Peck Full Service Community School Therapeutic Intervention Program

Investigation Report
February 16, 2016

Peck Full Service Community School Therapeutic Intervention Program

Investigation Report
February 16, 2016
I. Background
The following report details an investigation conducted by the Department of Elementary and
Secondary Education (ESE) and Holyoke Public Schools (HPS) into the findings described in a report by
the Disability Law Center (DLC) dated December 9, 2015, on the Therapeutic Intervention Program (TIP)1
at Peck Full Service Community School (Peck).
The purposes of this investigation were:
1.
2.

to determine the systemic failures that led to the findings in the DLC report and
to identify additional steps that will be taken to strengthen the work already underway to
improve the program.

DLC initially received a complaint about the treatment of students in the TIP at Peck on April 2, 2015,
and notified HPS of its intent to investigate on April 30, 2015. To conduct the investigation, DLC
reviewed documents, conducted interviews, and visited the program between May 12, 2015, and
November 10, 2015. When released in December 2015, the DLC report noted that HPS had already
taken corrective action relating to the TIP at Peck, and such actions were the result of a change in
governance and leadership of HPS. On April 28, 2015, the Board of Elementary and Secondary Education
voted to declare HPS chronically underperforming and placed it in Level 5 receivership. At that time, the
Commissioner became the interim receiver until he appointed Dr. Stephen Zrike as the permanent
receiver, effective on July 6, 2015. Based upon immediate concerns about TIP at Peck and in order to
ensure that TIP at Peck students were adequately supported at the start of the 2015-2016 school year,
the Receiver contracted with the Center for School Crisis Intervention and Assessment (Center School), a
private special education school, to provide staffing and support for the program. In addition, the
Receiver also engaged SchoolWorks, a school leadership partner, to improve the overall functioning of
Peck. Moreover, as a component of the Holyoke Turnaround Plan, Educational Development Center, Inc.
(EDC) is conducting a comprehensive evaluation of HPS special education services and provide ongoing
consultation to implement necessary improvements. More information about these supports is included
later in this report.
Having acknowledged that under the receiver HPS had taken steps to improve TIP at Peck, the DLC
report stated that it would be essential that continued progress be carefully monitored. In early
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The Therapeutic Intervention Program at the Peck School is designed to provide a therapeutic educational
program to students in grades 4-8 with emotional and behavioral disabilities.

February 2016, DLC, ESE, and HPS signed an agreement in which all the parties agreed to work together
to improve conditions at the TIP at Peck. DLC will receive reports from HPS and ESE and conduct site
visits of the program in order to track the effectiveness of the remedial plan.
II. Procedures for Investigation
Dr. Stephen Zrike, Receiver of Holyoke Public Schools, was the primary investigator for this report and
Dr. Russell Johnston, ESE Senior Associate Commissioner, directly supported the investigation. Other
staff members from HPS and ESE contributed to the investigation. Hereinafter, they will be referred to
as investigators. The investigation included interviews, meetings, document review, site visits, and
classroom observations.
Interviews
The investigators conducted a range of interviews, starting with those who had direct responsibility over
the Peck School and TIP at Peck and then extending the interviews to others who were involved with the
program or who had relevant information. The interviewees included current and former
administrators, educators, counselors, family liaisons, paraprofessionals and other staff members, and
parents of current and former students. In some instances, parents brought their children to interviews,
and they participated as well. Dr. Zrike and Dr. Johnston also interviewed representatives from an
external mental health counseling organization that provided support to Peck and TIP at Peck students
during the 2014-2015 school year. In addition, they held conference call interviews with the attorneys
who provided counsel to the district during the 2014-2015 school year. Finally, staff from the Holyoke
Department of Children and Families (DCF) office and from ESEs Program Quality Assurance (PQA) office
were also consulted as part of this investigation.
Meetings
Dr. Zrike hosted a parent meeting on December 15, 2015, to discuss the DLC report with the families of
students who attended the TIP at Peck in the 2014-2015 school year and/or the 2015-2016 school year.
Over 20 families attended and shared their experiences with the program. Parents were invited to
schedule subsequent one-on-one conversations if they had additional information to share. Nine
families met with the investigators to detail their impressions of the TIP at Peck.
Document Review
The investigators reviewed documents associated with Peck and TIP at Peck, including restraint data,
emails and written communication, DCF reports, job descriptions, student files, staff evaluations,
policies, personnel files, incident reports and notes, nurses files, and school committee minutes. The
investigators also reviewed an evaluation of the TIP program completed by the Westfield State
University Social Work Program in May 2015.
Site Visits and Observations
The investigators conducted site visits to the Peck School on several occasions during this investigation
to examine the facilities-related issues raised in the DLC report. In addition, the Massachusetts Child
Advocate and the Director of System Transformation from the Department of Mental Health
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Child/Adolescent Services conducted a site visit together with members of the investigation team, and
the Director of System Transformation returned to conduct additional site visits.
III. Findings
First and foremost, the investigators determined that the issues raised in the DLC report resulted from a
systemic failure. Despite some efforts by HPS during the 2014-2015 school year to improve the program
(e.g., weekly leadership meetings and staff workshops that commenced in February 2015), the
investigators found that the student experience at TIP at Peck was compromised by inadequate
oversight and support, and an absence of urgency from multiple HPS departments. This resulted in an
institutional environment in which HPS failed to address the poor treatment and inadequate educational
experience of some students with social and emotional needs. Concerns were brought to the attention
of senior administrators and appropriate action was not taken, resulting in issues that were not resolved
for extended periods of time.
Inadequate Training
During the 2014-2015 school year, the staff at TIP at Peck did not have the requisite in-depth training to
properly conduct restraints. While some staff members were trained at the beginning of the 2014-2015
school year, many staff in the program were not trained until midway through the school year (both full
training and refresher courses). The training that staff received included information on various aspects
of restraint, but did not cover the use of prone restraint. As a result, staff members repeatedly
implemented prone restraints during the 2014-2015 school year without having received the
appropriate training.
The investigation also showed that Peck and TIP at Peck staff were not trained on key district policies
and procedures. Several of these trainings are required for all staff annually and districts are reminded
of this responsibility each year when ESE publishes the annual Superintendents Checklist. Specifically,
the investigators learned that staff at Peck and TIP at Peck were not adequately trained on the
foundational elements of restraints. In contrast to the in-depth restraint training described above, all
staff members are required to receive an overview of the districts restraint policy, primarily intended to
inform staff about basic restraint guidelines and prevention techniques. In addition, staff did not receive
the required annual training on the process and expectations for reporting allegations of abuse or
neglect.
Additionally, staff were not properly trained on the process for completing incident reports and
conducting investigations. Among other things, this absence of training seemed to have resulted in
missed timelines for reporting restraints of 20 minutes or more or restraints that resulted in staff or
student injury to ESEs office of Program Quality Assurance (PQA) as required by regulations at the time.
Such reports were to be sent to PQA within five school working days of an incident but Peck
administrators did not send the reports to PQA until an extended period of time after the incidents took
place. Finally, HPS did not provide adequate training for Peck administrators on the use of progressive
discipline for staff misconduct.

Overuse of Restraint
During the 2014-2015 school year, there were an excessive number of restraints, and the number of
prone restraints was particularly concerning. Students were restrained over 200 times, and over 40 of
these incidents involved prone restraints. In particular, 3 students were restrained more than 20 times
and one student was restrained more than 50 times. Further, a review of the restraint reports indicated
that there were several cases where restraints were found to be unnecessary. This was corroborated by
staff members who expressed concern about certain restraints and questioned whether some
interactions were overly physical. Parents were not always informed when their children were
restrained and were not always provided a full report of the incident. Following a restraint, some
families told investigators that they would come to the school for more details and left feeling
disrespected by the staff in the program.
Facilities and Staffing
Additionally, the investigators learned that the program was understaffed during the 2014-2015 school
year. The ratio of students to educators was a concern for most of the school year. The investigators
were told that often a dozen students would be sent to a time-out room with only two staff members
present. The investigators learned that when a staff member was out for any reason, there were
occasions when a substitute was not assigned or did not possess sufficient expertise to support students
in the program. Staff also expressed concerns about the physical condition of the facility and the safety
of the therapeutic spaces in TIP at Peck. Maintenance requests were made, but limited effort was made
to rectify the issues raised by the staff during the 2014-2015 school year.
Students without IEPs and Other IEP-Related Issues
During the investigation, investigators also were told that some students were placed in TIP at Peck
without Individualized Education Programs (IEPs). At least 3 students were enrolled in the program with
504 plans but without IEPs. In other cases, documentation showed the following errors in IEP files:
missed deadlines for annual reviews and re-evaluations, and/or frequent incomplete progress reports.
TIP at Peck students were frequently assigned to the schools student support room even though TIP is
intended to be a therapeutic placement for students and their needs should be met within the program.
Student Support Rooms
The investigators found that the student support room at Peck was used as a disciplinary measure even
though it is meant to be structured as an intervention for struggling learners. Students from all grade
levels and programs were sent to the room that was staffed by at least four different teachers during
the 2014-2015 school year. The procedures and protocols for access to the room were unclear to the
staff interviewed. Logs showed that excessive numbers of students were sent to the room and many of
them spent most of the day in these spaces. As noted above, TIP at Peck students were also sent to the
student support room even though the TIP program had its own spaces that were to be used for the
purpose of calming students.

Relationships with Families

It was particularly distressing to hear parents accounts of their experiences at TIP at Peck. Parents
expressed concerns about the IEP process that ultimately assigned their children to TIP at Peck. Multiple
parents told investigators that they felt that if they did not sign IEPs accepting placement in TIP at Peck,
school personnel would notify DCF. Families said that their children entered TIP at Peck without a
transition plan, informational material, or a warm welcome. They discussed their disappointment with
communication about their childs academic performance and behavior and about the programs
philosophy and design. As was stated earlier, families expressed the belief that their concerns were not
taken seriously and questioned the administrations follow through, responsiveness, and interest in
listening to them.
Evaluations and Internal Investigations
TIP at Peck staff and those supervising TIP at Peck were either not evaluated or received evaluations
that were not reflective of the issues in the program. In particular, paraprofessionals and
interventionists did not receive evaluations during the 2014-2015 school year. Therefore, any concerns
that might have emerged about staff performance were not adequately documented or formally
communicated to the employees. Further, limited discipline was issued to staff members about the
incidents referenced in the DLC report. While some internal investigations were completed, they were
not comprehensive and did not adequately hold staff accountable for poor judgment and/or
misconduct.
IV. TIP at Peck Remedial Plan
Actions Previously Taken to Improve the TIP at Peck
As stated above, the TIP at Peck was an early focus of the receivership, and HPS made several important
changes to the program before the release of the DLC report. For example, at the start of the 2015-2016
school year, HPS engaged Center School, a private special education school in Holyoke, to provide direct
leadership and support for the TIP program. Center School has also provided staffing to the program,
particularly for interventionists and paraprofessionals. With the addition of Center School personnel, TIP
at Peck is fully staffed and appropriate student-to-staff ratios have been maintained for the 2015-2016
school year. HPS ensured that a team of TIP at Peck HPS employees and Center School employees
completed an in-depth training on restraint prevention and intervention at the start of the 2015-2016
school year. This training met the requirements of the new restraint regulations that went into effect on
January 1, 2016.
In addition, HPS is partnering with SchoolWorks, a Massachusetts-based education consulting group, to
provide support to the leadership team and teachers at Peck with a particular emphasis on improving
instruction at the school. In October, 2015, Dr. Zrike also made a leadership change at the Peck School
by hiring an experienced administrator to serve as acting principal for the remainder of the school year.
The acting principal had extensive experience as a school administrator until recently retiring from that
role before taking on this position. Finally, the school has also expanded parent outreach through
regular home visits.
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Ongoing Actions to Improve the TIP at Peck

As a result of the findings of this investigation, a series of leadership and programmatic changes are
warranted and being implemented. The district is in the process of identifying new leadership with the
expertise to effectively coordinate and enhance the quality of TIP at Peck. Significant changes in staffing
have taken place since the beginning of the 2015-2016 school year and the Receiver is confident that
there has been meaningful improvement in the services that students are receiving.
Efforts to Reduce Restraint
Seclusion is prohibited and is not occurring. HPS is taking multiple steps to support its staff in their
efforts to reduce the use of restraint, including:
HPS provided the required training on the HPS restraint policy to all staff at Peck and TIP at Peck
(as well as staff from other schools) on January 6, 2016. This training focused on the new state
restraint regulations that went into effect on January 1, 2016. Also on January 6, 2016, the
district trained all Peck and TIP at Peck staff (as well as staff from other schools) on the districts
policy about reporting suspected cases of abuse and neglect. Both these workshops will
continue to be provided to all staff annually.
The HPS school climate and culture directors have organized a trauma/mental health
conference in Holyoke on April 5, 2016 for HPS staff. The purpose of this event is to convene
local and statewide specialists in this work to begin the critical discussion of becoming a more
trauma-sensitive school district. This session will be open to all HPS staff and community
partners who work with children/families across the city of Holyoke.
HPS has posted a position for a districtwide behavior specialist whose role will be to partner
with teachers and school counselors to provide coaching, oversee the implementation of
behavior de-escalation techniques, and design and effectively implement functional behavior
plans for students across the district. HPS expects to fill this position before the end of the 20152016 school year.
Revising Policies and Establishing New Protocols on Restraint and Time Out
HPS has taken specific actions to ensure the safety and well-being of students. First, HPS has updated
the districts policy about restraint and time out so that it is consistent with the new state-wide
regulations that went into effect January 1, 2016. The Peck principal has appointed a restraint review
team to review restraint documentation weekly and provide the principal and director of special
education with ongoing updates about their findings. In addition, this team will provide feedback to the
staff at both Peck and TIP at Peck to refine and improve behavioral interventions so that fewer restraints
are required. Restraint reporting will be completed using newly updated forms provided during recent
training sessions and those reports will be kept in a central location in the school. Peck administrators
and behavioral specialists will ensure that notification to families is a priority and every effort will be
made to communicate with families as soon as possible after a restraint takes place, with the required
written report completed and sent to students homes within three school working days. The district has
also developed a protocol that offers guidance to staff on how to de-escalate challenging situations
before engaging in a restraint.
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Revising Policies and Establishing New Protocols for Involving the Police
Since the release of the DLC report, the Receiver has had meetings with the Holyoke Police Department
to discuss engagement between HPS and local law enforcement. This dialogue has been productive and
has culminated in the creation of a Memorandum of Agreement (MOA) between the schools and the
Holyoke Police Department. This MOA provides clear guidance on how schools and the police will
interface relative to incidents taking place at school.
Engagement with Families
At the December 15, 2015, parent session, HPS pledged to host regular meetings with families of TIP at
Peck students throughout the remainder of the year. On February 3, 2016, TIP at Peck hosted a restraint
training for families so that they might better understand the new regulations, ask questions, and
engage in a dialogue with staff about de-escalation practices in the program. On February 29, 2016,
district, school, and TIP at Peck leadership will reconvene with families to update them on changes to
the program and to continue soliciting input on the quality of the student/parent experience with TIP at
Peck. The districts newly hired Director of Family and Community Engagement will also be introduced
to families as an additional support and resource.
Ombudsman
The Receivers Chief of Staff has been assigned to investigate any complaints related to TIP at Peck
henceforth. The Chief of Staff will serve as an objective ombudsman who has the authority to respond
thoroughly and efficiently to any parent concerns that are raised about the program.
New Performance Evaluation Procedures
HPS has overhauled the performance evaluation procedures for all employees, including
paraprofessionals and interventionists. New guidelines have been developed complete with updated
evaluation instruments that match an employees job description. Moreover, HPS professional
educators are being evaluated in accordance with the guidelines established by ESE. Every employee will
receive a performance evaluation before the conclusion of the 2015-2016 school year.
Further Enhancement of TIP
To complete a comprehensive review of special education services across the district, the district has
contracted with the Education Development Center, Inc. (EDC). In addition to this overall review of
special education services across the district, HPS has engaged EDC to conduct a more exhaustive
analysis of the districts services for students with emotional impairment. This includes clearly
delineating the function and services provided in the districts current TIP programs. Additionally, HPS is
addressing the finding mentioned earlier in this report about students enrolled in TIP at Peck without
IEPs and other IEP related issues.
The Receiver directed the HPS Director of Student Support to review and update the policies and
procedures as needed for reporting suspected child neglect or abuse (51As). The Director of Student
Support will continue to oversee this work with school counselors, who are charged as point people in
schools for assistance and support to staff.
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The Receiver also directed the HPS Director of Student Support to review and update the districts
Bullying Prevention Plan as well as the bullying reporting forms and investigation/follow-up procedures
by the spring of 2016. Once the review and update are completed, the HPS Director of Student Support
will provide a training to staff districtwide on this topic before the end of the 2015-2016 school year. In
the meantime, bullying reporting forms have been updated and translated into Spanish.
Facility Improvements
In December 2016, the Massachusetts Child Advocate and the Director of System Transformation from
the Department of Mental Health Child/Adolescent Services (DMH) visited the Peck School and toured
the TIP program. They provided feedback on the buildings facilities and spaces used to calm students
which led to immediate improvements in several spaces in the school. For example, the district
completed needed repairs to the time-out rooms in order to increase their safety, and those rooms
were painted to create a more welcoming environment for students. The district has also retrofitted the
windows in TIP at Peck to prevent the possibility of students climbing outside. Specialists from DMH also
completed an environmental audit of the program in January 2016 and have provided additional
recommendations to improve the programs facilities. By spring 2016, the receiver will have developed a
plan to make the necessary improvements described in the environmental audit.
Monitoring
Ongoing monitoring of services, supports, and student outcomes TIP at Peck will be conducted through
a variety of formats. First, the district has committed to a monitoring process with DLC to track the
effectiveness of the TIP at Peck Remedial Plan. HPS will provide to DLC periodic data reports, including:
a) all restraint/seclusion reports and data collected by Peck/TIP on students in TIP; b) all Restraint
Evaluation Team logs; c) all records of restraints reported to ESE; d) records of all restraint/seclusion
training of TIP staff, including the names of staff trained; e) subject of the training, hours completed, and
who conducted the training; f) all nursing logs of post-restraint physical exams; g) documentation of any
improvements made to the building to promote a safe environment; h) reports involving police or crisis
intervention including why they were called and action taken as a result; i) all logs from the intervention
rooms; and j) documentation of other corrective action taken by HPS or other individuals working to
improve conditions at TIP at Peck. In addition, within 45 days of receiving the data reports, DLC will
conduct an on-site visit of the TIP at Peck. Finally, on June 29, 2016, HPS and ESE will submit an updated
remedial plan to DLC to report on what has taken place and what actions will take place in the
subsequent six months.
In addition, ESE will also be engaged in monitoring and evaluating services provided to students with
disabilities at Tip at Peck. A mid-cycle review has been scheduled for April 4, 2016, by ESEs PQA review
team, and the review team will investigate the use of restraint and time-out at TIP at Peck.
V. Conclusion
The TIP at Peck must provide students with a safe and supportive learning environment. All students
should have an experience that is individualized to address their academic, social, and emotional needs.
While additional work remains to enhance the program, there has been significant progress during the
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2015-2016 school year. The frequency of the use of restraints is reduced, communication with families
has improved, and more students are being included in the general education program. The district is
committed to working closely with DLC to build on these positive changes to ensure that students
receive an exemplary educational experience at TIP at Peck.