correction of non-compliance prior to notification monitoring and supervision march 11, 2013
TRANSCRIPT
What Does This Mean for Virginia?
DBHDS will officially notify Local Systems of their results for
compliance indicators on June 14 (within 3 months of receipt of
record review results).
The letter from the Commissioner will document
any findings of noncompliance.
What Does This Mean for Virginia?
There is a window of opportunity prior to June 14, 2013 during
which Local Systems may demonstrate correction of
noncompliance for Indicators 1, 7 and 8.
Correction prior to notification will positively impact the Local
System’s Determination!
Prong 1LA must review each individual case of noncompliance to ensure child-specific correction of the noncompliance
Prong 2Review a subsequent set of data to ensure that the Local System is correctly implementing the specific regulatory requirements (i.e. achieved 100% compliance during that review)
Verification of Correction of Noncompliance Process
Prong 1Prong 2
Verification of Correction of Noncompliance Process
Both prongs apply to correction of all findings of non-compliance, whether
there is a high level of compliance (but below 100%) or a low level of compliance.
Both prongs apply to correction of all findings of non-compliance, whether
there is a high level of compliance (but below 100%) or a low level of compliance.
Prong 1
Applicable in Virginia for Timely Initiation of Services and 45 day timeline
Timely Initiation of Services: Documentation that children who hadn’t yet started services now have (or are no longer in the EI system)
Prong 1
Applicable in Virginia for Timely Initiation of Services and 45 day timeline
45 Day Timeline: Documentation that children who hadn’t yet had their IFSP meeting now have (or are no longer in the EI system)
Prong 2
Data must be reviewed by the State Lead Agency to
confirm that the Local System is now
demonstrating 100% compliance
Prong 2
Local Systems are expected to be reviewing their data on the indicators on an ongoing basis.
Local Systems will know through their self-monitoring when they are consistently meeting the requirements.
With the new process, Local Systems will be able to notify ITVCA as soon as they are in compliance for a month’s time
Process for Correction of Noncompliance prior to June
Step 1: Know your local record review results
– Indicator 1: Review your local system record review results*
– Indicator 7: ITCVA Office will inform you around March 18 if your system is not at 100%
– Indicator 8: Review your local system record review results *
*Remember: Any instance of noncompliance requires correction.
1
Process for Correction of Noncompliance prior to June
Step 2: Local Systems are responsible for monitoring in order to identify when they are at 100% for a month.
Monitoring Tools are available from ITCVA for those systems who don’t currently have tools available.
2
Process for Correction of Noncompliance prior to June
Step 3: The Local System must notify ITCVA when they are ready for a review to confirm that they are at 100%.
May 10th is the last date a Local System can request a review to confirm that they have corrected prior to notification.
3
Process for Correction of Noncompliance prior to June
Step 4:• For Indicators 1 and 7: must verify
that children noted on Annual Record Review as not yet starting services or who had not yet had an IFSP meeting have now started services/had an IFSP meeting or are no longer in the system (Prong 1)
4
Process for Correction of Noncompliance prior to June
Step 4 : continuedThe Monitoring Consultant provides list of records for which data must be submitted for review along with a list of required documentation (Prong 2)•Review period is one month•Number of records is based on annual child count
4
Process for Correction of Noncompliance prior to June
Step 5: Local System submits required documentation
Documentation must be submitted to the Monitoring Consultant assigned to the indicator:Indicator 1 – Anne BragerIndicator 7 – Richard CorbettIndicator 8 – Mary Anne White
5
Process for Correction of Noncompliance prior to June
Step 5: continuedMonitoring Consultant reviews data to determine if the system has/hasn’t corrected.
If review of the documentation confirms correction, a letter confirming correction of noncompliance will be issued.
5
Potential Months for Correction of Noncompliance
Corresponding Month for ITCVA to Review Documentation/
Verify Correction
Indicator 1: Timely Initiation of Services
January March
February April
March May
Indicator 7: 45 Day Timeline
March April
April May
Indicator 8: Transition January February
February March
March April
April May
Months Available for Correction
Indicator 1: Timely Initiation of Services
Early March is earliest a Local System can determine if they were in compliance for January
Local System will be required to identify Annual IFSPs and/or IFSP Reviews that occurred during the month
Indicator 1: Timely Initiation of Services
Required documentation (to be submitted via secure server or fax):
Documentation that children identified in ARR as not starting services have now started or are no longer in the system (Prong 1)
For records identified by ITCVA (Prong 2)• Page 6 of the IFSP• Page 8 of IFSP (or Page 9 for IFSP Reviews)• Contact note for first visit• Service Coordinator note documenting family
reason for delay, if applicable
Indicator 1: Timely Initiation of Services
If DBHDS verifies that the LS has corrected, the date of correction will be the earliest IFSP date for the records that were reviewed.
Indicator 7:45 Day Timeline
For correction of noncompliance, records will be identified based on the IFSP date, rather than the referral date
The earliest month that can be reviewed for correction is March (referrals from December could have IFSP meetings in January and February)
April and May are opportunities to correct for March and April
Indicator 7:45 Day Timeline
Confirmation of correction of Prong 1– Richard Corbett will inform you about what
documentation is needed to confirm correction to the child level for children referred October 1 – December 31, 2012.
Required documentation (to be submitted via secure server or fax) for records identified by ITCVA (Prong 2):
– Intake form or SC note documenting referral date– Page 8 of the IFSP; if the parent signed on a different
date from the date the meeting was held, SC notes documenting the date of the IFSP must be submitted
– If applicable, SC notes documenting family reasons for delay
Indicator 7:45 Day Timeline
If corrected, the date of correction will be the earliest IFSP date for the records reviewed.
Indicator 8:Transition
February is earliest a Local System can determine if they were in compliance in January
Required documentation for records identified by ITCVA (to be submitted via secure server or fax):
– Page 7 of the IFSP– SC notes to provide additional information, if
all of the required information is not included on the IFSP
If the Local System Corrects by March/April/May:
• A letter will be sent from the EI Administrator notifying the LSM that the non-compliance has been corrected.
• The June 14, 2013 notification from the Commissioner will reflect 100%, not the Annual Record Review results
• The Annual Record Review results will be reported in the APR
If the Local System Corrects by March/April/May:
• The Annual Record Review results will be documented on the Determination Form, but the Local System will receive 0 points
• While the Annual Record Review results will be reported in the Public Report, a notation will be included indicating that the Local System has corrected
Section 1: SPP/APR Compliance Indicators
IndicatorState
Target
Local Record Review Result
Date Corrected
SubsequentNoncompliance Identified
andNot Corrected
by 6/30/12
Score
01: Timely Initiation of Services 100% 65% 2/4/2013 0
07: 45-Day Timeline 100% 65% 2
08A: Transition Steps and Services 100% 94% 1
08B: Transition Notification to LEA 100% 94% 1/3/2013 0
08C: Transition Conference 100% 100% 0
Scoring is per indicator; possible points = 5 x 2 = 1095%-100% OR correction to 100% by end of monitoring year (06/30/12) = 0 points70%-94% OR identification of isolated noncompliance after record review = 1 point
<70% OR identification of systemic noncompliance after record review = 2 points
3
How Correction Prior to Notification Impacts Determination
Section 7: Local EIS Determination Tabulation Table
SectionPossibl
e Points
Score
Section 1: SPP/APR Compliance Indicators 10 3
Section 2: SPP/APR Results Indicators 2 0
Section 3: Timely Correction of Noncompliance 2 0
Section 4: Dispute Resolution 2 0
Section 5: Fiscal Monitoring 2 0
Section 6: Data Quality 2 0
Local EIS 2013 TOTAL Points 3Local EIS 2013 Determination % [ = (20-Local System 2013 Total
Points) / 20]85%
Local EIS Lowest Compliance Indicator % 65%
Local EIS 2013 Determination Category NA
Enforcements Required
Section 1: SPP/APR Compliance Indicators
IndicatorState
Target
Local Record Review Result
Date Corrected
SubsequentNoncompliance Identified andNot Corrected
by 6/30/12
Score
01: Timely Initiation of Services 100% 65% 2/4/2013 0
07: 45-Day Timeline 100% 65% 2
08A: Transition Steps and Services 100% 94% 1
08B: Transition Notification to LEA 100% 94% 1/3/2013 0
08C: Transition Conference 100% 100% 0
Scoring is per indicator; possible points = 5 x 2 = 1095%-100% OR correction to 100% by end of monitoring year (06/30/12) = 0 points70%-94% OR identification of isolated noncompliance after record review = 1 point
<70% OR identification of systemic noncompliance after record review = 2 points
3
Without correction of noncompliance prior to notification, this system’s score for the compliance indicators would have been 6.
Section 1: SPP/APR Compliance Indicators
IndicatorState
Target
Local Record Review Result
Date Corrected
SubsequentNoncompliance Identified andNot Corrected
by 6/30/12
Score
01: Timely Initiation of Services 100% 83% 2/4/2013 0
07: 45-Day Timeline 100% 100% 0
08A: Transition Steps and Services 100% 100% 0
08B: Transition Notification to LEA 100% 95% 1/3/2013 0
08C: Transition Conference 100% 100% 0
Scoring is per indicator; possible points = 5 x 2 = 1095%-100% OR correction to 100% by end of monitoring year (06/30/12) = 0 points70%-94% OR identification of isolated noncompliance after record review = 1 point
<70% OR identification of systemic noncompliance after record review = 2 points
0
Section 7: Local EIS Determination Tabulation Table
SectionPossible Points
Score
Section 1: SPP/APR Compliance Indicators 10 0
Section 2: SPP/APR Results Indicators 2
Section 3: Timely Correction of Noncompliance 2
Section 4: Dispute Resolution 2
Section 5: Fiscal Monitoring 2
Section 6: Data Quality 2
Local EIS 2013 TOTAL Points Local EIS 2013 Determination % [ = (20-Local System 2013 Total
Points) / 20]Local EIS Lowest Compliance Indicator % 100%
Local EIS 2013 Determination Category
Enforcements Required
Without correction of noncompliance prior to notification, this local system’s score for the compliance indicators would have been 2 and their lowest compliance indicator would have been 83% which would keep them from achieving “meets requirements.”
If Noncompliance is Not Corrected
Notification Letter from Commissioner will identify the noncompliance and will provide information about required actions including:
– Monthly Local System Monitoring and opportunities for correction
– Improvement Plan requirements
Specific Information will be provided in Webinar
May 30 at 9:00 AM.