Program Quality Assurance Services
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
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 6/12/2012.
Mandatory One-Year Compliance Date: 6/12/2013
Summary of Required Corrective Action Plans
Summit Academy, Inc CPR/Program Review Onsite Year: 2011-2012
Programs under review for the agencyA - Summit Academy - Day Program
Criterion # / Criterion Title / CPR Rating / Applies To / CAP Status
8.8 / IEP - Progress Reports / Partially Implemented / A / Approved
12.1 / New Staff Orientation and Training / Partially Implemented / A / Approved
12.2 / In-Service Training Plan and Calendar / Partially Implemented / A / Approved
15.3 / Information to be Translated into Languages Other Than English / Partially Implemented / A / Approved
16.7 / Preventive Health Care / Partially Implemented / A / Approved
PROGRAM REVIEW
CORRECTIVE ACTION PLAN
Corrective Action Plan Detail
Summit Academy, Inc
CPR/Program Review Onsite Year: 2011-2012
A - Summit Academy - Day Program
PS Criterion #8.8 - IEP - Progress Reports
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/12/2013Program Review Finding / While documentation, student record reviews and interviews revealed that two progress reports dated 2/14/12 and 4/12/12 have been issued, past progress reports were not documented and not all progress reports indicate progress toward students' annual goals as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / For the last three quarters, progress reports have been completed on a quarterly basis and going forward, all progress reports will include detailed written information on the student's progress toward the annual goals in the IEP. Upon staff returning to school for the 2012-2013 school year, in-service training will be implemented and presented by the Special Education Director to review the process of writing progress reports that report measurable progress toward IEP goals and objectives. This training will be repeated with any new staff and at least twice a year with all staff. Responsible teachers and therapists will write accurate and measureable progress reports as often as quarterly report cards are generated, and submit these to the Special Education Director who will review all progress reports to ensure compliance prior to sending to parents and districts.
* Evidence of Completion of Corrective Action / A copy of the training agenda and participants will be kept on file to document this activity. This training will include practice with measurable goals and data collection in order to accurately report progress each quarter. Additionally, copies of progress reports will be kept in students cumulative special education file with a cover sheet documenting the date the progress report was sent home and sent to the district. A spread sheet of the districts and dates sent will also be kept up to date.
* Description of Internal Monitoring Process / Summit Academy is purchasing/implementing and IEP tracking program that will enable progress reports to be written onto one program, and will facilitate the electronic tracking of these reports by the Special Education Director and Program Director for ongoing monitoring and evidence of continued compliance.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Summit Academy has indicated their understanding of this requirement and discussed with the liaison ways to come into compliance and ongoing monitoring of this criterion.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
10/01/2012
12/03/2012
Required Elements of Progress Report(s) / Summit Academy must submit a training agenda indicating name and position of those in attendance, date of the training, time of the training and who conducted the training by 10/1/12. Summit Academy must also submit evidence of its procedures to insure that all progress reports will include detailed written information on the student's progress toward the annual goals in the IEP by submitting 10 randomly selected Progress Reports for the first term of the 2012-2013 school year, a Student Roster which indicates to whom and the date the Progress Report was mailed for all students by 12/3/2012.
PQA Review Complete
Applies To:
A - Summit Academy - Day Program
PS Criterion #12.1 - New Staff Orientation and Training
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/12/2013Program Review Finding / While staff interviews revealed that new staff orientation occurs, documentation and staff record reviews revealed that not all staff are fully trained prior to being assigned direct care duties with students, and new staff orientation training is not consistently documented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Summit Academy has written plan for staff orientation and training that is consistent with the needs of the student population and includes an orientation-training program for all new staff to ensure an understanding of the school's philosophy, organization, program, practices and goals. Initial staff orientation includes provision for training in emergency procedures, behavior management procedures and requirements related to student protections as provided in 603 CMR 28.09(12). 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. The training plan includes provisions for the orientation of interns, volunteers or others who work at the program. New staff may not be assigned direct care duties with students until they have participated in all mandated trainings listed under criterion 12.2 a-e through their orientation program. All staff must undergo orientation and partipate in all mandated trainings prior to working with children. All orientation (for staff or volunteers) is coordinated by the Executive Director, Director of Special Education or Program Director and/or their designees. A orientation committee was formed which included Executive Director, Special Education Director, Program Director and Office Manger. This committee developed a comprehensive orientation packet that documents all trainings for new employees as well as ensures compliance in all areas of required orientation. Tracking of orientation is done by the office manager through a check list. Office Manager coordinates and schedules all trainings for new employees. Trainings are provided by qualified and appropriate Summit staff members and certified outside professionals. Documentation of these trainings are detailed and signed off on by both the provider and the new employee and are added to the orientation packet. Once completed office manager forwards completed packet and checklist to Special Education Director and Executive Director for approval.
* Evidence of Completion of Corrective Action / Current packet and checklist is on file.
* Description of Internal Monitoring Process / Prior to direct care responsibilities office manager ensures all appropriate trainings have been completed and documented and forwarded to administration. Special Education Director, Program Director and Executive Director check trainings and sign off on packet and interview new employee for ensure orientation is complete and understood. Executive Director signs off on packet which is then put into the employee personnel file.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Summit Academy has indicted their understanding of this requirement and discussed with the liaison ways to come into compliance and ongoing monitoring of this criterion by stating that all staff are fully trained prior to being assigned direct care duties with students, and that new staff orientation training is consistently documented as required.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
10/01/2012
12/03/2012
Required Elements of Progress Report(s) / Summit Academy must submit a New Staff Orientation checklist that includes all of the following required elements: 1. Program's Philosophy; 2. Organization; 3. Program; 4. Practices; 5. Goals; 6. ESE required topics (12.2 a-e); and provisions for orientation intern, volunteers or others who work at the program. If Applicable, Summit Academy must upload copies of all completed orientation checklists for all new staff hired for the 2012-2013 school year that includes the name of the staff member, date of hire, and completion date for all required training topics.
PQA Review Complete
Applies To:
A - Summit Academy - Day Program
PS Criterion #12.2 - In-Service Training Plan and Calendar
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/12/2013Program Review Finding / Documentation, staff record reviews and interviews revealed that staff in-service training is not consistently documented, and that some staff were unclear whether some topics were presented as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / Summit Academy School provides an annual in-service training in August prior to the opening of each new school year for all staff and additional staff training throughout the school year that is consistent the regulations and with the needs of both professional and non-professional staff and is relative to the school's population. Regular meetings will be held for discussions about students, school issues, and policy review. See attached Training Calendar. An In-service committee was formed to stream line the process for in-service planning and documentation to ensure compliance in all criterion of 12.2. All in-services have sign-in sheets for staff and for provider which will be given to the Special Education Director at the completion of each session. In-service certificates will be provided to each participant and filed in staff personnel files
* Evidence of Completion of Corrective Action / Sign-in sheets and certificates of reguired in-service development will be kept in staff professional files and monitored by the Executive Director and Special Ed. Director.
* Description of Internal Monitoring Process / Office Manager maintains in-service training calendar. The Executive Director, Special Education Director and Program Director ensure that all required trainings are scheduled and provided for staff. Executive Director signs off on calendar to ensure compliance with DESE regulations. All trainings have documentation of agenda, participants and sign-offs from both staff and provider. This document is forwarded to the Special Education Director who approves documentation and generates certificates for attending in-service by staff. These certificates are forwarded to the Executive Director who approves and signs off on documentation which will be kept in the staff personnel files. A copy of the certificate is distributed to the participants after a review and clarification of in-service content.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Summit Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance and ongoing monitoring of this criterion by revising their Annual In-service Training Plan to include signed attendance for each training which will be kept in individual staff files.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
10/01/2012
12/03/2012
Required Elements of Progress Report(s) / Summit Academy must submit the In-Service Training Plan and Calendar for the 2012-2013 school year that includes all ESE required trainings. Evidence (sign in sheets with signatures of attendees, required topic, date, length of time and name of presenter) must also be submitted for all trainings that occur prior to the 10/1/12 submission date to show documentation that all new and returning staff members, interns and volunteers (if applicable) have participated in all required in-service training topics which must be provided annually and also submit evidence of at least two hours training per month on sign-in sheets.
PQA Review Complete
Applies To:
A - Summit Academy - Day Program
PS Criterion #15.3 - Information to be Translated into Languages Other Than English
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/12/2013Program Review Finding / Documentation, student record review, and interviews revealed that one student has a parent with limited English language skills and the program did not ensure that important school information is sent to the parent in a timely manner and provided to the parent in a language that they understand, either through written translations of documents or through oral interpreters as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / When students have parents or guardians with limited English language skills, Summit Academy will ensure that important school information is sent to them in a timely manner and will be provided to them in a language they understand, either through written translations of documents or through oral interpreters. Specifically, Summit will hire a translation service. Summit will collaborate with the sending district to hire a translation service. Within the next twenty-four to forty eight hours, the translation will be provided.
* Evidence of Completion of Corrective Action / Summit Academy has documents of current compliance regarding this one student sited.
* Description of Internal Monitoring Process / Prior to team meetings, Special Education Director will review administrative data page and contact district regarding collaborative compliance for non-english speaking participants. Special Education Director will create a data base for all non-english speaking students to track compliance and appropriate services. Executive Director will have access to this data base and will monitor for compliance.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Summit Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance by contacting sending school districts regarding the current primary language of parents as noted on the cover page of the IEP to determine if translations/translators of important information and Progress Reports will be required.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
10/01/2012
12/03/2012
Required Elements of Progress Report(s) / The Special Education Director will review administrative data page of new students and contact district regarding collaborative compliance for non-English speaking participants and create a data base to track compliance and appropriate services. Summit Academy must upload a copy of the data base that tracks students and/or parents with limited English language skills.
PQA Review Complete
Applies To:
A - Summit Academy - Day Program
PS Criterion #16.7 - Preventive Health Care
Program Review Rating / Partially Implemented / Mandatory One-Year Compliance Date / 06/12/2013Program Review Finding / Documentation, student record review, and interviews revealed that not all students had evidence of dental examinations, and vision, hearing, and postural screenings as required.
* Indicates required field
District/Agency Corrective Action Plan
* Title/Role(s) of Responsible Person(s) / / * Expected Date of Completion
* Description / At the time of intake, the school will require a complete medical history including medications, treatment of acute medical problems, known allergies, and other special medication conditions/needs. All direct care staff of Summit will participate in a comprehensive medical orientation within three (3) months of hire. Summit Academy's nursing staff will work with the student's family and/or responsible human service agency to ensure that each student receives an annual physical and dental exam. A Parent/Guardina will be asked for consent and to provide the school with a copy of the physician's report, including any recommendations for the student. In cooperation with the student's public school and the student's parent or guardian a written plan will be developed at the time of intake to ensure that vision, hearing, and postural and other related screenings will be conducated on a scheduled basis. Follow up will be monitored by the program's Nurse and documented in the student's medical file. Summit Academy nurse has procured testing equipment and partnered with the Worcester Public Schools to complete exams regarding: vision, hearing and postural screenings. All screenings will be completed the first week of school provided the students are in attendance. Any new students or students that missed the first week of school will have their screenings completed within the first week of their attendance. In regards to dental exams office manager will send to students home by email and letter a notice requiring documentation of dental exam to be turned in prior to the first day of school. A follow up reminder notice will be sent out 1 week prior to school if paperwork has not been submitted. Any child without dental exam paperwork on the first day of school will a notice sent home as well as email. This notice will state that dental exam paperwork or an upcoming dental appointment is needed for the student to be in compliance with the DESE and Summit regulations. The district will be included in this notice. The nurse will be monitoring the students checklist and working with the office manager to make sure notices are sent in a timely manner. A list of students that are not compliant in dental exams will be given to the Executive Director on the first day of school to monitor progress in compliance.
* Evidence of Completion of Corrective Action / All required documentation will be kept in student's medical files.
* Description of Internal Monitoring Process / Office Manager will keep record of communications with parents/agencies regarding exams. Registered nurse will keep checklist to ensure all appropriate exams have been completed. Nurse will monitor communications with parents and agencies. Executive Director will be given a list of student not in compliance the first week of school and will oversee the completion of the checklist with the Nurse and Office Manager.
Complete
For PQA Use Only
Corrective Action Plan Status / Approved Disapproved In Process Partially Approved Submitted / Plan Status Date / Correction Status / Corrected Not Corrected
Basis for Status Decision / Summit Academy has indicated their understanding of this requirement and discussed with this liaison ways to come into compliance and ongoing monitoring of this criterion and proceed to require proof of exams and screenings and documentation of efforts to receive them from parents/guardians based on annual or Department of Public Health requirements.
Department Order of Corrective Action
Progress Reports Required
(Check all Due Dates that apply) / Progress Report Due Date(s)
10/01/2012
12/03/2012
Required Elements of Progress Report(s) / Summit Academy must submit a chart containing the names of students, dates of birth, grade, and dates of the following for all currently enrolled students: 1. Last physical exam 2. Last dental exam 3. Last vision screening 4. Last hearing screening 5. Last postural screening. If not applicable due to the grade or age of the student, indicate NA on the chart.
PQA Review Complete
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