Library: Policy

340:110-1-21. Child Care Services (CCS) program evaluation

Revised 6-1-22

CCS is responsible for Licensing program evaluation.  • 1

(1) The quality assurance (QA) manager is responsible for program evaluation activities, including QA reviews and CCS employee and child care industry feedback surveys.

(2) CCS establishes a method for continuously improving the internal review program through feedback and recommendations from all concerned parties.  The review:

(A) determines Licensing requirement, rule, and procedure implementation;

(B) evaluates CCS program's effectiveness; and

(C) provides objective evidence supporting the reduction, elimination, and prevention of inconsistent rules and Licensing requirement interpretation.

INSTRUCTIONS TO STAFF 340:110-1-21

Revised 6-1-22

1. (a) Review schedule.  The quality assurance (QA) manager schedules and conducts an annual review of each Licensing supervisory group including the residential and child-placing agency group.  A review may also be conducted when significant change in Child Care Services (CCS) process and service occurs or QA corrective action follow-up is necessary.

(b) Review scope.  CCS state office management identifies CCS process criteria and rules for review.  When applicable, the previous plan of correction is reviewed and evaluated.  The review includes:

(1) a review of Licensing records analyzing rules and requirements for performance consistency, compliance, relevance, and clarity;

(2) observed positive practices; and

(3) Licensing database system utilization.

(c) Review plan.

(1) The review plan is provided to the Licensing supervisor and regional program manager (RPM) or residential and child-placing agency program manager, at least 30-calendar days prior to the scheduled review and includes the:

(A) review objective, scope, and schedule;

(B) review team members' names; and

(C) identification of the supervisory group being reviewed.

(2) The review plan may change emphasis depending on review information.

(A) Review plan details are communicated throughout the review when disclosure does not compromise objective evidence collection.

(B) The QA manager may revise the review plan ensuring objectives are achieved.

(3) The QA manager selects cases meeting review criteria.

(d) QA manager responsibilities.  The QA manager responsibilities include:

(1) ensuring adequate team member participation and contacting review team members;

(2) developing the review plan, per (c) of this Instruction;

(3) providing review notification;

(4) conducting team member orientation, ensuring members are familiar with expected roles and duties;

(5) preparing review checklists;

(6) conducting conferences discussing information, per (g) of this Instruction.  Conferences occur:

(A) at the conclusion of the first day with the Licensing supervisor or residential and child-placing agency program manager; and

(B) on the final day with the Licensing staff; including the supervisor and RPM or residential and child-placing agency program manager;

(7) preparing the preliminary review report;

(8) interviewing Licensing staff regarding case management of selected criteria;

(9) preparing and submitting the final review report; and

(10) maintaining review information for four years in a confidential manner.

(e) Review team members.  Licensing supervisors and child care licensing specialists IIIs are required to participate in reviews annually.  When a team member is unable to participate in a previously scheduled review, supervisor approval is needed, and the staff must arrange for participating on the next available review.  Team members:

(1) consist of the QA manager and at least three CCS staff with a majority having at least three years licensing field experience;

(2) obtain supervisory approval for participation;

(3) are not supervised within the region being reviewed;

(4) are not representatives from the same supervisory group; and

(5) are responsible for:

(A) being both prepared and unbiased;

(B) observing, evaluating, and reviewing licensing records to determine adequacy, effectiveness, and compliance of licensing requirements and rules within the review scope;

(C) analyzing evidence determining findings, per (g) of this Instruction;

(D) documenting review information objectively;

(E) acting in an ethical manner; and

(F) keeping all review information confidential.

(f) Review checklists.  Checklists document review results. 

(g) Findings.  The QA manager analyzes review information.

(1) A finding occurs when three or more records indicate the same specific rule Section or procedure is not followed.  Findings also include, but are not limited to:

(A) falsifying information;

(B) breach of confidentiality;

(C) one-time rule violation that could place children at risk; or

(D) unethical behavior.

(2) Findings reference specific Licensing requirements or rules being reviewed.

(3) When actions are not identified as a finding, but not supported by division practice, the action is identified as an area of concern.

(4) Significant inconsistencies are documented and investigated even when not within the review scope.

(h) Entrance conference.  The QA manager conducts an entrance conference with the Licensing supervisor or residential and child-placing agency program manager for the purpose of:

(1) explaining review scope and objectives;

(2) clarifying the review plan;

(3) describing the review methods and procedures; and

(4) confirming the review schedule.

(i) Exit conference.  At the review conclusion, the QA manager conducts an exit conference with the Licensing supervisor and RPM or residential and child-placing agency program manager and Licensing staff.  The QA manager discusses the preliminary findings written report, including:

(1) the review summary;

(2) identified findings;

(3) areas of concern;

(4) recommendations;

(5) observed positive practices; and

(6) an overall evaluation of the reviewed activities.

(j) Final report.  The final report contains:

(1) the review dates, scope, and objectives;

(2) review team members' names;

(3) identification of all reference documents used during the review, such as licensing requirements and rules;

(4) findings, per (g) of this Instruction;

(5) observed positive practices;

(6) review team member recommendations;

(7) plan of correction forms; and

(8) the review report distribution list.

(k) Final report distribution.  The QA manager distributes the final report to the Licensing supervisor and RPM or residential and child-placing agency program manager, policy manager, statewide licensing coordinator, and CCS director within 30-calendar days after the review conclusion.

(l) Plan of correction.

(1) The plan of correction includes corrective action addressing the findings, per (g) of this Instruction.

(2) The Licensing supervisor and RPM or residential and child-placing agency program manager submit a plan of correction to the QA manager within 30-calendar days after receiving the final report.  When an extension of time is needed to complete the plan of correction, a written request is submitted to the QA manager explaining why an extension is necessary.

(3) CCS State Office schedules training addressing the findings, per (g) of this Instruction.

(m) Final review approval.  The RPM approves the final review and corrective action plans.  When the proposed plan of correction is not approved, the plan is returned to the Licensing supervisor or residential and child-placing agency program manager for modification.  Corrective action is implemented by CCS supervisory or management staff.