policy.
Title/Role(s) of Responsible Persons:
James Yeaman, Program Director / Expected Date of Completion:
09/30/2013
Evidence of Completion of the Corrective Action:
A copy of the revised Student Separation Resulting from Behavior Management policy
A copy of the log used to document when students are separated from their designated program activities for the purpose of behavioral management
Agenda of the training, the audience to whom the training was provided, the dates and time of the training and a list of all attendees of the training
Description of Internal Monitoring Procedures:
Training rosters will be monitored and maintained by the Human Resources Director; daily residential checklists will be monitored by the Quality of Life Coordinator and reviewed at quarterly at Individual Service Plan meetings and annually at Individualized Educational Program meetings.
CORRECTIVE ACTION PLAN APPROVAL SECTION
Criterion:
PS 9.1(a) Student Separation Resulting from Behavior Management / Corrective Action Plan Status: Partially Approved
Status Date:07/26/2013
Basis for Partial Approval or Disapproval:
While Eagleton states that documentation regarding student separation as a result of behavior management will be documented and the policy will be revised, the description of the internal monitoring process does not address the ongoing monitoring procedures by the Program Director that will be used to determine whether this area of identified noncompliance has been corrected and how the program will ensure continued compliance.
Department Order of Corrective Action:
Eagleton must submit a description of the internal monitoring process by the Program Director that will be used to determine whether this area of identified noncompliance has been corrected and how the program will ensure continued compliance.
Required Elements of Progress Report(s):
In the 10/01/2013 progress report, Eagleton must submit the revised copy of the written policies and procedures regarding behavior management specific to student separation; the agenda and attendance sheets of training conducted regarding the revised policy and a copy of the log used to document students separation resulting from behavior management. Eagleton must also submit a description of the internal monitoring process by the Program Director that will be used to determine whether this area of identified noncompliance has been corrected and how the program will ensure continued compliance. In the 01/06/2014 progress report, Eagleton must submit documentation maintained to record student separation for students from 10/01/2013 and 01/06/2014. Eagleton must also submit the results of it's internal monitoring.
Progress Report Due Date(s):
10/01/2013
01/06/2014
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