1.A.4 I II III General Supervision System for Monitoring Implementation of Part C Policy Index: Purpose: Policy #: 1.A.4 Distribution: Public Date Policy Developed: 4/27/2011 Date Policy Revised: TBD Date Policy Signed: TBD Date Policy Effective: TBD Supersedes Policy Dated: 8/10/2011 Scheduled Review: February, 2014 Tracking #: 4 Applicable Units: All Responsible Authority BWEIP Manager The purpose of this policy is to describe BWEIP s general supervision and monitoring system including the responsibilities of the state early intervention office and the local programs in the monitoring process. This general supervision system includes multiple mechanisms to: 1) identify and correct noncompliance with IDEIA and other requirements; and 2) facilitate continuous improvement. These methods and strategies are interrelated and, as a whole, ensure that the 15 local programs are implementing IDEIA and improving results for children and their families. Definition(s): Annual Performance Report (APR): The Annual Performance Report is the formal document completed by the BWEIP, required by and submitted to OSEP on an annual basis identifying the outcomes of the SPP targets. Baby and Toddler Online Tracking System (BTOTS): Baby and Toddler Online Tracking System (BTOTS) is a Utah database application designed to track EI activities and information, assist EI providers in day-to-day activities, encourage compliance with state and federal regulations and simplify compliance monitoring by allowing the BWEIP access to statewide child information. Compliance Indicators: Compliance indicators are SPP/APR indicators that assess compliance performance at onehundred (100%). DRAFT Corrective Action (CA): The corrective action is the EI programs correction of any findings of noncompliance identified by the BWEIP (See Attachment 3). Page 1 of 7
Correction of Noncompliance: Correction of noncompliance is a formal verification by the BWEIP that the EI program has corrected all instances of noncompliance by: A review of data that demonstrate correction of each individual instance of noncompliance; A review of data that demonstrate that any required actions took place, although late, for timeline-specific requirements, unless the child is no longer under the jurisdiction of EI; and A review of subsequent data that demonstrate full compliance at one-hundred percent (100%). Early Intervention (EI): Early Intervention (EI) refers to programs or services which are selected in collaboration with parents, and are designed to meet the developmental needs of a child and the needs of the family to assist in the child s development. Finding of Noncompliance: A finding of noncompliance is any finding of noncompliance determined by the BWEIP through off-site or on-site monitoring that includes: A written notification of the requirement with which noncompliance is identified; A summary of the data that details noncompliance; and The requirement that the noncompliance be corrected as soon as possible but no later than one (1) year from the date of the written notification of the finding of noncompliance. Incentives: Incentives are BWEIP recognition of EI programs that have met or exceeded established targets or have demonstrated full compliance of one-hundred percent (100%). Individuals with Disabilities Education Improvement Act (IDEIA): The Individuals with Disabilities Education Improvement Act is the federal law set forth by the United States that governs how states and public agencies provide early intervention special education and related services to children with disabilities. Interagency Coordinating Council (ICC): The ICC is designed to advise and assist the Utah Baby Watch Early Intervention Program (BWEIP) in performing the responsibilities set out in part C of the IDEIA. As required by statute, the ICC is comprised of a body of people appointed by the governor representing families, EI providers, agencies and representatives from the community. Low Performance - SPP/APR and BWEIP Results Indicators: These indicators may impact a program s annual determination and may result in a requirement for performance improvement activities. DRAFT Noncompliance: Noncompliance is any instance in which SPP/APR compliance indicators are performed less than one-hundred percent (100%). Office of Special Education Programs (OSEP): The Office of Special Education Programs (OSEP) is the federal program dedicated to improving results for infants, toddlers, children, and youth with disabilities ages birth to twenty-two (22) by providing leadership and financial support to assist states and local districts, to include part C. Page 2 of 7
Off-site Monitoring: Off-site monitoring is the oversight of activities of EI programs by BWEIP to promote compliance, technical assistance, improvement strategies, corrective actions, sanctions or incentives to ensure timely correction of all noncompliance and performance in the following areas: Review of data accountability plans; Review of compliance/monitoring reports collected through BTOTS; and Review of materials requested by the BWEIP. On-site Monitoring: On-site monitoring refers to any BWEIP oversight activities of EI programs provided at their locations to promote compliance and performance that may identify noncompliance, the need for corrective action technical assistance, improvement strategies and incentives or sanctions to ensure timely correction of all instances of noncompliance. Part C: Part C of IDEIA supports states in providing EI services for infants and toddlers with disabilities from birth to age three (3) and their families. Program Determinations: As required by IDEIA, program determinations are based on an annual BWEIP review of EI programs performance to determine if programs are meeting IDEIA part C requirements (See Attachment 2). Sanctions: Sanctions may be imposed on EI programs by the BWEIP when performance has not improved or noncompliance is not corrected in a timely manner. SPP/APR Results and BWEIP Indicators: Results indicators or those indicators set forth by OSEP that measures early intervention activities as compared to state determined targets. State Performance Plan (SPP): A State Performance Plan is a formal document developed by the BWEIP outlining a six (6) year plan to evaluate the state s implementation of part C regulations and how the state will improve such implementation. The SPP shall include compliance indicators (of which targets are onehundred percent (100%) and results indicators (of which targets have been established by the BWEIP). Training and Technical Assistance (TA System): Training and TA are services provided to EI program providers to ensure compliance with IDEIA requirements and evidence-based practices. DRAFT Utah s Complaints/Dispute Resolution System: The Utah Complaints/Dispute Resolution System is an established part C process utilized to identify and correct noncompliance in the implementation of IDEIA requirements, to identify components of the system that need improvement and to ensure parents rights are being met. Utah Department of Health, Baby Watch Early Intervention Program (BWEIP): The Utah Department of Health, Baby Watch Early Intervention Program (BWEIP) has been designated by the governor as the lead agency with the single line of responsibility to carry out all the provisions of the part C program under IDEIA. Page 3 of 7
IV Principles and Procedures: A. State General Supervision System Framework: 1. The State General Supervision System Framework (See Attachment 1) demonstrates the state s tiered intervention framework for general supervision. a. General Activities: An annual review of every program. 1) The BWEIP shall conduct several annual general supervision activities for each EI program to monitor the implementation of IDEIA and identify possible areas of noncompliance and low performance. The general activities include: a) Collection and verification of BTOTS data for the SPP/APR compliance and results indicators; b) Program Determinations; c) Review of program data accountability plan; d) Fiscal Management; e) Collection and verification of 618 data in BTOTS618 data; and f) Targeted technical assistance and professional development. b. Focused Activities: An annual review of selected EI programs 1) The BWEIP shall conduct annual focused monitoring activities with selected EI programs. The programs and areas of focus are determined annually based on state aggregated data, individual program data and other information. a) EI programs and the ICC may be included in determining which EI programs will be reviewed and what focused activities will be reviewed. b) Focused monitoring activities may include: i) Off-site monitoring activities to include in-depth review of data entered in BTOTS. ii) On-site monitoring activities to include file reviews, interviews, observation and follow-up monitoring visits. iii) Additional activities completed as determined necessary by the BWEIP. c. Intensive Activities: A review of EI programs, as needed. 1) The BWEIP shall conduct intensive monitoring activities in EI programs, as needed. a) Intensive activities may be necessary based on issues identified through general or focused monitoring activities, the complaints/dispute resolution system, or other means. Intensive activities include: i) On or Off-site monitoring activities, including an in-depth review of data entered in BTOTS; ii) Interviews; iii) Follow-up monitoring visits; and iv) Additional activities determined necessary by the BWEIP. B. Identification of Noncompliance: 1. Noncompliance may be identified at all levels within the State General Supervision System Framework through relevant activities. 2. If the BWEIP finds noncompliance with any compliance indicator, it shall make a written notification of the finding of noncompliance and require a corrective action (CA) of full correction of all noncompliance from the respective EI program. Page 4 of 7
V VI C. Correction of Noncompliance: 1. All noncompliance, once it is identified and notification is given to the EI Program, shall be corrected as soon as possible, but in no case later than one (1) year from the date of the written notification of findings of noncompliance. 2. The BWEIP shall require CAs for all noncompliance. 3. The actions and reporting required varies based on the level of noncompliance as delineated in the Corrective Action Overview (See Attachment 3). 4. If noncompliance is not corrected within one (1) year of the written finding of noncompliance, the BWEIP may impose sanctions, such as: a. More explicit details required within the CA; b. On-site visits to determine root causes of noncompliance; c. Additional reporting requirements deemed necessary to ensure compliance; and d. Extensive technical assistance. 5. The BWEIP may require that the EI program provide detail in the CA on how they may revise necessary policies, procedures or practices that contributed to any noncompliance. D. Training and Technical Assistance: 1. The BWEIP may provide training and TA that is directly linked to the SPP/APR and state monitoring activities to assist EI programs in: Authority: a. Understanding the requirements related to these indicators; b. Developing and implementing meaningful improvement plans to correct any noncompliance; c. Enhancing their program performance; and d. Improving outcomes for children and families within their program. 34 CFR 303.101: State eligibility requirements for a grant under this part; and 34 CFR 303.120: Lead agency role in supervision, monitoring, funding, interagency coordination, and other responsibilities. DRAFT Related Directive(s): 20 U.S.C. 1435(a)(10)(A); and Section 616 and 642 of the 2004 Amendments of the IDEA Page 5 of 7
VII Revision Log: April 2011: New policy June 2011: Revised Purpose statement. Added definition of Compliance Indicators. Revised title of State Indicators to APR/SPP Results and LA Indicators and its content. Revised definition of Noncompliance. Added reference to access by LA staff and Note to Attachments 1 and 2. August 2011: Added definitions of Low Performance SPP/APR and Low Performance Determined by the LA within Definitions section. Deleted reference to SPP/APR results indications and LA indicators from definition of Noncompliance and deleted definition of Corrective Action Plan. Deleted former ss (A1a1)b) referencing data submitted in BTOTS for state indicators, added ss (A1a1)d-f), added reference to on in ss (A1c1)a)i), added ss (ii-iv) within ss (A1c1)a) and deleted ss (A1c2) regarding file review all within State General Supervision System Framework. Deleted Correction from section title of Identification and Correction of Noncompliance, deleted reference to noncompliance shall be corrected as soon as possible in former ss (B3) and deleted former ss (B4 & B4 Note) regarding LAs require CAs for all noncompliance and actions required may vary based on the level of noncompliance all within ss (Identification of Noncompliance). Revised former subsection title of Corrective Action to Correction of Noncompliance within ss (C), added new ss (C1-4a-d). deleted former ss (C2 and C5) referencing EI programs cited for noncompliance shall be released from the CA and reference to LA imposed sanctions all within Correction of Noncompliance. Deleted former ss (D) regarding Corrective Action Plan. Added new Attachment 2. Revised minor wording and bulleting throughout policy. January 2013: Deleted definition of LA, added definition of Utah Department of Health, BWEIP, and updated definitions. Replaced IDEA with IDEIA and LA with BWEIP throughout policy. Added section V. Revised attachment formatting. As per 34 CFR 303.208, this policy awaits public comment. The policy shall be revised as needed after public comment. UNDER REVIEW Susan Ord, BWEIP Program Manager 0-0-13 Date Page 6 of 7
Attachment 1: State General Supervision System Framework 1. The State General Supervision System Framework may be accessed on the BWEIP website by clicking here. Attachment 2: Program Determinations 1. The Program Determinations may be accessed on the BWEIP website by clicking here. Attachment 3: Corrective Action Overview 1. The Corrective Action Overview may be accessed on the BWEIP website by clicking here. Page 7 of 7
State General Supervision System Framework Please refer to BWEIP policy 1.A.4 General Supervision System for Monitoring Implementation of Part C Intensive Activities Individual Programs, As Needed Focused Activities Some Programs, Each Year General Activities Every Program, Every Year Created: 4/14/2011 Page 1 of 1
PROGRAM DETERMINATIONS BWEIP s Determination Criteria for Local Program Performance in Meeting the Requirements and Purposes of the IDEA Please refer to BWEIP policy 1.A.4 General Supervision System for Monitoring Implementation of Part C Determination Criteria Substantial compliance on all SPP/APR compliance indicators (1, 7, 8A, 8B, and 8C.) Performance on Results Indicator (For implementation in FFY 2010-2011) Timely correction of ANY noncompliance identified through Audit Findings (monitoring, file review, database, site visits, etc.) Valid and reliable data on ALL (including results) indicators Timely Dispute Resolution Meets Requirements Demonstrates 95%-100% compliance on all compliance indicators Meets or exceeds the state target Demonstrates timely correction of all noncompliance identified in the previous fiscal year AND Has improvement activities to timely correct all noncompliance identified in the previous fiscal year All indicators have valid and reliable data No disputes OR Demonstrates timely resolution of all disputes Needs Assistance (Sanctions imposed after two consecutive years see below) Demonstrates 80% - 94.99% compliance on one or more compliance indicators Does not meet state target AND Demonstrates progress toward the state target Does not demonstrate timely correction of all noncompliance from previous fiscal year AND Has made significant progress toward correcting all noncompliance identified in the previous fiscal year One or more indicators are missing valid and reliable data Does not demonstrate timely resolution of one or more disputes. Needs Intervention (Sanctions imposed after three consecutive years see below) Demonstrates 70% - 79.99% compliance on one or more compliance indicators Does not meet state target AND Does not demonstrate progress toward the state target Does not demonstrate timely correction of all noncompliance identified in the previous fiscal year AND Has not made significant progress toward correcting all noncompliance identified in the previous fiscal year One or more indicators are missing valid and reliable data AND Does not demonstrate significant progress in correcting data problems identified through monitoring or other means Does not demonstrate timely resolution of any disputes Needs Substantial Intervention (Sanctions imposed see below) Demonstrates less than 70% compliance on one or more compliance indicators Does not meet state targets AND/OR Does not demonstrate progress toward state target AND/OR Shows unwillingness to improve performance. Failure to substantially comply significantly affects core requirements of the program AND Shows unwillingness to comply to correct noncompliance One or more indicators are missing valid and reliable data AND Failure to correct data problems significantly affects core requirements of the program AND/OR Shows unwillingness to comply to correct data problems Does not demonstrate timely resolution of any disputes AND/OR Shows unwillingness to resolve disputes Created: 3/10/2011 Page 1 of 3
DEFINITIONS OF DETERMINATIONS CRITERIA: Substantial compliance on compliance indicators : 1. Having a program rating of 95% or higher, based on compliance reviews and Baby Toddler Online Tracking System (BTOTS) data on all compliance indicators, as shown on the most recent State Performance Plan (SPP) or Annual Performance Report (APR). 2. However, any level of compliance less than 100% is considered noncompliance and will require full correction to 100%. Indicator 1: Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner (45 days). Indicator 7: Percent of eligible infants and toddlers with IFSPs for whom an evaluation and assessment and an initial IFSP meeting were conducted within Part C s 45-day timeline. Indicator 8: Percent of all children exiting Part C who received timely transition planning to support the child s transition to preschool and other appropriate community services by their third birthday including: A. IFSPs with transition steps and services; B. Notification to LEA, if child potentially eligible for Part B (compliance expected as of FFY 09 in accordance with OSEP acceptance of Utah s Disclosure of Directory Information Policy); and C. Transition conference, if child potentially eligible for Part B. Performance on results indicators Meet or exceed state targets on results indicators. Criteria to be determined for FFY 2010-2011. Timely correction of ANY noncompliance identified through Audit Findings (monitoring, file review, BTOTS, site visits etc.) The noncompliance is corrected i.e., a plan of corrective action (CA) has been developed, implemented, and resolved no later than one year after BWEIP informed the local program in writing of the noncompliance. Correction has been verified through the review of data collected or submitted demonstrating that each individual instance of noncompliance has been corrected and subsequent data demonstrates 100% compliance with the specific regulatory requirements. AND/OR Significant progress in correcting noncompliance : Means a CA has been developed and implemented AND BWEIP s monitoring of progress indicates that the program is on track to resolve the action within one year of the date of the CA. All individual instances of noncompliance have been verified as corrected. Subsequent data have been collected or submitted that show that the program has nearly demonstrated 100% compliance and will likely demonstrate 100% compliance within one year of notification of noncompliance. Valid and reliable data : 1. No evidence of noncompliance was identified through the compliance review process; AND 2. The accuracy of BTOTS data was verified by the Program Directors and BWEIP staff. Timely dispute resolution All disputes were resolved within the proscribed timeframe. Created: 3/10/2011 Page 2 of 3
Additional Information: As required by IDEA (sections 616(a)(1)(C)(ii) and 642), BWEIP will impose sanctions, as necessary, based on its determinations. When BWEIP determines that a program: 1. Needs Assistance for two consecutive years, BWEIP will take one or more of the following enforcement actions: o Advise programs of available sources of technical assistance to address areas on which the program needs assistance; or o Identify programs as high risk grantee and impose conditions on use of funds. 2. Needs Intervention for three or more consecutive years, BWEIP will take one or more of the following actions: o Require the program to prepare or implement a corrective action plan to correct the identified area(s); or o Withhold, in whole or in part, further payments to programs. 3. Needs Substantial Intervention at any time, BWEIP will take the following enforcement action: o Withhold, in whole or in part, any Part C funds. In addition to the minimum enforcement actions noted above, BWEIP may use any other enforcement mechanisms and actions available to it to enforce the IDEA. For example, BWEIP might advise an EIS program of available technical assistance on areas on which the program needs assistance after the first year the program is identified as needing assistance, or require more rigorous reporting on the area needing improvement. Created: 3/10/2011 Page 3 of 3
CORRECTIVE ACTION OVERIVIEW FFY 2009-2010 Corrective Action Overview Based on APR Compliance Indicators Data collected Please refer to BWEIP policy 1.A.4 General Supervision System for Monitoring Implementation of Part C 100% Compliance Indicators Indicator 1: Percent of infants and toddlers with IFSPs who receive the early intervention services on their IFSPs in a timely manner. (20 U.S.C. 1416(a)(3)(A) and 1442) Indicator 7: Percent of eligible infants and toddlers with IFSPs for whom an evaluation and assessment and an initial IFSP meeting were conducted within Part C s 45-day timeline. (20 U.S.C. 1416(a)(3)(B) and 1442) Indicator 8: Percent of all children exiting Part C who received timely transition planning to support the child s transition to preschool and other appropriate community services by their third birthday including: A. IFSPs with transition steps and services B. Notification to Local Education Agency (LEA)*, if child potentially eligible for Part B: *(compliance expected as of FFY 09 in accordance with OSEP acceptance of Utah s Disclosure of Directory Information Policy) and; (8A and 8B.based on FFY 09-10 onsite compliance monitoring at 5 programs) C. Transition conference, if child potentially eligible for Part B. (20 USC 1416(a)(3)(B) and 1442) Performance on any compliance indicators of less than 100% is noncompliance and requires corrective action. The following corrective action requirements and reporting apply to each indicator where noncompliance is identified. To effectively monitor the implementation of Part C of the IDEA by EI programs/providers, as required by IDEA sections 616, 635(a)(10)(A), and 642,34 CFR 303.500 303.501, the State must have a general supervision system that corrects noncompliance in a timely manner. In addition, as noted in OSEP Memorandum 09-02, Reporting on Correction of Noncompliance in the Annual Performance Report Required under Sections 616 and 642 of the Individuals with Disabilities Education Act, dated October 17, 2008 (OSEP Memo 09-02), in order to verify that previously identified noncompliance has been corrected, the State must verify at the EIS program and/or provider: (1) is correctly implementing the specific regulatory requirements (ie., achieved 100% compliance) based on a review of updated data such as data subsequently collected through on-site monitoring or a State data system; and (2) has corrected noncompliance for each child, unless the child is no longer within the jurisdiction of the EI program and/or provider. Created: 3/10/2011 Page 1 of 2
Compliance Level Action Required? Program Corrective Action Requirements Corrective Action Reporting to BWEIP 100% Compliance No None N/A 95% to 99.9% Compliance Yes Determine status and cause of each late event, unless the child is no longer in Part C. Periodic self-review of monitoring report(s) in the indicator(s) of concern. Data report to BWEIP showing correction for all individual instances (or completion, although late) for timeline indicators (1, 7, 8c)). Subsequent data report at 100% for each indicator of concern per BWEIP specification. 80% to 94.9% Compliance Yes Analysis of cause(s) of noncompliance. Written implementation plan to address cause(s) with specified timeline, submitted to and approved by BWEIP. TA conference call(s) as needed. Onsite BWEIP TA as needed. Data report to BWEIP showing correction for all individual instances (or completion, although late) for timeline indicators (1, 7, 8c). Subsequent data report at 100% for each indicator of concern per BWEIP specification. Quarterly review and reporting to BWEIP of monitoring report(s) for the indicator(s) of concern. Final written report to BWEIP detailing progress by 6/1/11. 70% to 79.9% Compliance Yes Analysis of cause(s) of noncompliance Written implementation plan to address cause(s) with specified timeline, submitted to and approved by BWEIP. Bi-monthly TA call with BWEIP. Onsite monitoring visit. Onsite BWEIP TA. Data report to BWEIP showing correction for all individual instances (or completion, although late) for timeline indicators (1, 7, 8c). Subsequent data report at 100% for each indicator of concern per BWEIP specification. Bi-monthly review and reporting to BWEIP of monitoring report(s) for the indicator(s) of concern. Monthly written reporting and TA call with BWEIP. Final written report to BWEIP detailing progress by 6/1/11. < 70% Compliance Yes Analysis of cause(s) of noncompliance Written implementation plan to address cause(s) with specified timeline, submitted to and approved by BWEIP. Monthly TA call with BWEIP. Onsite monitoring visit(s). Onsite BWEIP TA. Data report to BWEIP showing correction for all individual instances (or completion, although late) for timeline indicators (1, 7, 8c). Subsequent data report at 100% for each indicator of concern per BWEIP specification. Monthly review and reporting to BWEIP of monitoring report(s) for the indicator(s) of concern. Monthly written reporting and TA call with BWEIP. Final written report to BWEIP detailing progress by 6/1/11. Created: 3/10/2011 Page 2 of 2