Correction of Non-Compliance Prior to Notification Monitoring and Supervision March 11, 2013.

Correction of Non-Compliance Prior to Notification

Monitoring and SupervisionMarch 11, 2013

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


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


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


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


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


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


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


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


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


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


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


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

Indicator 8:Transition

Correction date = earliest discharge date for records reviewed

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


IndicatorState

Target


Date Corrected

SubsequentNoncompliance Identified andNot Corrected

by 6/30/12

Score


07: 45-Day Timeline 100% 65% 2






3

Without correction of noncompliance prior to notification, this system’s score for the compliance indicators would have been 6.


IndicatorState

Target


Date Corrected

SubsequentNoncompliance Identified andNot Corrected

by 6/30/12

Score


07: 45-Day Timeline 100% 100% 0






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.

Questions?

Let’s Chat!

Correction of Non-Compliance Prior to Notification Monitoring and Supervision March 11, 2013.

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