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 9-14-24

1.  (a) Review schedule.  The quality assurance (QA) manager schedules and conducts an annual review of each Licensing supervisory  and 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)  At least 30-calendar days prior to the scheduled review, the review plan, including objective, scope, and schedule, is provided to the identified Licensing supervisor and regional program manager (RPM) or residential and child-placing agency program  supervisor and statewide licensing coordinator.

(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.

(d) QA manager responsibilities.  The QA manager:

(1)  selects cases meeting review criteria;

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

(3)  provides review notification;

(4)  prepares review checklists;

(5) interviews Licensing staff regarding case management of selected criteria;

(6) conducts an entrance conference with the Licensing supervisor or residential and child-placing agency program supervisor to discuss the review process and procedure;

(7) performs the QA review in a responsible, unbiased, confidential and ethical manner, including the:

(A) review and evaluation of licensing records to determine adequacy, effectiveness, and licensing requirement and rule compliance, per the review scope;

(B) analysis of evidence to determine findings, per (e) of this Instruction; and

(C) documentation of review information objectively and accurately on the review checklist; and

(8) conducts daily review conferences with the Licensing supervisor or residential and child-placing agency program supervisor to discuss information, per (e) of this Instruction;

(9) conducts an exit conference with the Licensing supervisor and RPM or residential and child-placing agency program supervisor and statewide licensing coordinator and Licensing staff.  The QA manager discusses the preliminary findings written report, including:

(A) the review summary;

(B) identified findings;

(C) areas of concern;

(D) recommendations;

(E) observed positive practices; and

(F) an overall evaluation of the reviewed activities; and

(10)  prepares and  submits the final review report.  The final report includes:

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

(B) identification of all reference documents used during the review, such as licensing requirements, rules, database guidelines, and current CCS processes and enforcement practices;

(C) findings, per (e) of this Instruction;

(D) observed positive practices;

(E) areas of concern;

(F) QA manager recommendations;

(G) plan of correction forms; and

(H) the review report distribution list.  Within 30-calendar days after the review conclusion, the QA manager distributes the final report to the:

(i) Licensing supervisor and RPM or residential and child-placing agency program supervisor;

(ii) policy manager;

(iii) statewide licensing coordinator; and

(iv) CCS director; and

(11) conducts a mid-year review when applicable; and

(12)  maintains review information for four years in a confidential manner.

(e)  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.

(f) Plan of correction.

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

(2)  Within 30-calendar days after receiving the final report, the Licensing supervisor and RPM or residential and child-placing agency program  supervisor and statewide licensing coordinator submit a plan of correction to the QA manager .  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 (e) of this Instruction.

(g) Final review approval.  The RPM and when applicable, the statewide licensing coordinator, 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  supervisor for modification.   CCS supervisory or management staff implement corrective action.