Archived Information

**FEBRUARY 26, 1998**

**Honorable James Howell**

**Secretary**

**Department of Health**

**1309 Winewood Boulevard, Building 6**

**Tallahassee, Florida 32399-0700**

**Dear Mr. Howell:**

**During the week of January 13, 1997, the Office of Special Education
Programs (OSEP),**

**U.S. Department of Education, conducted an on-site review of the
Department of Health's (DOH) implementation of Part H of the Individuals
with Disabilities Education Act (IDEA). The purpose of the review was to
determine whether DOH is meeting its responsibility to ensure that
services for infants and toddlers with disabilities are administered in
a manner consistent with the requirements of Part H. During that week,
OSEP also reviewed the Florida Department of Education's (FLDE)
implementation of Part B of the IDEA, to determine the status of
Florida\'s compliance with the Federal requirements related to the
provision of special education and related services for children and
youth with disabilities in Florida. OSEP's findings concerning Part B
have been addressed in a separate letter to FLDE, dated September 26,
1997.**

**Enclosure A to this letter describes OSEP\'s monitoring methodology
and corrective action procedures; Enclosure B lists several commendable
initiatives by DOH; and our findings and requirements for specific
corrective actions are in Enclosure C. We have also included a section,
Enclosure D, that addresses some overarching concerns related to the
design of Florida's early intervention system, and that is offered for
technical assistance purposes only.**

OSEP\'s monitoring places a strong emphasis on those requirements most
closely associated with positive results for children with disabilities
and their families. Dr. Bobbi Stettner-Eaton, of OSEP, and Dr. Bonnie
Strickland, of the Maternal and Child Health Bureau in the U.S.
Department of Health and Human Services, discussed the team\'s
preliminary findings with members of your staff and the Florida
Interagency Coordinating Council for Infants and Toddlers at an exit
conference held at the conclusion of OSEP\'s on-site visit. At that
time, DOH was invited to provide any additional information for
consideration by OSEP in the development of this letter of findings. No
further information was received.

**The findings in this letter are final, unless\--within 15 days from
the date on which DOH receives this letter\--DOH concludes that evidence
of noncompliance is significantly inaccurate or that one or more
findings is incorrect and requests reconsideration of such finding(s).
Any request for reconsideration must specify the finding(s) for which
DOH requests reconsideration, and the factual and/or legal basis or
bases for the request, and must include documentation to support the
request. OSEP will review any DOH request for reconsideration and, if
appropriate, issue a letter of response informing DOH of any revision to
the findings. A request for reconsideration of a finding will not delay
Corrective Action Plan development and implementation timelines for
findings not part of the reconsideration request. Our staff is available
to provide technical assistance during any phase of the development and
implementation of DOH's corrective actions. Please let me know if we can
be of further assistance.**

**I would like to thank you for the assistance and the cooperation that
Ms. Fran Wilber, the Part H Coordinator for Florida, her staff, and DOH
contractors provided during our review. Throughout the monitoring
process, staff was very responsive in providing information that enabled
OSEP staff to acquire a better understanding of the implementation of
Part H in Florida.**

**The Committee Report that accompanied the recent reauthorization of
the IDEA, Pub. L. 105-17, recognized the importance of early
intervention services for infants and toddlers with disabilities and
reconfirmed our belief that it is in the best interest of these
children, their families, schools, and society in general that services
continue to be provided. We thank you for your continuing efforts to
improve early intervention services and results for the youngest of
children with disabilities in Florida.**

> **Sincerely,**
>
> **Thomas Hehir**
>
> **Director**
>
> **Office of Special Education Programs**

**Enclosures**

**cc: Ms. Fran Wilber**

**Part H Coordinator**

#### **[ENCLOSURE A]{.smallcaps}**

##### **[OSEP\'s Monitoring Methodology]{.smallcaps}**

##### 

##### **Pre-site Document Review:** 

##### **As in all States, OSEP used a multifaceted process to review the implementation of Part H in Florida. In addition to on-site visits, this process included: review and approval of the State\'s Part H application which sets out the State\'s statutes and regulations, policies and procedures, and interagency agreements that impact the provision of services to infants and toddlers with disabilities and their families; review of the State's Part H self-assessmen**[^1]**, other correspondence, and telephone calls that OSEP received regarding the State\'s implementation. Prior to its visit to Florida, OSEP also requested and reviewed additional documentation regarding the State\'s compliance with requirements regarding due process hearings, complaint resolution, and monitoring, as well as the child count.** 

##### 

##### **Involvement of Parents and Advocates:** 

##### **During the week of October 28, 1996, OSEP conducted five public meetings in Chipley, Ocala, Tampa, Miami, and Oakland Park. Also during that week, Mr. Charles Laster (OSEP's Team leader) and Ms. Sheila Friedman (OSEP\'s Part B contact for Florida), and Dr. Bobbi Stettner-Eaton (OSEP's Part H contact for Florida), met with representatives from various advocacy groups in two outreach meetings, including representatives from the Family Network on Disabilities and the Superintendent's Advisory Group of Dade County. Dr. Stettner-Eaton also conducted a small parent focus group meeting in Tampa. The purpose of the public and outreach meetings was to solicit comments from parents, advocacy groups, service providers, administrators and other interested citizens regarding their perceptions of Florida\'s implementation of the IDEA, both Parts H and B. In the letters inviting interested parties to the public meetings, OSEP also invited them to provide written comments and telephone input regarding their perceptions.** 

##### 

##### **During the on-site visit, OSEP conducted small group parent interviews in four of the public providers it visited, as well as in Tallahassee, in order to hear parents\' impressions of the early intervention services provided to their children. These meetings provided OSEP staff with parents\' views of the effectiveness of the early intervention services provided to infants, toddlers and their families, as well as the challenges. OSEP was also interested in determining the extent to which family-oriented and culturally competent early intervention services were being delivered. OSEP focused its inquiry on specific aspects of implementation of Part H, particularly child find, transition out of Part H, and the array of early intervention services provided to eligible children and their families in natural environments.**

##### 

### **Selection of Monitoring Issues and Providers to Visit**

### **OSEP focuses its compliance review in all States on core requirements that are closely related to child and family results: States' systems for ensuring effective implementation through monitoring and identification and correction of areas of non-compliance; ensuring that all eligible children with disabilities receive appropriate early intervention services as determined through the development and implementation of an individualized family service plan; the provision of needed transition services; and ensuring that parents are appropriately included in all aspects of the decision-making process. Information that OSEP obtained from its pre-site public and outreach meetings, interviews with State officials, review of State documentation and the Part H self-assessment assisted OSEP in: (1) identifying the issues facing parents and others interested in the provision of early intervention services in Florida; (2) selecting additional monitoring issues for review while on-site; and (3) selecting the early intervention providers to be visited.** 

### 

### **On-site Data Collection and Findings:** 

### **In an effort to provide a more comprehensive examination of the implementation of Part H in Florida, which is administered by the Children's Medical Services Program Office, OSEP invited the Federal Interagency Coordinating Council (FICC) member from the Maternal and Child Health Bureau (MCH-B) in the U.S. Department of Health and Human Services to partner with OSEP on this monitoring visit. Both Federal offices endorsed this interagency monitoring effort and viewed it as a means to better model and promote collaboration in programs for young children at the Federal and State level. Dr. Bonnie Strickland, a Senior Public Health Analyst with Maternal and Child Health Bureau, and Dr. Stettner-Eaton conducted this visit.**

### 

### **Drs. Stettner-Eaton and Strickland interviewed various State lead agency executive staff; the Self-assessment team; several State interagency collaborators, including the SEA; and reviewed relevant documentation. They visited and collected implementation data from early intervention programs operated by a variety of entities. Where appropriate, OSEP has included in Enclosure C data that it collected from those providers that support or clarify its findings regarding the sufficiency and effectiveness of the State's early intervention system for ensuring compliance with the requirements of Part H.** 

### 

### **The information in Enclosure D, provided for purposes of technical assistance only, enumerates some of the over-arching concerns related to Florida's systems development that were shared at the exit conference and again in a follow-up memorandum, dated January 31, 1997, to Dr. Eric Handler of Children's Medical Services.**

### 

### **Because the findings in Enclosure C focus on the effectiveness of DOH\'s system for ensuring compliance, rather than compliance by any particular provider, OSEP has not used the name of any of the providers in that Enclosure. Instead, the early intervention providers visited by OSEP are identified only with alphabetical designations, as follows:** 

### 

+-----------------------------------------------+----------------------+
| ### **PROVIDER**                              | ### **DESIGNATION**  |
+-----------------------------------------------+----------------------+
| ### **Miami ARC**                             | ### **PROVIDER A**   |
+-----------------------------------------------+----------------------+
| ### **Mailman Center, Miami**                 | ### **PROVIDER B**   |
+-----------------------------------------------+----------------------+
| ### **Children'                               | ### **PROVIDER C**   |
| s Diagnostic and Treatment Center, Broward**  |                      |
+-----------------------------------------------+----------------------+
| ### **Tampa Early Intervention Program**      | ### **PROVIDER D**   |
+-----------------------------------------------+----------------------+

### 

### **In order to support the development of a mutually agreeable corrective action plan that will correct the findings in Enclosure C and improve results for young children with disabilities, OSEP proposes that DOH representatives confer with OSEP staff to discuss the findings and the most effective methods for ensuring compliance and improving programs for children with disabilities in the State, and to agree upon specific corrective actions. We also invite a representative from the Florida Interagency Coordinating Council for Infants and Toddlers to participate in that discussion. The corrective action plan must be developed within 45 days receipt of this letter. Should we fail to reach agreement within this 45 day period, OSEP will be obliged to develop the corrective action plan.**

### 

### **Enclosure C outlines the general corrective actions that DOH must take to begin immediate correction of the findings in the Enclosure, as well as guidelines for the more specific actions that DOH must take to ensure correction of each of the specific findings in Enclosure C.** 

#### **ENCLOSURE B**

+-----------------------------------------------------------------------+
| #### **COMMENDABLE INITIATIVES**                                      |
+=======================================================================+
| ####                                                                  |
|                                                                       |
| OSEP identified the following commendable DOH initiatives as part of  |
| its on-site review:                                                   |
|                                                                       |
| 1\. Administration of Part H by Children's Medical Services.          |
|                                                                       |
| 2\. When the administration for Part H became the responsibility of   |
| Children's Medical Services within the newly organized Department of  |
| Health, consideration of health issues for young children was greatly |
| enhanced. This became particularly apparent for those children who    |
| were dually eligible for services under the Part H Program and the    |
| Children with Special Health Care Needs, under the Maternal and Child |
| Health Program under Title V of the Social Security Act. The          |
| increased collaboration between health care personnel and early       |
| intervention providers has resulted in improved access to health care |
| for these children.                                                   |
|                                                                       |
| 3\. Dedicated resources for transition from Part H to Preschool       |
| Services.                                                             |
|                                                                       |
| 40 Both DOH and FLDE are to be commended for their collaborative      |
| support of the transition process from Part H to Preschool Special    |
| Education. This has been demonstrated by DOH's support of a staff     |
| position in FLDE to facilitate transition, dedicating staff and other |
| resources to the interagency transition training team, and the        |
| implementation of a policy to initiate transition planning when a     |
| toddler is two years six months old. The training materials that have |
| been developed have focused on improving families' understanding of   |
| the transition process and empowering them as active participants.    |
| The transition staff person operates equally well in the DOH and FLDE |
| arenas and is viewed as an asset.                                     |
|                                                                       |
| 30 Cultural sensitivity.                                              |
|                                                                       |
| 40 DOH and the early intervention service providers have made         |
| concerted efforts to recruit and hire qualified personnel and support |
| persons who are culturally and linguistically diverse, to support the |
| families of Part H eligible children. Informational resources, as     |
| well as a statement of parental rights have been developed in         |
| multiple languages. The array of culturally relevant materials are    |
| excellent resources within the State and have been shared with many   |
| other States. Staff at all levels is committed, caring, and           |
| knowledgeable about services to young children and their families.    |
| The service coordinators are a group to be particularly commended.    |
| Self-assessment respondents expressed "strong satisfaction with the   |
| role service coordinators play" in meeting the needs of the families. |
| (However, see page 2 of Enclosure C.)                                 |
|                                                                       |
| 50 State self-assessment.                                             |
|                                                                       |
| 60 DOH contracted out the self-assessment process to the Institute    |
| for Child Health Policy. The contractor worked closely with DOH       |
| staff, as well as the OSEP project officer, to ensure that the        |
| process was thorough and informative for all, and that the short      |
| timelines were accomplished. The process and end product were         |
| extremely professional, thorough, and useful in identifying areas in  |
| need of systemic improvement by the State. DOH reported that both the |
| process of completing the self-assessment and developing the one-year |
| action plan were extremely useful as they began to re-conceptualize   |
| the system design.                                                    |
|                                                                       |
| Strong local collaboration.                                           |
|                                                                       |
| The focus on local coordination and collaborative efforts to effect   |
| family-focused early intervention services has resulted in            |
| coordinated services to families in many areas of the State. As       |
| reported in the self-assessment, 73 percent of those surveyed         |
| reported that services were coordinated effectively at the local      |
| level.                                                                |
+-----------------------------------------------------------------------+

#### **ENCLOSURE C**

####### **FINDINGS AND CORRECTIVE ACTIONS**

####### 

######## **GENERAL CORRECTIVE ACTIONS**

######## 

######## **In order to begin immediate correction of the findings set forth in the table following, DOH must take the following general corrective actions:**

######## 

**1. DOH must develop a memorandum informing all early intervention
providers of OSEP\'s findings, and directing them to determine whether
they have complied with Part H requirements, as clarified by OSEP\'s
Letter of Findings. The memorandum must further direct these agencies to
discontinue any noncompliant practices and implement procedures that are
consistent with Part H. DOH must submit this memorandum to OSEP within
30 days of the date of this letter. Within 15 days of OSEP\'s approval
of the memorandum, DOH must disseminate it to all early intervention
providers throughout the State.**

**2. DOH must also disseminate a memorandum to the early intervention
providers in which OSEP found deficient practices, as identified in
Enclosure C of this letter, requiring those agencies to immediately
discontinue the deficient practice(s) and submit documentation to DOH
that they have implemented revised procedures that correct the
deficiencies and comply with Part H requirements. DOH must submit this
memorandum to OSEP within 30 days of the date of this letter. Within 15
days of OSEP\'s approval, DOH must disseminate the memorandum to those
public agencies in which OSEP found deficient practices. DOH must send
to OSEP verification that these providers have completed all of these
corrective actions.**

######### **FINDINGS AND SPECIFIC CORRECTIVE ACTIONS**

+---------------------------------------------------+------------------+
| # **REQUIREMENTS AND FINDINGS**                   |                  |
+---------------------------------------------------+------------------+
| # **Prior t                                       |                  |
| o the onsite review, OSEP identified core compone |                  |
| nts that help to focus its review of early interv |                  |
| ention services under Part H of IDEA (e.g., child |                  |
|  find, transition from Part H to Part B and other |                  |
|  services, family participation, provision of ser |                  |
| vices in natural environments, etc.). OSEP review |                  |
| ed the preliminary results from DOH's self-assess |                  |
| ment, Florida's Part H policies and procedures, i |                  |
| nformation from the public meetings, DOH's monito |                  |
| ring reports, and other implementation documents. |                  |
|  OSEP conducted small group interviews with paren |                  |
| ts at each of the early intervention provider sit |                  |
| es. Where appropriate, OSEP has included in this  |                  |
| section data collected from those parent intervie |                  |
| ws to support or clarify OSEP's impressions regar |                  |
| ding the effectiveness of Florida's system to ens |                  |
| ure compliance with the requirements of Part H.** |                  |
+---------------------------------------------------+------------------+
| # **1. Service coordination - §303.22**           |                  |
|                                                   |                  |
| #                                                 |                  |
|  **Each eligible child must be assigned a service |                  |
|  coordinator once s/he is initially referred to t |                  |
| he public agency for evaluation (§303.321(e)).**  |                  |
|                                                   |                  |
| Service coordination is an active, ongoing        |                  |
| process that assists and enables an eligible      |                  |
| child and the child's family to receive the       |                  |
| rights, procedural safeguards, and services that  |                  |
| are authorized to be provided under Part H.       |                  |
| Service coordinators must be able to effectively  |                  |
| carry out their functions on an interagency       |                  |
| basis, serving as the single point of contact in  |                  |
| helping parents obtain the services and           |                  |
| assistance they need.                             |                  |
|                                                   |                  |
| Service coordinators provide a broad range of     |                  |
| service to families, particularly integrating     |                  |
| direct services and linking families to other     |                  |
| needed services. Insufficient time available for  |                  |
| coordination activities and large caseloads have  |                  |
| been identified as the greatest barriers to       |                  |
| integrating services for families, providing      |                  |
| ongoing support to families, and enhancing child  |                  |
| and family outcomes (Roberts, Akers, and Behl,    |                  |
| 1996; Roberts and Wasik, 1990; Roberts, Behl, and |                  |
| Akers, 1996).                                     |                  |
+---------------------------------------------------+------------------+
| REQUIREMENTS AND FINDINGS                         | EXPECTED RESULTS |
+---------------------------------------------------+------------------+
| [Finding]{.underline}: Service coordination,      | DOH must ensure  |
| which is an active, ongoing process, must be      | that eligible    |
| provided each eligible child and the child's      | children and     |
| family. §303.22(a). OSEP finds that, due to       | their families   |
| reported high caseloads, many children and        | receive service  |
| families are not receiving active, ongoing        | coordination, in |
| service coordination. Service coordinators from   | accordance with  |
| Provider C reported that each coordinator has a   | §303.22, and     |
| caseload of 150 to 200 families; however, they    | that families    |
| each provide active, ongoing service coordination | are not denied   |
| to only approximately 60 to 70 of those families. | needed service   |
| Similarly, service coordinators from Provider D   | coordination due |
| reported that each service coordinator is only    | to excessively   |
| able to work actively with 50 to 60 of the        | high caseloads.  |
| his/her 175 to 225 family caseload. In addition,  |                  |
| service coordinators from Providers B and C       |                  |
| reported that due to the size of their caseloads, |                  |
| they were not able to provide all the service     |                  |
| coordination needed by the families with whom     |                  |
| they work.                                        |                  |
|                                                   |                  |
| Some service coordinators from these providers    |                  |
| reported that they were able to contact their     |                  |
| families only once per month, or every other      |                  |
| month. An interagency collaborator from Agency C  |                  |
| also confirmed the existence of high caseloads.   |                  |
| Service coordinators from Providers A and B       |                  |
| informed OSEP that, particularly for families who |                  |
| receive initial service coordination through the  |                  |
| Early Intervention Program, the caseloads are     |                  |
| extremely high and the required service           |                  |
| coordination functions are not consistently       |                  |
| provided.                                         |                  |
|                                                   |                  |
| In addition, results from the service provider    |                  |
| surveys included in the Part H Self-assessment    |                  |
| identified that service coordinator "caseloads    |                  |
| are too large, and as a result, the quality of    |                  |
| services \[service coordination\] they can        |                  |
| provide is sometimes compromised."                |                  |
+---------------------------------------------------+------------------+
| 2\. Services provided, to maximum extent          |                  |
| appropriate, in natural environments -            |                  |
| §§303.12(b) and 303.344(d)(1)(ii)                 |                  |
|                                                   |                  |
| To the maximum extent appropriate to the needs of |                  |
| each child, early intervention services must be   |                  |
| provided in natural environments, including the   |                  |
| home and community settings in which children     |                  |
| without disabilities participate. §303.12(b). The |                  |
| determination of the extent to which a child will |                  |
| receive services in natural environments, must be |                  |
| made on an individualized basis by the IFSP team  |                  |
| for the child. §303.344(d)(1)(ii).                |                  |
+---------------------------------------------------+------------------+
| REQUIREMENTS AND FINDINGS                         | EXPECTED RESULTS |
+---------------------------------------------------+------------------+
| [Finding]{.underline}:                            | DOH must ensure  |
|                                                   | that early       |
| OSEP finds that many children receive early       | intervention     |
| intervention services in settings other than      | services are     |
| natural environments based on the service models  | designed to meet |
| in the State rather than an individualized        | a child's        |
| determination as part of the IFSP development, in | developmental    |
| accordance with §303.344(d)(1)(ii).               | needs and are to |
|                                                   | be provided, to  |
| Across the State, program administrators, service | the maximum      |
| personnel, and parents told OSEP that the         | extent           |
| preferred service model was center-based.         | appropriate to   |
| Providers A and B told OSEP that when             | the needs of the |
| center-based slots were filled, children were put | child, in        |
| on waiting lists for center-based services to     | natural          |
| open up. However, while waiting for a             | environments,    |
| center-based slot, these children were receiving, | including the    |
| in their homes, all the early intervention        | home and         |
| services identified on their IFSPs. DOH's         | community        |
| monitoring report for Provider A stated that      | settings in      |
| "most of the children are served in a             | which children   |
| center-based setting. Developmentalists provide   | without          |
| early intervention services for those infants and | disabilities     |
| toddlers who are awaiting placement in a          | participate, as  |
| center-based program." The State did not ask      | determined on an |
| Provider A to change its practice of providing    | individualized   |
| services to the majority of its children in the   | basis by the     |
| same location, regardless of the child's unique   | IFSP team for    |
| needs or results of the evaluations and           | each child.      |
| assessments.                                      |                  |
|                                                   | DOH must ensure  |
| Service providers from Provider D reported that   | that nothing in  |
| most children received their early intervention   | funding policies |
| services at a center. They stated that travel to  | discourages the  |
| and from a child's home and preparation time was  | provision of     |
| not reimbursed as a part of the cost of providing | early            |
| therapy, if services were to be provided in the   | intervention     |
| child's home. They told OSEP that because of the  | services in      |
| financial disincentive, services would continue   | natural          |
| to be provided at a center, rather than in a      | environments     |
| child's home or other settings.                   | (e.g.,           |
|                                                   | reimbursement of |
|                                                   | travel costs for |
|                                                   | service          |
|                                                   | providers).      |
+---------------------------------------------------+------------------+
| REQUIREMENTS AND FINDINGS                         | EXPECTED RESULTS |
+---------------------------------------------------+------------------+
| The Children's Medical Services Early             | DOH must revise  |
| Intervention Program Service Guidelines, updated  | its Service      |
| 8/96, lists seven types of early intervention     | Guidelines,      |
| service options, including center-based day       | updated 8/1/96,  |
| program services, group session, home visit       | consistent with  |
| session, individual session, special instruction  | the obligation   |
| consultation service, special instruction         | to ensure that   |
| consultation plan development service, and        | the location of  |
| special instruction cooperating agency service. A | services is      |
| center-based day program is defined in that       | determined by    |
| document as one in which early intervention       | the IFSP         |
| services are provided on a six, five, or          | team-based on an |
| four-hour per day basis, including "special       | individual       |
| instruction and early intervention services to    | child's needs,   |
| children in a group setting for an extended,      | and the needs of |
| continuous period of time \..." These service     | the family, as a |
| guidelines identify the location in which early   | result of        |
| intervention services may be provided without     | evaluations and  |
| linking that decision to individually determined  | assessments.     |
| decisions by the IFSP team, considering the       |                  |
| results of a child's evaluations and assessments, | DOH must revise  |
| or the unique needs of the child. Further, the    | its monitoring   |
| service guidelines document does not presume that | procedures to    |
| services are provided in natural environments,    | ensure that it   |
| but rather provides significant rationale for     | has an effective |
| services in center-based facilities.              | method to        |
|                                                   | monitor for      |
| In addition, the one-year action plan included in | compliance with  |
| the State's self-assessment identified the need   | this provision.  |
| to focus on providing services to children within |                  |
| natural environments, including the development   |                  |
| of a long-range strategic plan to increase        |                  |
| availability of child care services to children   |                  |
| with disabilities.                                |                  |
+---------------------------------------------------+------------------+
| REQUIREMENTS AND FINDINGS                         | EXPECTED RESULTS |
+---------------------------------------------------+------------------+
| 3\. Access to all needed early intervention       |                  |
| services - §303.344(d)                            |                  |
|                                                   |                  |
| The IFSP for each child must include a statement  |                  |
| of the specific early intervention services       |                  |
| necessary to meet the unique needs of the child   |                  |
| and the family to achieve the outcomes identified |                  |
| in the child's IFSP. Transportation and related   |                  |
| costs are to be specifically identified as an     |                  |
| early intervention service on a child's IFSP if   |                  |
| necessary to enable a child and the child's       |                  |
| family to receive early intervention services, in |                  |
| accordance with §303.12(d)(15). Early             |                  |
| intervention services included in a child's IFSP  |                  |
| may also include such services as the provision   |                  |
| of respite and other family support services,     |                  |
| based on the results of the evaluations and       |                  |
| assessments, needs of the child, and concerns,    |                  |
| priorities, and resources of the child's family.  |                  |
| §303.12(d) and Note following.                    |                  |
+---------------------------------------------------+------------------+
| [Finding A]{.underline}:                          | DOH must ensure  |
|                                                   | that all         |
| (Respite Care) Service coordinators from Provider | appropriate      |
| A reported that in-home respite care necessary to | early            |
| meet the needs of some children and families, was | intervention     |
| neither available nor provided. In some cases,    | services are     |
| "programs attempted to partially address the need | available, in    |
| by serving the children in centers" rather than   | accordance with  |
| their home. Program directors from Provider B     | a child's IFSP.  |
| told OSEP that respite care was typically not     |                  |
| available for children under 36 months of age. In | DOH must revise  |
| the Tallahassee meeting with parents, some        | its monitoring   |
| parents reported that although they identified a  | procedures to    |
| need for respite services in the IFSP meeting,    | ensure that      |
| respite care was not included in the IFSP because | IFSPs are        |
| they were told that there were no funds available | developed and    |
| for respite care services, regardless of          | implemented in   |
| individual child and family needs.                | accordance with  |
|                                                   | §§               |
|                                                   | 303.340-303.345. |
+---------------------------------------------------+------------------+
| [Finding B]{.underline}:                          | DOH must ensure  |
|                                                   | that             |
| (Transportation and related costs) As with all    | transportation   |
| early intervention services, the determination of | is available for |
| what, if any transportation services to include   | those children   |
| in the IFSP for a child, must be determined by    | who need it in   |
| the IFSP team, based on the individualized unique | order for        |
| needs of the child and the child's family. In     | eligible         |
| some areas of the State families are not all      | children and     |
| receiving the transportation services they need   | their families   |
| due to limited available resources.               | to receive early |
|                                                   | intervention     |
| Parents, service coordinators, and interagency    | services.        |
| collaborators from Provider A reported that       |                  |
| transportation services are provided to all       |                  |
| children attending their center-based early       |                  |
| intervention programs, as a part of the service   |                  |
| package. However, Provider A reported that, due   |                  |
| to the cost of transportation, all of the         |                  |
| children receiving services at the center,        |                  |
| regardless of individual need, would be picked up |                  |
| only at designated stops, rather than being       |                  |
| picked up at their homes as had previously been   |                  |
| done; therefore, the provision of transportation  |                  |
| is not based on the individual needs of the       |                  |
| child.                                            |                  |
|                                                   |                  |
| Provider C and parents from the Tallahassee       |                  |
| meeting reported that children who were           |                  |
| previously receiving services in center-based     |                  |
| programs were now receiving services exclusively  |                  |
| in the home setting because of a reported lack of |                  |
| funds for transportation. The location of         |                  |
| services decision was not being made on an        |                  |
| individualized basis.                             |                  |
+---------------------------------------------------+------------------+
| REQUIREMENTS AND FINDINGS                         | EXPECTED RESULTS |
+---------------------------------------------------+------------------+
| Parents and service coordinators across the State |                  |
| reported that many children who were both         |                  |
| Medicaid and Part H eligible did not receive      |                  |
| transportation they needed because of cuts in     |                  |
| Medicaid reimbursed transportation. Provider D    |                  |
| reported dependence on Medicaid reimbursed        |                  |
| transportation to pay for needed transportation   |                  |
| for its Medicaid-eligible children, and stated    |                  |
| that unless Medicaid paid for transportation, it  |                  |
| was not available. Staff from Provider D and      |                  |
| service coordinators from Provider B reported     |                  |
| that families who needed transportation, but did  |                  |
| not receive it as an early intervention service,  |                  |
| often missed therapy appointments for their child |                  |
| because they relied solely on public              |                  |
| transportation. Service coordinators from         |                  |
| Provider B reported that they often gave families |                  |
| bus tokens for public transportation to get to    |                  |
| the child's therapy appointments because of       |                  |
| reduction in Medicaid reimbursed transportation   |                  |
| services. Parents in the Tallahassee meeting      |                  |
| reported that some families were not able to      |                  |
| access the early intervention services on the     |                  |
| child's IFSP because the provider restricted      |                  |
| transportation services to only the Part H        |                  |
| eligible child and a family member, thereby not   |                  |
| accommodating the other siblings.                 |                  |
+---------------------------------------------------+------------------+

#### **ENCLOSURE D**

+-----------------------------------------------------------------------+
| ### **Overarching concerns related to systems development**           |
+-----------------------------------------------------------------------+
| ### **In the exit conference the following issues of concern          |
| were raised as technical assistance to DOH as further refinements of  |
| the statewide system of early intervention service delivery occurs:** |
+-----------------------------------------------------------------------+
| ### **1. While the Children's Medical Servi                           |
| ces has responsibility for the implementation of Part H, the relation |
| ship between primary medical health care and Part H is not well estab |
| lished across the State. Children who are dually eligible for Childre |
| n's Medical Services and Part H appear to have the best opportunity f |
| or comprehensive health services, while those children who are only P |
| art H eligible are less likely to have comprehensive medical care.**  |
+-----------------------------------------------------------------------+
| ### **2. While recogn                                                 |
| izing the strengths of the State's child find and public awareness ac |
| tivities, OSEP concurs with results of the State's Self-assessment wh |
| ich identified the need for better child find, particularly with hosp |
| itals and physicians. The 5-year action plan from the Self-assessment |
|  identified multiple strategies for improving child find activities.  |
| OSEP believes that expanded efforts in public awareness and child fin |
| d will ensure that more potential referral sources become informed.** |
+-----------------------------------------------------------------------+
| ### **3. The overall configuration of the e                           |
| arly intervention system appears to invest heavily in the administrat |
| ive structures for local implementation, particularly where the Early |
|  Intervention Programs are hospital-based. The effect of this appears |
|  to have resulted in fewer dollars for direct supports and services t |
| o infants, toddlers, and their families in many areas of the State.** |
+-----------------------------------------------------------------------+
| ### *                                                                 |
| *4. There is a tension between local control and consistent implement |
| ation of the system statewide. While it is important for communities  |
| to tailor the early intervention system to reflect their own characte |
| ristics, the variance in the implementation of the early intervention |
|  system has created problems of access and service provision. This is |
|  of particular concern for families as they move within the State.**  |
+-----------------------------------------------------------------------+

### 

### 

[^1]: ^?^ During a 4-month period prior to OSEP**s on-site visit, the
    State conducted a self-assessment using OSEP-developed materials,
    which included the formation of a State self-assessment team to
    coordinate the self-assessment process, collecting data from surveys
    of providers and parents, and developing a one-year action plan for
    improvement of the States system for early intervention. The final
    report from the self-assessment, including the action plan, was
    submitted to OSEP in early January, 1997, prior to the on-site visit
    and were extremely useful in planning the visit.**