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340:110-1-8.3. Certification of programs to receive a differential quality rating and improvement level

Revised 3-13-2020

340:110-1-8.3. Certification of programs to receive a differential quality rating and improvement level

(a) Purpose.  The differential quality rating and improvement system was developed to improve the overall quality of care by increasing the professional development and education of child care providers and to provide the public with a method to evaluate child care.  Certification is required for a program to receive a differential quality rating for children whose families are receiving subsidized child care benefits through the Oklahoma Department of Human Services (DHS).

(b) Criteria for child care centers and homes certification levels.  The certification process and quality rating and improvement criteria for child care programs are described in Oklahoma Administrative Code (OAC) 340:110-1-8.3 through 340:110-1-8.10.

(c) Request for star certification process.  The process in (1) through (4) of this subsection is required for certification.

(1) Criteria for one star centers and homes.  A program operating on a permit or license is automatically designated as a one star program.

(2) Criteria for one star plus centers and homes.  For approval as a one star plus program, the owner and director or primary caregiver, when applicable, complete and submit Form 07LC025E, Request for Child Care Center Star Certification, or Form 07LC027E, Request for Family Child Care Home Star Certification, and:

(A) meet all criteria described in (b) of this Section; and

(B) when licensed as a child care center, meet at least the minimum required number of master teachers, per applicable Licensing requirements and are not eligible for master teacher probationary periods.

(3) Criteria for two star centers and homes.  For approval as a two star program, the owner and director or primary caregiver, when applicable, complete and submit the appropriate request for star certification, and meet:

(A) all one star plus and two star criteria described in (b) of this Section; or

(B) Licensing status and compliance, per OAC 340:110-1-8.4, and provide documentation the program is:

(i) accredited by a national accrediting organization approved by Child Care Services (CCS); or  • 1

(ii) a Head Start grantee and compliant with Head Start Program Performance Standards.

(4) Criteria for three star centers and homes.  For approval as a three star program, the owner and director or primary caregiver, when applicable, must:

(A) complete and submit the appropriate request for star certification; and

(B) meet one star plus and two star criteria described in (b) of this Section, and be:

(i) accredited by a national accrediting organization approved by CCS; or  • 1

(ii) a Head Start grantee and compliant with Head Start Program Performance Standards.

(d) Approval for certification for centers and homes.  The procedures in this subsection are followed for initial approval and requests for higher star certification level.

(1) The owner and director or primary caregiver, when applicable, submit the appropriate request for star certification and required documentation to CCS.  • 2 & 3

(2) The stars outreach specialist determines when certification criteria are met by reviewing the case file and submitted documentation.  When it has been four months since the last monitoring visit, the stars outreach specialist requests Licensing staff conducts a full-monitoring visit.  Prior to approval, the stars outreach specialist reviews all information consulting with Licensing staff and the stars program administrator or designee as needed.

(A) The monitoring visits and substantiated complaints for the last 24 months of operation are reviewed for criteria compliance determination.  • 4  The request may be denied when the program has:

(i) numerous, repeated, or serious non-compliance, per OAC 340:110-1-8.4;

(ii) a single serious incident resulting in injury or imminent risk of harm to a child within the 24-month period;

(iii) an Emergency Order or notice of proposed request for license denial or license revocation issued;

(iv) a serious substantiated complaint;

(v) failed to employ a qualified director for six months or more; or

(vi) a consent agreement, per OAC 340:110-1-9.5.  • 5

(B) When the program meets the criteria, the stars outreach specialist provides a letter confirming the approval and the effective date, and updates the database.  • 6  When numerous, repeated, or serious non-compliance was identified during case review for the star certification request, the letter states these non-compliances are considered, and may result in star certification reduction when subsequent serious non-compliances occur.

(C) When the program fails to meet the criteria, the stars outreach specialist provides a letter identifying criteria not met.  The request for star certification is also reviewed determining when another star certification level can be met and updating the database accordingly.  • 7

(D) The owner and director or primary caregiver, when applicable, may reapply when criteria are met.  When the request for a higher star certification level is denied due to numerous, repeated, or serious non-compliance with Licensing requirements, the program is not approved for a higher star certification level prior to six months after the program receives the denial letter by certified mail.  The regional programs manager (RPM) may reduce the six-month waiting period based on case file evaluation, corrective action written documentation, and Licensing staff observation and documentation of substantial compliance improvement.  The RPM provides the program written notification regarding reduced timeframes.

(E) The owner may withdraw the request for star certification prior to denial.

(F) The owner may request a reduction in star certification level.  The request is made in writing to CCS.  Quality rating and improvement system (QRIS) personnel or the designee provides a letter to the owner documenting the reduction request, including the new star certification level effective date, and updates the database with the program's new star certification level.  A reduction request does not constitute a reduction in star certification level, per (h) of this Section, and the right to request an administrative review is waived. 

(e) Complaint investigations.  Pending complaint investigations may impact star certification request approval.  • 4 & 5

(f) Ongoing review.  The procedures in this subsection are followed for ongoing review.

(1) Program notification to CCS.  The owner, director, or primary caregiver is required to notify CCS within five program-business days of changes affecting the program's star certification level.  The case is reviewed by Licensing staff, determining whether criteria continue being met.  • 8

(2) Periodic certification reviews.  Licensing staff completes a minimum of three reviews annually, using Form 07LC026E, Child Care Center Star Certification Review, or Form 07LC028E, Family Child Care Home Star Certification Review.  The three reviews consist of two partial- and one full-star certification criteria reviews.

(A) For programs having a licensed capacity of fifty or more, the annual criteria review may be scheduled at least one week in advance, when requested by the program owner or director.

(B) Programs:

(i) operating less than a full-year or having a cooperative licensing agreement with a tribal program are required to have a minimum of one partial- and one full-star certification reviews annually; and

(ii) exempt from state licensure including federal or tribal programs, have all applicable stars criteria reviewed at least annually.  • 9

(3) Master teacher change.  When an individual replaces a master teacher:

(A) Form 07LC031E, Probationary Master Teacher Agreement, is completed;

(B) the probationary master teacher is granted a one-year probationary period to fulfill the master teacher educational qualifications per applicable Licensing requirements and QRIS criteria; and

(C) Licensing may extend the probationary period for a second year, providing the probationary master teacher is actively pursuing educational qualifications as identified on Form 07LC031E.  • 10

(4) Non-compliance.  The star certification level of a one star plus, two, or three star program may be reduced, when a program has:

(A) serious non-compliance with Licensing requirements, within a 24-month period;

(B) a serious incident resulting in injury or imminent risk of harm to a child;

(C) an Emergency Order or notice of proposed request for license denial or license revocation issued;

(D) a serious substantiated complaint;

(E) failed to employ a qualified director for six months or more; or

(F) other star certification criteria violations.  • 4 & 5

(5) Violations.  When violations of certification criteria are documented, or the program notifies CCS of criteria changes, the procedures in (A) through (E) of this paragraph are followed.

(A) Licensing staff provides written notification documenting the violations, including a statement that a reduction in the star certification level may occur, when the program has:

(i) serious non-compliances with Licensing requirements;

(ii) a serious incident occurs resulting in injury or imminent risk of harm to a child;

(iii) an Emergency Order or notice of proposed request for license denial or license revocation issued;

(iv) a serious substantiated complaint;

(v) failed to employ a qualified director for six months or more; or

(vi) star criteria violations not corrected in the agreed on time frame.

(B) Licensing staff documents a plan of correction indicating a specific agreed on correction time frame:

(i) for each star criteria violation documented during a criteria review; or

(ii) when a program notifies Licensing of star criteria violations.

(C) When previous star criteria violations were not corrected in the agreed on time frame, an additional plan of correction may be documented indicating a reduced correction time frame.

(D) When the program fails to meet additional plans of correction, Licensing staff may submit a referral for star certification reduction or notify the program of a request for extension of time to comply, including timeframes.

(E) When the program does not apply for an extension of time to comply, there is no acceptable plan of correction; Licensing staff may submit a referral for star certification reduction.  • 11 & 12

(6) Follow-up of star criteria violations.  Licensing staff is responsible for verifying star certification criteria violations are corrected as determined by the approved plan of correction.

(7) Written notice.  Licensing staff provides written notice that star certification criteria are not being met, when a program has:  • 13

(A) serious non-compliance with requirements, per OAC 340:110-1-8.4;

(B) a serious incident resulting in injury or imminent risk of harm;

(C) a serious, substantiated complaint that may place the children's health, safety, or well-being at imminent risk of harm;

(D) failed to employ a qualified director for six months or more; or

(E) star criteria violation.

(g) Extension of time to comply.

(1) A request for an extension of time to comply may be submitted when violations of star criteria cannot be corrected within the agreed on plan of correction time frame.

(2) A request for an extension of time to comply to meet Licensing requirements, such as director qualifications, is not approved.

(3) The owner, director, or primary caregiver submits Form 07LC074E, Request for Extension of Time to Comply, no later than 10-calendar days after the plan of correction expires.

(4) The decision to approve or deny an extension of time to comply is made by the stars program administrator or designee.  One or more discretionary extensions of time to comply may be granted.  Approval of an extension of time to comply does not set a precedent and each request is independently evaluated.  The owner and director or primary caregiver, when applicable, is notified in writing of the decision.  • 14

(h) Reduction in one star plus, two, and three star certification levels.

(1) A reduction occurs when CCS issued a written Emergency Order or notice of proposed request for license denial or license revocation.  • 15

(2) A reduction may occur, when the program has:

(A) numerous, repeated, or serious non-compliance with Licensing requirements within a 24-month time frame;  • 4 & 5

(B) a serious incident resulting in injury or imminent risk of harm to a child;

(C) a serious, substantiated complaint;

(D) violations not corrected within the agreed on time frame; or

(E) failed to employ a qualified director for six months or more.  • 16

(3) The procedures in this subsection are followed when a reduction is warranted.

(A) Licensing staff reviews the case with the supervisor and RPM.  The decision to make a referral to the stars program administrator or designee is made by the RPM and referrals are made in writing to the stars program administrator or designee.  The RPM may offer or accept a request from the owner of a licensed program for an alternative settlement in lieu of reduction.  The alternative settlement documents how the program will go above and beyond minimum Licensing requirements and ensure a higher standard or quality of care.  It is the RPM's decision to accept or deny the alternative settlement.  • 17

(B) When a reduction is warranted, the stars program administrator or designee provides the owner and director or primary caregiver, when applicable, a letter sent by certified mail documenting the reduction in star certification level and notifying the program of the right to request an administrative review of the decision.

(C) The certified mail delivery receipt card is addressed to return to the CCS director or designee.

(D) In order to receive an administrative review, the owner submits a written request to the CCS director or designee within 15-calendar days of reduction notification letter receipt.

(E) The request includes written documentation stating the program's grounds for appeal.

(4) QRIS personnel or a designee updates changes in the star certification level and payment rate following verification of certified letter receipt and the administrative review, when requested.  • 18

(5) The administrative review process includes determining when a star certification level reduction was in accordance with DHS rules and substantially supported by the evidence.  The procedures in (A) through (C) of this paragraph are followed when an administrative review is requested.

(A) Within 30-calendar days of receiving the request for an administrative review, a letter is provided notifying the owner and program of the administrative review.  Prior to the administrative review, the owner is provided at least a 14-calendar day written notice.  All correspondence indicates the administrative review date, time, and location.  The owner may submit written documentation prior to, or at the beginning of the administrative review, with copies provided to all representatives.

(B) The administrative review panel:

(i) provides review;

(ii) consists of one DHS staff not involved in the decision to reduce the star certification level; and

(iii) includes two Child Care Advisory Committee (CCAC) members, one being a center owner or operator, per OAC 340:110-1-17.

(C) The stars review panel makes a determination affirming or reversing the CCS decision at the administrative review.  Time constraints or the complexity of issues may require the panel to take a matter under advisement.  The determination decision is completed within 10-calendar days from the panel review date.

(6) The owner and director or primary caregiver, when applicable, may reapply for a higher star certification level when criteria are met.  When the star certification level is reduced due to serious non-compliance with Licensing requirements, the program is not approved for a higher star certification level for six months after receiving the reduction letter, sent by certified mail.

(i) Change in ownership.  When there is a change in program ownership or form of business entity, the case is closed and the star certification level is removed, unless otherwise determined, per OAC 340:110-1-9.  For approval as a higher star certification level, the new owner and director or primary caregiver, when applicable, completes and submits the appropriate star certification request, meeting all the criteria applicable to the requested star certification level.

(j) Transitional change of ownership.  When a program requests a transitional change of ownership (1) through (7) of this subsection are followed.

(1) Licensing staff conducts a full-star criteria review within five DHS-business days:

(A) verifying all applicable criteria are met; and

(B) obtaining the appropriate request for star certification completed by the prospective owner and director or primary caregiver, when applicable.  • 19 & 20

(2) The stars outreach specialist reviews the request for star certification completed by the prospective owner and verifies star level certification criteria are met, per (d) of this Section.

(3) Transitional change of ownership procedures are followed, per OAC 340:110-1-9.

(4) Periodic and ongoing criteria reviews are conducted and maintained, per (f) of this Section.

(5) All star certification criteria reviews and correspondence are provided to both the current and prospective owners.

(6) Change of ownership procedures are followed, per (i) of this Section by the end of 90-calendar days, when applicable.

(7) When programs notify Licensing that transitional change of ownership is no longer proceeding, Licensing staff verifies program operation status and consults with the supervisor for appropriate action.

(k) Inactive status.  When a program is determined inactive, per OAC 340:110-1-9, all applicable star certification criteria is reviewed prior to resuming care.  • 21

(l) Address change.  When the program's address changes, Licensing staff completes the appropriate star certification review, verifying compliance with criteria at the new address.  Licensing staff determines when a partial- or full-star certification review is conducted.

(m) Record-keeping.  Periodic certification review, request forms, and supporting documentation are maintained in the case file or in a separate open-record file.  When maintained, any information, including children's photographs is kept confidential, per OAC 340:110-1-14.

INSTRUCTIONS TO STAFF 340:110-1-8.3

Revised 3-13-20

1. (a) Approved national accrediting bodies are the:

(1) Association of Christian Schools International's Preschool Accreditation (ACSI);

(2) National Association for the Education of Young Children (NAEYC), Early Learning Program Accreditation;

(3) National Early Childhood Program Accreditation (NECPA);

(4) Council on Accreditation (COA);

(5) National Accreditation Commission for Early Care and Education Programs (NAC);

(6) Accredited Professional Preschool Learning Environment (APPLE);

(7) Commission on Accreditation of Rehabilitation Facilities (CARF);

(8) National Association of Family Child Care (NAFCC); and

(9) Cognia.

(b) Program accreditation may be transferable.

2. It is the program owner's responsibility to initiate the certification process and provide required documentation. Programs are not required to have a current provider contract to request certification.

3.The stars outreach specialist notifies Licensing staff when Form 07LC025E, Request for Child Care Center Star Certification, or Form 07LC027E, Request for Family Child Care Home Star Certification, is received. Licensing staff notify the stars outreach specialist (SOS) when concern exists. The SOS determines when certification criteria are met by reviewing the case file and documentation submitted by the program.

4.The program's case file of up to 24 months is considered, including the case file from previous licenses. When a program files a grievance, per Oklahoma Administrative Code (OAC) 340:110-1-15, the violation is not considered as part of an approval or reason for denial or reduction while pending an Oklahoma Department of Human Services (DHS) decision.

5. (a) When making the determination to deny or reduce the certification, Licensing staff considers:

(1) the number of serious non-compliances or substantiated complaints;

(2) the non-compliance duration;

(3) the degree of risk to children;

(4) if non-compliances could have been prevented;

(5) the response timeliness and effectiveness; and

(6) if notice was given regarding denial or reduction of star certification.

(b) Numerous and repeated non-compliance are included with reduction referrals only in problematic case situations and when the case is being reviewed for denial or license revocation.

(c) Numerous non-compliances during the initial Licensing visit prior to permit, may be disregarded when evaluating compliance, when all items were corrected in a timely manner.

(d) The certification request may be denied even though there are more than six months of compliant monitoring history, while on a consent agreement.

6.The appropriate request for star certification and the professional development documentation is maintained in the official case file, but other documentation may be returned to the program.

7. When a request for star certification is denied, copies of documentation supporting the denial are maintained in the case file. Originals are returned to the program.

(1) When the program contacts Child Care Services (CCS) to discuss concerns regarding the star certification denial, attempts are made to resolve the matter by making the appropriate referrals based on the denial reason.

(2) When the matter is not resolved, Licensing staff advises the program of the right to file a grievance, per OAC 340:110-1-15 providing grievance procedure policy, when requested.

(3) When it is determined the program meets a different star certification level other than requested, the stars outreach specialist notifies the owner and director or primary caregiver, when applicable, documenting the discussion on Form 07LC080E, Licensing Services Supplemental Information. The owner and director or primary caregiver, when applicable, also updates or completes and submits a new, appropriate request for star certification for the different star certification level.

8. Licensing staff complete a plan of correction when star certification criteria are not met.

9. Periodic certification reviews.

(1) At the two partial-stars certification criteria reviews, criteria in (A) through (G) are reviewed, when applicable:

(A) compliance with minimum Licensing requirements;

(B) master teacher qualifications and review of Form 07LC031E, Probationary Master Teacher Agreement, when applicable;

(C) required number of master teachers;

(D) primary caregiver qualifications;

(E) interest and activity areas;

(F) professional development for a director hired since the last review; and

(G) star criteria violations from the previous review.

(2) All applicable stars certification criteria are reviewed annually.

(3) Licensing staff documents in discussion the names of program personnel that the review or follow-up is conducted with, including any witnesses.

(4) Star reviews may be reduced when the required number of minimum monitoring visits is reduced.

(5) Stars certification criteria is reviewed when the program is monitored for a consent agreement, per OAC 340:110-1-9.5.

(6) Quality rating and improvement system staff reviews programs exempt from state licensure, verifying all applicable criteria are met.

(7) Programs approved as two star by meeting Licensing status and compliance, with current accreditation or Head Start grantee and compliant with Head Start Program Performance Standards are monitored for these two criteria only. Two star programs meeting criteria with accreditation or Head Start Performance Standard compliance are only monitored for licensing compliance and approved accreditation or performance standards.

 10. When replacing a master teacher, actively pursuing educational qualifications include, completing at least:

(1) three college credits toward a Certificate of Mastery, Child Development Associate (CDA) or Certified Childcare Professional (CCP);

(2) three college credits in Early Childhood Education (ECE), Child Development (CD), or School Age (SA); or

(3) 40-clock hours of professional development toward CDA or CCP.

 11.The time frame for correcting violations is negotiated between the director, primary caregiver, owner, or personnel in charge, and Licensing staff. Time frames are based on the time needed to correct the violation and level of risk to children. Licensing staff is responsible for tracking and follow-up on the plan of correction.

12. When information is received regarding a program not meeting certification criteria, and no written documentation exists, CCS staff documents the violation on Form 07LC080E. Licensing staff contacts the program, documenting the violation and plan of correction.

13. Documentation considered a notice for star criteria not being met include:

(1) the appropriate star certification review;

(2) Form 07LC037E, Notice to Comply; or

(3) the statement regarding star reduction in a letter or in office conference documentation: "A reduction in star certification may occur, when:

(A) the program had serious non-compliance with Licensing requirements;

(B) serious substantiated complaints or a serious incident occurs resulting in injury or imminent risk of harm to a child;

(C) violations are not corrected in the agreed on time frame; or

(D) an Emergency Order, proposed request for license denial, or license revocation is issued."

 14. Criteria considered when determining approval or denial of an extension request, includes the:

(1) request timeliness;

(2) program's compliance record;

(3) length of time needed to meet the criteria;

(4) program's evidence of effort or actions to correct violations or meet criteria;

(5) impact on available care in the area for children whose care is subsidized; and/or

(6) program's proximity to services, classes, and resources.

15.When reduction in one star plus, two, or three star certification level is initiated due to either Emergency Order issuance, request for license denial, or license revocation, a separate star certification level reduction appeal request may not be made. Procedures in OAC 340:110-1-9.4 and 340:110-1-10 are followed for requests or appeals addressing the action taken regarding the license.

16. The star level is reduced to the criteria level the program currently meets.

17. Licensing staff is responsible for monitoring alternative settlement compliance. Whenthe decision to refer the case to the stars program administrator or designee is made, documentation made available in the database includes:

(1) an appropriate request for star certification copy, Form 07LC004E, Request for License Child Care Program, and supporting proof of ownership;

(2) copies of monitoring visits and complaints documenting serious non-compliance and substantiated complaints;

(3) pertinent or applicable documentation including letters, notices to comply, supplemental pages, and complaint summaries; and

(4) additional information needed to make a decision.

18. Per Form 08CC001E, Child Care Provider Contract, the payment rate is reduced to the appropriate star certification level at the expiration of four months, from the first day of the month, immediately following certified receipt of letter or notice of reduction sent to program.

19. Transitional change of ownership.

(1) Criteria reviews are conducted under the current owner's program and copies are filed in the prospective owner's case file.

(2) All Licensing correspondence copies are filed in both the current and prospective owners' case files.

(3) All of the current owner's criteria review information is available to the prospective owner on request, including reduction of star certification levels.

20.Program accreditation may be transferable between the current and prospective owner depending on the accrediting organization.

21.Inactive status.

(1) During inactive status, star certification reviews are not conducted.However, Licensing contacts the program every four months verifying inactive status and Professional Development Ladder (PDL) certification.Licensing discusses ongoing PDL certification maintenance, alleviating future non-compliance upon resuming care.Program contacts and discussions are documented on Form 07LC080E, Licensing Services Supplemental Information.

(2) Upon resuming care, a partial-star certification review is conducted and may be combined with the Licensing monitoring visit.

(3) When a full-star certification review was due during inactive status, Licensing conducts a full-star certification review upon resuming care.Criteria not applicable during inactive status, such as parent surveys and conferences, and personnel evaluations, are not documented as violations.Licensing consults with the program regarding appropriate time frames for completing applicable criteria.

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