Department  of  Health and Human Services 
OFFICE  OF 
INSPECTOR  GENEW 
EVALUATING  HEAD  START EXPANSION 
THROUGH  PERFORMANCE  INDICATORS 
MAY  1993  OE.I-B91-(X)762 
..  EXECUTIVE  SUMMARY

PURPOSE

This  inspection  used  selected  performance  indicators  to assess the  impact  of Head

Start  expansion  on grantees  and  delegates.

BACKGROUND

Head  Start  operates  on the  premise  that  children  are  best  prepared  for success  in

school  when  they  and  their  parents  participate  in a comprehensive  program  that

addresses  their  educational,  economic,  social, physical,  and  emotional  needs.  In

addition  to providing  children  with classes  and  health  services,  Head  Start  addresses

the  needs  of the  entire  family.

Both  Congress  and  the  Administration  are  committed  to expanding  Head  Start.  Since

Fiscal  Year  (FY)  1990, the  total  funding  for Head  Start  has increased  more  than

$1 billion,  and  the  number  of children  served  has increased  by almost  300,000.

Within  the  Department  of Health  and  Human  Semites  (HHS),  the  Administration  for

Children  and  Families  (ACF)  is responsible  for administering  Head  Start.  The  ACF,

the  Assistant  Secretary  for Management  and  Budget  (ASMB),  and  the  Assistant

Secretary  for Planning  and  Evaluation  (ASPE)  requested  that  the  Office  of Inspector

General  (OIG)  review  the  implementation  and  status  of Head  Start  expansion  because

they were  concerned  that  rapid  expansion  might jeopardize  the  quality  of services.

This  report  is one  in a series  prepared  by the  OIG  on this subject.

From  May  through  July  1992, we conducted  either  on-site  visits or telephone

interviews  with  a random  sample  of 80 Head  Start  grantees  and  delegates  using

structured  discussion  guides.  In a companion  report  entitled  Head  Start  Expansion:

Grantee  Experiences  (OEI-09-91-O0760),  we reported  the  results  of these  interviews.

According  to the  grantees,  expansion  posed  problems  for them  in such  areas  as child

enrollment,  facility acquisition,  staffing,  transportation,  and  social  services.

Nevertheless,  grantees  told  us that  they were  still able  to meet  all of Head  Starts

performance  standards.  This  is consistent  with the  data  that  grantees  report  to ACF

in their  annual  Program  Information  Reports  (PIRs).  Based  on the  following  findings,

however,  we question  the  accuracy  of some  of these  self-reported  data  and

assessments.

In addition  to the  intemiews,  we reviewed  health,  education,  and  social  semice  files for

more  than  3100 children  as well as other  performance  data  which were  maintained  by

the  80 sampled  grantees.  We assessed  grantee  performance  by applying  18 specific

performance  indicators  that  we developed  with input  from  ACFS Head  Start  Bureau,

ASPE,  ASMB,  Head  Start  grantees  and  delegates,  program  experts,  and  researchers.

In most  cases,  the  performance  indicators  mirror  ACFS performance  standards.  We

primarily  used  ACFS policy guidance  to grantees  on the  performance  standards  to

i  assess  grantees  ability  to provide  services  to children  and  families  and  to measure  the 
quality  of sewices  provided  in general.  The  results  of this assessment  are  contained  in 
this report. 
FINDINGS 
The  original  purpose  of this inspection  was to assess the  impact  of expansion  on Head 
Start  grantee  performance.  We  did not  find any statistically  significant  difference  in 
grantee  performance  as a result  of expansion.  We did, however,  find that  the  level of 
grantee  performance  as measured  by our  indicators  was considerably  lower  than  the 
level  of performance  reported  by grantees  and  published  by ACF.  Because  of 
(1) inadequate  grantee  record  keeping,  (2) the  lack of specificity  in the  Head  Start 
performance  standards,  and  (3) the  fact that  many grantees  disregard  ACF  policy 
guidance,  we are  unable  to determine  if the  program  and  performance  data 
weaknesses  that  we found  reflect  serious  deficiencies  in the  quality  of services 
provided  by Head  Start.  Our  specific  findings  are: 
l%e ACFS l%ogram Information Report  (PIR) data do not accurate~  reflect information 
iia childrenk  health recomk 
During  our  review  of grantees  files, we found  that  grantees  are  not  providing  medical 
and  dental  services  and  follow-up  to the  extent  that  they report  in their  PIRs. 
Children may not be jWy  immunized  before they leave the Head  Start program 
Our  review  of health  files and  all other  available  information  provided  by grantees 
revealed  that  only 43.5 percent  of Head  Start  children  were  fully immunized  as 
defined  by ACF  guidelines  at the  end  of the  1991-92 school  year. 
Gmntees fiequent~  do not identifi  or addkxs famlitx socidl senaceneeh 
Grantees  frequently  did not  administer  family needs  assessments  (FNAs),  did not 
identi~  family  needs  or goals when  conducting  an FNA,  rarely  used  Family  Assistance 
Plans,  and  did not  help  families  meet  all or most  of their  needs. 
Gmntees jk  and recortk jiequendy  are incomplete,  inconszken~ and dificult  to rewew 
Some  grantees  have  developed  exemplary  internal  record  keeping  requirements,  but 
others  prematurely  disposed  of files and  maintained  childrens  files in a haphazard 
manner. 
ii  RECOMMENDATIONS 
T7w Secretary shouId convene a task foce  to conduct a formal  and thorough review of 
the management  of the Head  S~atiprogram 
The  task  force  should  analyze  the  respective  roles  and  functions  of the  Head  Start 
Bureau,  ACF  regional  offices,  grantees,  and  delegates.  It should  review  how the  Head 
Start  program  is currently  organized  and  managed  and  how it can best  be  structured 
to administer  the  current  and  anticipated  expansions.  The  task  force  should  examine 
the  planning,  distribution  of funds,  grants  management,  oversight,  technical  assistance, 
management  information  systems,  and  performance  standards  that  are  currently  used 
to manage  the  program. 
The  Secretary  has  initiated  a comprehensive  examination  of Head  Start  with a 
particular  emphasis  on quality  and  accountability.  The  Secretarys  initiative  includes 
(1) immediately  identi~ng  poorly  performing  grantees,  designing  corrective  actions, 
providing  technical  assistance,  and  ensuring  that  grantees  that  provide  high quality 
services  receive  program  funds  and  (2) conducting  an in-depth  review  of the  program 
with  the  help  of an intellectually  diverse  expert  study  panel  and  using the  results  to 
design  the  Head  Start  program  of the  future.  This  plan  addresses  our  concerns  and  is 
consistent  with  our  recommendation.  We anticipate  that  the  examination  will consider 
all of the  issues  that  we have  identified  as well as the  following  recommendations: 
l%e ACF  should create, dknbute, and mandate  specific record keeping and childrens file 
maintenance  ihstrucOonfsor grantees 
Standardized  record  keeping  and  file maintenance  would  assure  easy access  to 
childrens  files.  Grantees  could  identify  missing semices  or needed  follow-up  more 
readily,  and  on-site  reviews  could  be completed  more  expeditiously. 
%  ACF  shouki strengthen its monitoring of grantetx to better identifi  and address 
pmblkm  areas 
We believe  that  ACF  should  consider  restructuring  and  condensing  its on-site  program 
reviews  so that  more  time  and  resources  can be  devoted  to monitoring  and  providing 
technical  assistance  to the  most  needy  grantees.  Furthermore,  ACF  should  randomly 
sample  PIR  data  to assure  its validity. 
Ihe ACF  should develop  a modified  FNA form that should be requtied of all Head  Start 
-~ 
The  Model  FNA  should  be  less cumbersome  and  be  more  conducive  to an  open 
dialogue  with the  family.  The  ACF  should  require  grantees  to use  the  revised  FNA 
throughout  the  school  year  to track  and  follow up on family needs. 
111
 AGENCY  COMMENTS 
As discussed  in the first recommendation,  the  Secretary  has initiated  a comprehensive 
review  of the  management  of the  Head  Start  program. 
We received  written  comments  on the  draft  report  from  ACF,  ASPE,  and  ASMB. 
The  ACF  generally  concurred  with our  recommendations  but  was concerned  about  the 
presentation  of some  of the  data  and  conclusions  in our findings.  They  were 
particularly  concerned  about  the  immunization  and  social setices  findings.  We found 
their  comments  helpful.  As a result,  we have  revised  the  immunization  section  and 
presented  additional  data  to explain  and  clari~  our finding.  In addition,  we have 
provided  a detailed  response  to all of ACFS comments,  including  immunizations  and 
social  semices,  in appendix  C.  The  ASPE  and  ASMB  provided  editorial  and  technical 
comments  and  suggestions  which  have  been  incorporated  in the  final  report.  The 
complete  text  of the  ASPE  and  ASMB  comments  can be found  in appendix  D. 
iv  TABLE  OF  CONTENTS 
EXECUTIVE  suMMARY 
INTRODLKXION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
OIG  PERFORMANCE  INDICATORS  .  . . . . . . .  .  6 
..0..  .0  .  ...0    .  .  .      ...0.  . 
FINDINGS  . . . . . . . . . . . . . . . . . . . . .  .  7 
.  .  .  .  .  .  .  ..****    *.*  .  ..0..0  .000  .00   
Health  services  . . . . . . . . . .  7 
    *..**    .0...0  ..0.  .0  .0..,    ..000.     
  Immunizations  .**  . . . . ..*.  .  .  .  .  .  .  .  ..0...    ..*    ..**..  .  .  ...*.  .    9 
  Social  services  . . . . . . . . . . . .  .  .  .  .  .  .*.*...  .*..  .  .  .  .  .  .  .  .0  .0..0    11 
Grantee  record  keeping  . . . .  14 
  .*.*..  .*...*.  .  .  .  .  .  .  .  .  .  .  .    *...*.  . 
RECOMMENDATIONS  AND  AGENCY  COMMENTS  . . . .  16 
.  .  .  .  .  .  .  .  .  ...0.  . 
APPENDICES 
k  Performance  Indicator  Methodology 
B:  How  Head  Start  Program  Performance  Changed 
According  to the  OIG  Performance  Indicators 
c  ACF  Comments  on the  Draft  Report  and  Detailed  OIG  Response 
D:  ASPE  and  ASMB  Comments  on the  Draft  Report 
  INTRODUCTION 
PURPOSE 
This  inspection  used  selected  performance  indicators  to assess the  impact  of Head 
Start  expansion  on grantees  and  delegates. 
BACKGROUND 
Head  Start  operates  on the  premise  that  children  are  best  prepared  for  success  in 
school  when  they  and  their  parents  participate  in a comprehensive  program  that 
addresses  their  educational,  economic,  social,  physical,  and  emotional  needs.  In 
addition  to providing  children  with classes  and  health  services,  Head  Start  addresses 
the  needs  of the  entire  family. 
The  Administration  for Children  and  Families  (ACF)  is responsible  for administering 
Head  Start.  The  ACF,  the  Assistant  Secretary  for Management  and  Budget  (ASMB), 
and  the  Assistant  Secretary  for Planning  and  Evaluation  (ASPE)  requested  that  the 
office  of Inspector  Genera]  (OIG)  review  the  implementation  and  status  of Head 
Start  expansion  because  they were  concerned  that  rapid  expansion  might jeopardize 
the  quality  of semices.  This  report  is one  in a series  prepared  by the  OIG  on this 
subject. 
71ie Head  Start R-ogram 
Head  Start  is a child  development  program  funded  primarily  by the  Federal 
government.  At  the  headquarters  level, ACFS Head  Start  Bureau  provides  leadership 
and  develops  legislative  and  budgetary  proposals  for Head  Start  management  and 
operations.  In each  regional  office, ACFS Head  Start  and  Youth  Branch  monitors  all 
Head  Start  programs,  except  Native  American  and  migrant  programs  which  are 
monitored  by branches  within  headquarters.  According  to ACF,  Head  Start  served 
approximately  622,000 children  with Federal  support  of $2.2 billion  in 
Fiscal  Year  (FY)  1992. 
Head  Start  programs  are  community-based,  so agencies  can  respond  to local  needs 
and  coordinate  with other  community  organizations.  As a result,  program  options, 
locations,  and  hours  vary.  The  Federal  government  awards  grants  to a public  or 
private  nonprofit  agency  (called  a grantee)  to operate  a Head  Start  program.  A 
grantee  may  contract  with one  or more  other  public  or private  nonprofit  organizations 
in the  community  (called  delegates)  to  run  all or part  of its Head  Start  program.  For 
the  purposes  of this report,  we will refer  to both  grantees  and  delegates  as grantees 
unless  specific  differences  need  to be noted. 
Head  Start  programs  consist  of four  major  components:  health,  education,  social 
services, and parent  involvement.  Specific  performance  standards,  which  have  been 
1  published  in the  Code  of Federal  Regulations,  require,  among  other  things,  that 
grantees: 
  develop  childrens  intellectual  skills by encouraging  them  to solve problems, 
  provide  children  medical  and  dental  screenings  and  examinations, 
  offer  children  nutritious  meals  and  snacks,  and 
  identi~  families  social  semice  needs  and  work with other  community  agencies 
to meet  those  needs. 
All grantees  must  comply  with the  performance  standards.  In addition  to the 
performance  standards,  ACF  has issued  guidance  material  which elaborates  on the 
intent  of the  performance  standards  and  provides  methods  and  procedures  for their 
implementation.  The  guidance  material,  however,  is not  mandated. 
Head  Start Expanston 
Both  the  Administration  and  Congress  are  committed  to expanding  Head  Start.  The 
Head  Start  Supplemental  Authorization  Act  of 1989 and  the  Dire  Emergency 
Supplemental  Appropriation  of 1990 marked  the  beginning  of expansion  for all 
grantees  and  provided  funding  for the  first two expansions.  Since  FY  1990, the  total 
funding  for  Head  Start  has  increased  more  than  $1 billion,  to an FY  1993 total  of 
$2.779 billion.  The  Human  Senices  Reauthorization  Act  of 1990 continues  the  Head 
Start  program  through  FY  1994 with the  goal  to serve  all eligible  children  by 1994. 
The  following  table  summarizes  the  portions  of the  funding  increases  that  have  been 
allocated  for expanding  enrollment: 
HEAD START EXPANSIONS, 1990-1993 
F-l  Announcement  Proposed Number  Funds to  Additional 
Year  Date  of Additional  Expand Enrollment  Expansion 
Children  Funding 
Expansion I  1990  Februmy 6, 1990  37,500  $99,980,000  $51,335,000 
Expansion 11  1990  June 12, 1990  60,000  $165,315,000  None 
Expansion III  1991  undated  51,000  $159,447,000  $240,363,000 
Expansion IV  1992  Februaty  19, 1992  38,500  $131,513,000  $118,487,000 
Expansion V  1993  December  17, 1992  100,000  $372,706,000  $201,779,600 
IOTAL  287,000  $92&961,000  $611,964,600 
2  The  additional  expansion  funding,  identified  in the  chart  on the  preceding  page,  was

set  aside  for,  among  other  things,  quality  improvement,  salary  enhancement,  cost-of-

living increases,  and  training  and  technical  assistance  improvement.  Grantees

generally  use  quality  improvement  funding  to increase  salaries  and  benefits,  strengthen

.	 the  social  semice,  parent  involvement,  and/or  health  components,  improve  semices  to 
disabled  children,  initiate  or improve  family literacy  programs,  and/or  otherwise 
enhance  services  to children  and  families. 
To  receive  the  allocated  funds,  grantees  submitted  expansion  proposals.  These 
proposals  specified  planned  objectives,  such  as the  number  of additional  children  they 
would  enroll  and  the  staff they would  require  to serve  these  children.  The  Head  Start 
Bureau  advised  grantees  to prepare  proposals  that  would  result  in high quality  services 
that  fully comply  with  the  Head  Start  performance  standards. 
The  ACF  monitors  compliance  with Head  Start  performance  standards  primarily  by 
conducting  on-site  reviews.  During  site visits, review  teams  assess  compliance  with the 
performance  standards  using the  On-Site  Performance  Review  Instrument  (OSPRI). 
The  Head  Start  Act  requires  that  ACF  review  each  grantee  or delegate  at least  once 
every  3 years  to measure  compliance  with the  Head  Start  performance  standards 
[42 U.S.C.  9836].  The  Head  Start  Improvement  Act  requires  that  ACF  review  each 
new grantee  or delegate  after  its  first year  and  conduct  follow-up  reviews of all 
grantees  when  appropriate. 
In addition  to conducting  on-site  reviews,  ACF  requires  each  grantee  to report 
performance  data  annually  using the  Program  Information  Report  (PIR).  The  PIR 
contains  data  that  ACF  can use to assess  individual  grantee  and  overall  program 
performance. 
Concerns about Ezpansion 
This  report  is one  in a series  prepared  by the  OIG  concerning  Head  Start  expansion. 
A companion  report,  Head  Start  Expansion:  Grantee  Experiences 
(OEI-09-91-O0760),  describes  the  problems  that  Head  Start  grantees  and  ACF  staff 
experienced  during  the  1990 and  1991 expansions  as well as concerns  about  their 
ability  to handle  future  expansions. 
METHODOLOGY 
We  selected  a random  sample  of 80 regional  and  Native  American  Head  Start 
grantees  and  delegates.  We excluded  migrant  grantees  because  of the  unique  nature 
of their  programs,  and  we conducted  a separate  study, Migrant  Head  Start  Grantees: 
Perspectives  and  Challenges  (OEI-09-91-00761),  to assess  their  experiences  with 
expansion.  From  a universe  of the  50 States  plus the  District  of Columbia,  Puerto 
Rico,  and  the  Trust  Territories  (hereafter  referred  to as localities), we randomly 
selected  8 localities  with probability  proportional  to size with replacement.  f% a 
result,  California  was selected  twice.  The  total  amount  of Federal  funding  received  in 
3  ~1991  determined  thesize  ofeachof  the  localities.  The  following table  presents 
the  localities  selected,  their  probability  ofselection  based  upon  their  total  budget,  and 
the  number  of grantees,  original  and  adjusted,  in each  location: 
I  I 
Probability  Number of Grantees 
I 
Total Budget,  of 
State  Original  Adjusted 
All Grantees  Selection 
California (One)
 $184,762,665  10.87%  133  95 
California (Two)
 $184,762,665  10.87%  133  95 
Florida
 $57,466,594  3.38910  49  49 
Maine
 $7,601,468  0.45%  13  13 
Michigan
 $71,904,040  4.23%  80  80 
Puerto  Rico
 $70,947,229  4.17%  34  28 
Texas
 $95,413,705  5.61%  85  60 
Washington
 $24,586,682  1.45%  29  26 
Sampled
 $697,445,048  41.03% 
All States
 $1,700,448,467 
I 
Because  not  all grantees  and  delegates  received  expansion  funds,  not  all were  eligible 
for  selection  at the  second  stage  of sampling.  At  this stage,  we selected  grantees  and 
delegates  using  simple  random  sampling  until we obtained  10 grantees  or delegates 
within  each  locality  who received  expansion  funds  in FYs  1990 or  1991. 
The  adjusted  number  of grantees  in the  above  table  represents  the  estimated  number 
of grantees  and  delegates  that  received  expansion  funds  based  upon  our  sampling 
results.  Projections  used  in this report  are  based  upon  this adjusted  number  of 
grantees. 
From  May  through  July  1992, we conducted  either  on-site  visits or telephone 
interviews  with  each  grantee  and  delegate  using structured  discussion  guides  and 
reviewed  childrens  files and  other  performance  data.  For  the  childrens  file review, 
we selected  a random  sample  of 20 children  enrolled  during  the  1988-89 school  year 
and  20 children  enrolled  during  the  1991-92 school  year  for each  program.  We 
reviewed  health,  education,  and  social sewice  files for more  than  3100 children  as well 
as other  performance  data  which were  maintained  by the  80 sampled  grantees. 
P~onnance  Indicaton 
we  assessed  grantees  experiences  with expansion  based  on specific  performance 
indicators.  The  Head  Start  Bureau  developed  the  initial  list of indicators.  We 
modified  and  expanded  the  list with input  from  ASPE,  ASMB,  Head  Start  grantees 
and  delegates,  program  experts,  and  researchers.  In most  cases,  the  performance 
indicators  mirror  ACFS performance  standards.  We  primarily  used  ACFS policy 
guidance  to grantees  on the  performance  standards  to assess grantees  ability  to 
4
 provide  sexvices to children  and families  and  to measure  the  quality  of semices 
provided  in general.  See  page  6 for a list of the  indicators. 
At  the  completion  of the  fieldwork,  we weighted  all data  to project  to the  universe  of 
Head  Start  grantees  and  delegates  that  received  expansion  funds.  We  determined 
statistical  significance  by assessing overlapping  confidence  internals.  After  we 
completed  our  analysis,  we conducted  follow-up  interviews  with several  grantees  to see 
if we could  ascertain  the  reasons  for the  discrepancies  between  our  data  and  theirs  (as 
reported  in the  PIRs). 
Appendix  A contains  a description  of how we collected  and  reviewed  grantee 
management  and  performance  data.  Appendix  B compares  grantee  performance  in 
1988-89 to  1991-92 using the  OIG  performance  indicators. 
We  conducted  this inspection  in accordance  with the  QuaZity Sfandard  for Impectiorw 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
-5  OIG  PERFORMANCE  INDICATORS 
.In@ator  ~  Description  Data  Source 
,. 
1 Percent of chil(irenmedicallyscreened  Childrenshealth file review 
percent of children receivingthe needed medical 
2 Childrenshealth file review
treatment 
3 Percent of children receivingdental exams  Chiltlrenshealth file review 
Percent of children receivingthe neededdental 
4 Childrenshealth file review
treatment 
5 Percent of children fullyimmunized  Childrenshealth file review 
6 Programprovidesnutritious meals and snacks  Grantee menu analysis 
percent of children for whomthe teacher has  Childrenseducationfile review, 
7 entered in the childsfolderobservational  teacher/educationcomponent 
commentsat least once a month  files 
Enrollment data, attendance 
8  Averageclasssize 
record sample 
Percent of familiesfor whoma familyneetls  Childrenssocialservicesfile 
9 
assessmenthas been completed  review 
Percent of families with identified needs for  Childrens social services file 
10  whom the Head Start program has attempted to  review, social services 
meet these needs  component log and file review 
Percent of parents volunteering at least 50 hours  Grantee interviews, volunteer 
11 
per year  and in-kind file review 
Enrollment data, attendance 
12  Percent of full enrollmen t 
data review 
Grantee interviews, attendance 
13  Average vacancy time 
data review 
14  Program is not at fiscal or program high risk  ACF regional office data 
Child-to-staff (teaching, sacial service, health,  Program-provided staff tally, 
15 
parent involvement, total ) ratio  enrollment data 
Number of volunteer trai,ningsand parent  Grantee intewiews, volunteer, 
16 
workshops  training, and in-kind file review 
Childrens social semices file 
17  Average number of conta :ts with each parent  review, social se~ices 
component log and file review 
18  Average daily attendance  Attendance data review 
6  FINDINGS 
The  original  purpose  of this inspection  was to assess  the  impact  of expansion  on Head 
Start  grantee  performance.  Using the  18 specific  performance  indicators  listed  on the 
previous  page,  we reviewed  records  for pre- and  post-expansion  school  years.  We 
found  no statistically  significant  differences  in these  indicators  before  and  after  the  first 
three  expansions.  Appendix  B contains  tables  comparing  grantees  performance  in the 
1988-89 and  1991-92 school  years. 
Although  grantee  performance  was relatively  stable  in both  school  years,  we found 
that  the  level  of performance  as measured  by the  OIG  performance  indicators  was 
considerably  lower  than  that  reported  in ACF  databases  and  published  reports. 
Because  of (1) inadequate  grantee  record  keeping,  (2) the  lack of specificity  in the 
Head  Start  performance  standards,  and  (3) the  fact  that  many  grantees  disregard  ACF 
policy guidance,  we are  unable  to determine  if the  program  and  performance  data 
weaknesses  that  we found  reflect  serious  deficiencies  in the  quality  of services 
provided  by Head  Start.  Since  the  level of performance  in both  school  years  was 
lower  than  the  performance  indicated  in ACFS databases,  we focused  our  analysis  on 
these  discrepancies.  We  present  the  results  in this report. 
This  report  is based  primarily  on the  data  related  to the  OIG  performance  indicators. 
A companion  report,  Head  Start  Expansion:  Grantee  Experiences,  describes 
problems  that  grantees  reported  enrolling  children,  obtaining  facilities,  hiring  qualified 
staff,  providing  transportation,  providing  social se~ices,  and  planning  for past  and 
future  expansions.  Despite  these  problems,  grantees  indicated  that  they were  able  to 
meet  ACFS performance  standards  during  expansion.  This  is consistent  with the  data 
reported  in their  PIRs.  Our  data,  however,  question  the  accuracy  of some  of these 
self-reported  data  and  assessments. 
THE  ACFS  PIR  DATA  DO  NOT  ACCURATELY  REFLECT  INFORMATION  IN 
CHILDRENS  HEALTH  RECORDS 
Grantees  are  not  completing  the  minimum  health  requirements  to the  extent  reported 
in ACFS Project  Head  Start  Statistical  Fact  Sheet  from  January  1992.  The 
Statistical  Fact  Sheet  reports  aggregate  data  submitted  by grantees  in their  PIRs.  The 
PIR  data  are  self-reported.  The  ACF  does  not veri~  or confirm  the  accuracy  of PIR 
data.  The  following  table  illustrates  the  contrast  between  ACFS statistics  and  ours: 
7  ACCORDING  TO THE OIG PERFORMANCE  INDICATORS, 
PIR DATA ARE INACCURATE 
ACFS Statistical Fact 
Indicator  Sheet, Janua~  1992  OIGS Review of Childrens Head Start 
(1990-91 Program Year)  Health Files for 1991-92 Program Year 
Percent of  97percent  of children  91.7  percent of children received a medical screen, 
children  enrolled  90 days  or more  but only 53.8 percent received all required health 
receiving medical  completed  medical  screen assessments.* Overall, 70.2 percent of the 
screens  screening  including  al! of  children received a medical screen within 90 days 
the appropnate  tests. u  of enrollment, 11.4 percent received one after 
90 days, and 10.1 percent received one during the 
previous year.  The Head Start performance 
standards simply require grantees to ensure that 
children receive health screens.  The ACFS 
guidance to grantees urges that the screenings be 
completed within 90 days of enrollment.  The 
guidance also informs grantees that children who 
have received screens in the past 12 months do not 
need to be reevaluated. 
Percent of  97percent  of those  Of the children requiring follow-up medical 
children with  tientified  as needing  treatment, 76.2 percent had all of their medical 
medical needs  [medical]  treatment  needs met and 5.5 percent had only some of their 
who received the  received  treatment.    needs met.  Approximately 18.2 percent received 
needed treatment  no follow-up treatment. 
Percent of  94.5percent  of the  84.7  percent of children received a dental screen. 
children  chi~dren enrol[ed  90 days  While 67.6 percent of children received a dental 
receiving dental  or more  completed  dental  screen 90 days before or after enrollment, an 
screens  exanukations.  n  additional 17.1 percent received the screen after 
90 days. In most cases, we found no 
documentation explaining why a child did not 
receive a dental screen.  The performance 
standards require that each child receive a dental 
screen.  The ACFSguidance to grantees states that 
the screen should be performed within 90 days of 
enrollment. 
Percent of  94.5percent  of those  Of the children requiring follow-up dental 
children with  needing  dental  treatment  treatment, 66.6 percent had aI1of their dental 
dental needs who  received  treatment.    needs met and 7.4 percent had only some needs 
received the  met.  Approximately 26 percent received no follow-
needed treatment  up treatment. 
*  According  to the Head  Start  guidelines,  the required  eiements  include  growth,  speech,  and 
immunization  assessments  and special  needs  identification  annual~  and  vkion  testing  heatig 
testing  and  hemoglobin  or hematocrit  determination  evety  2 years.  Because  of the different 
methodr  that  grantees  use to identifi  special  needs  and  lack  of documentation  about  whether  a 
child  was  in his second  year  in the program,  we determined  that  a child  received  alI appropnate 
tests if he received  the growth,  speech,  and  immunuation  assessments. 
8  CHILDREN  MAY  NOT  BE FULLY  IMMUNIZED  BEFORE  THEY  LEAVE  THE

HEAD  START  PROGRAM

The  Head  Start  performance  standards  require  that  grantees  assess  each  childs

immunization  status  and  assure  that  each  child receives  all recommended

immunizations,  as appropriate.  To  evaluate  grantee  compliance  with this standard,  we

used  ACFS published  guidance  to grantees  which was developed  by the  Centers  for

Disease  Control  and  complies  with the  recommendations  of the  American  Academy  of

Pediatrics.  Our  review  of health  files and  all other  available  information  provided  by

grantees  revealed  that  only 43.5 percent  of Head  Start  children  were  fully immunized

at the  end  of the  1991-92 school year,  according  to the  following  age-specific

guidelines:

\,.., 
:. 
:...  ACFS  IMMUNIZATION  GUIDANCE  TO  GRANTEES 
~~lhe requtied  immunizations  include  DPT  (diphtheria,  pertussis,  tetanus),  polio,  MUR  (measles, 
 mumps,rubella),  and  HIB  (haemophilus  injluenzae  type b).  The minimum  number  of doses  by 
4-year-olds:	 5* DPT 
4*POL1O 
1 MMR 
1 HIB 
*~ a child h not immunized as an infaruand 
tvceives the last dose afkr /t& 4th birthday, he 
child tnay receive one less dose and be considered 
Jidlyimmunized 
Some  children  required  several  immunizations  to be fully immunized.  The  following 
chart  shows how many  immunizations  Head  Start  children  required  at the  end  of the 
1991-92 school  year: 
HOW  MANY  IMMUNIZATIONS  DID  CHILDREN  NEED 
TO  BE  FULLY  IMMUNIZED? 
NumberofNeededImmunizations  PercentofChildren 
o 
43.5 
1  19.8 
2  29.5 
3 or More  7.2 
.
9  Obtaining  the  serial  immunizations  (DPT  and  polio)  posed  the  most  problems  for 
grantees.  Grantees  had  not  provided  ~  DPT  immunizations  during  the 
1991-92 school  year  for 61 percent  of the  378,000 children  who were  not  fully 
immunized  for DPT.  In addition,  grantees  had  not  provided  any polio  immunizations 
during  the  school  year  to almost  66 percent  of the  244,000 children  who were  not fully 
immunized  for polio. 
In general,  children  had  received  the  required  MMR  and  HIB  immunizations,  which 
they  are  supposed  to receive  before  entering  Head  Start.  Approximately  97 percent 
of the  children  had  received  the  required  MMR  immunization  and  91 percent  had 
received  the  HIB  immunization.  The  table  below illustrates  how many  DPT,  polio, 
MMR,  and  HIB  immunizations  children  required  to be fully immunized  at the  end  of 
the  1991-1992 school  year: 
HOW  MANY  OF  EACH  IMMUNIZATION  DID  CHILDREN  NEED 
TO  BE  FULLY  IMMUNIZED? 
Numberof Nccdcd 
~  of Immunization  Immunizations  Pcrccntageof Chikircn 
o  47.6 
1  47.9 
2  3.3 
DPT 
3  0.9 
4  0.3 
5  0.0 
o  66.3 
1  32.4 
POLIO 
2  1.0 
3  0.3 
4  0.0 
1  , 
II  I  I 
o  97.4 
MMR 
1  2.6 
0  91.0 
HIB 
1  9.0 
In contrast  to our  finding  that  43.5 percent  of Head  Start  children  are  fully 
immunized,  ACFS PIR  data  indicate  that  88 percent  of children  are  fully immunized, 
and  an  additional  8 percent,  although  not  fully immunized,  are  up-to-date  in their 
immunizations.  The  major  reason  for this discrepancy  is conflicting  definitions  of what 
constitutes  complete  immunization  for 4-year-olds.  The  ACFS guidance  to grantees, 
10  which we used  to measure  full immunization,  contlicts  with the  definition  that  grantees 
use to report  complete  immunization  in the  PIR.  The  PIR  instructions  allow grantees 
to consider  4-year-olds  fully immunized  if they have  received  4 DPT  and  3 polio 
immunizations.  This  is one  less of each  immunization  than  recommended  by the 
Centers  for Disease  Control,  the  American  Academy  of Pediatrics,  and  ACFS own 
published  guidance.  If we apply  the  PIR  instruction  to our  data,  we find that 
84 percent  of children  are  fully immunized.  This  corresponds  much  more  closely to 
ACFS published  figure  of 88 percent. 
Several  other  factors,  which were  validated  in our  follow-up  conversations  with 
grantees,  may contribute  to the  low immunization  rates  that  we found: 
.  Some  grantees  are  ignoring  ACFS guidance  and  are  applying  less-stringent 
State,  local,  or other  immunization  standards  to Head  Start  children; 
  Some  grantees  do not  keep  childrens  health  files up-to-date; 
.  A few grantees  are  having  difficulty finding  providers  who are  willing to provide 
immunizations  throughout  the  school year;  and 
  Not  all parents,  who have  been  referred  to providers  for immunizations, 
schedule  or keep  appointments. 
G&WVTEES  FREQUENTLY  DO  NOT  IDENTIFY  OR  ADDRESS  FAMILIES 
SOCIAL  SERVICE  NEEDS 
During  both  the  1988-89 and  1991-92 school years,  grantees  frequently  did not 
administer  family  needs  assessments  (FNAs),  did not  identi~  family needs  or goals 
when  conducting  an  FNA,  rarely  used  Family Assistance  Plans,  and  did not  help 
families  meet  all or most  of their  needs. 
Gmntea  ofien did not conduct FNh  or iiient~y familj  neek  and goak 
Families  who participate  in Head  Start  are  low-income  and  often  must  struggle  to 
meet  their  basic  needs.  The  ACFS guidance  to grantees  states  that: 
In order  to accomplish  the  comprehensive  objectives  of the  Social 
Services  component,  the  Head  Start  program  should  use some  form  of 
FNA  with  every  family  having  a child enrolled  in the  program ....  The 
FNA  will identify  the  interests,  desires,  goals,  needs,  and  strengths  of the 
family,  and  will help  the  Social Services  staff  determine  how Head  Start 
can  best  work  with the  family to maximize  and  maintain  its strengths, 
while  strengthening  areas  of need  and/or  concern. 
Despite  this, our  file review  revealed  that  grantees  frequently  did not  complete  family 
needs  assessments.  In other  cases,  grantees  (1) conducted  FNAs  but  did not  identi~ 
11  any family needs,  (2) only partially  completed  FNAs,  (3) used  scaled-down  forms  to 
accelerate  the  needs  assessment  process,  or  (4) substituted  intake  or application  forms 
for a formal  FNA. 
Approximately  140,000--or  26.3 percent--families  participating  in Head  Start  nationally 
did not  receive  an FNA.  This  represents  an improvement  over  1988-89 when  more 
than  one  in three  families  received  no FNA. 
Grantees  that  use the  Model  FNA  developed  by the  Head  Start  Bureau  were  more 
likely to  conduct  a needs  assessment  than  grantees  that  developed  their  own form. 
Fewer  than  40 percent  of grantees  use  the  Model  FN~  however.  Grantees  that  use 
the  Model  FNA  completed  it for 87.7 percent  of the  families  they served  during  the 
1991-92 school  year.  In comparison,  grantees  that  do not  use the  Model  FNA 
completed  a needs  assessment  for only 63.5 percent  of their  families.  The  chart  on 
page  13 describes  the  key components  of the  Model  FNA. 
Grantees  that  do not  use  the  Model  FNA  believe  that  it is too  cumbersome,  requires 
too  much  staff  time  to administer,  and  is not  conducive  to an open  dialogue  with the 
family.  Five  percent  of programs  claim  that  they have  never  received  or seen  the 
Model  FNA. 
Even  when  grantees  administered  an FNA,  they  frequently  did not  identi~  family 
needs  or goals.  In addition  to the  approximately  140,000 families  who received  no 
FN~  an  additional  70,000 families  who received  an FNA  in 1991-92 had  no needs  or 
goals  identified.  This  represents  approximately  20 percent  of all families  who received 
FNAs  during  the  1991-92 school  year.  This  percentage  is virtually  the  same  as in 
1988-89. 
Grantees rarely utiltied  comprehensive  Family Assktance  Plans as a blueprint to meet 
fami&  neeak and goaik 
Although  ACF  does  not  require  grantees  to use Family  Assistance  Plans  (FAPs),  the 
FAP  is an important  part  of the  needs  assessment  process.  It outlines  and  describes 
the  specific  measures  that  Head  Start  staff  and  family members  will take  to meet  the 
familys needs.  Head  Start  grantees  developed  comprehensive  FAPs  for only one-third 
of the  families  who received  a needs  assessment  and  had  needs  identified. 
Even  though  the  FAP  is part  of the  Model  FNA,  grantees  that  administer  the  Model 
FNA  were  only slightly more  likely to complete  full FAPs  (35.9 percent)  than  grantees 
that  use  their  own needs  assessment  (29.5 percent). 
Head  Stati  attempted  to meet  all or most  familj  neeh  fork  than  half  of the familitx
.-
with identified neeh 
By reviewing  childrens  files and  social  service  files and  logs, we assessed  efforts  to 
meet  family  needs  identified  in the  FNAs.  Grantees  attempted  to meet  all or most 
12  WHAT ELEMEIW3  DOES A COMPREHENSIVE  FAMILY NEEDS

ASSESSMENT CONTAIN?

A LOOK AT THE MODEL FNA

:  The Model FNA includes several discrete forms designed to obtain a full Picture of a 
: familvssocial service needs and to develop  a stratew  to meet  these  needs.  The  Model 
FNA contains: 
U51?	 Intake/Family  Profile:  This  includes  information  about  the  familys composition, 
health,  income,  education,  employment,  social semices  historv, and resources. 
,::=  Family Needs  Form:  This form prompts  social sexvice staff to describe  anv needs 
...::.,,:,.. ,:,:: 
,...  for financial  assistance,  employment,  education  or training,  housinq 
.:.,., 
.,.. transportation,  health  and nutrition,  mental  health,  family inter-relationships,  and
:,,.
:,..   parenting.  The  form also has a space  for staff to list any Head  Start  classes that
:. might  help  the familv meet  some  of these  needs. 
,...:, 
.. 
I@?  Family Goals  Sheet:  This sheet  lists family needs and goals and sets  target  dates 
for the  family to meet  them.  The  interviewer  probes  the family to identifj  the 
strengths it Possesses to meet these goals and identities communitv resources they 
mav need to achieve the goal. 
,.:..,,,.,,,;.,,.,.,., .. 
:,:;;,.@  Family &istance  Plan:  The intemiewer uses this form to work with the family 
on the s~ecific actions that will be necessarv to meet family needs, who will take 
these actions, and when. 
R3F  Family Contact Notes:  Social semice staff may use this form throughout the year 
to document contacts with family members and any referrals made on behalf of 
the familv. 
..... 
(Jla? 
Family Goals Attainment  Checklist:  Social services staff use this checklist

..,,,.

..,  throughout  the Vear to track a familysprogress in achieving its ~oafs.

:.,:,.
,

needs  for approximately  46.8 percent  of families  with identified  needs  during  the

1991-92 school  year.  Overall,  this represents  28.0 percent  of all families  who

participated  in Head  Start.

13
 The  following  chart  illustrates  Head  Starts  attempts  to meet  identified  needs: 
Grantees  Had  Difficulty  Meeting  Families'  Needs  During  the  1991-92 School  Year 
Families with 
Percent  of families  for whom  Head  Start:  identified  All families 
needs 
attempted  to meet all or most family needs  46.8  28.0 
attempted  to meet. some family needs  22.7  13.6 
attempted  to meet few or none of family needs  26.9  16.1 
identified family needs, but deemed no action necessary  3.7  2.2 
conducted an FNA but did not klenti~ family needs  --------------- 13.9 
did not conduct an FNA  --------------- 26.3 
Despite  these  findings,  three-quarters  of all Head  Start  directors  believe  that  their 
social  sexvices components  have  improved  or have  not  changed  because  of expansion. 
Furthermore,  based  on the  results  of ACF  on-site  reviews,  less than  13 percent  of the 
grantee  directors  indicated  that  they are  not  able  to meet  the  performance  standards 
for social  services. 
Nationwide,  the  Head  Start  child-to-social-service-staff  ratio  increased,  in contrast  to 
the  education,  health,  and  parent  involvement  components,  where  the  ratios 
decreased.  The  number  of children  per  social service  staff  rose  from  91.2 in 
1988-89 to 94.5 in 1991-92.  This is well above  the  35-to-1  ratio  recommended  by the 
National  Head  Start  Social  Services  Task  Force  in 1988. 
The  OIG  companion  report,  Head  Start  Expansion:  Grantee  Experiences,  describes 
grantees  difficulties  serving  children  and  families  with severe  problems.  Grantees  are 
concerned  about  providing  quality setvices  with the  diminishing  availability  of 
community  semices  and  decreasing  numbers  of professionals  w-ho are  willing to donate 
services. 
GRANTEES  FILES  AND  RECORDS  FREQUENTLY  ARE  INCOMPLE~ 
INCONSISTENT,  AND  DIFFICULT  TO  REVIEW 
Some  grantees  have  developed  exemplary  internal  record  keeping  requirements  and 
procedures,  while  others  need  technical  assistance  and  guidance  in this area.  The 
ACFS Grants  Management  Branch  has issued  instructions  that  require  grantees  to 
maintain  childrens  records  for 3 years,  but  has issued  no other  record  keeping 
guidelines.  As a result,  it frequently  was difficult  to review  and  verify performance 
indicator  data.  In summary: 
14  .	 Several  grantees  hadalready  disposed  of 1988-89 files despite  being  informed 
that  they  should  keep  these  records  for at least  3 years. 
.	 Certain  record  keeping  was haphazard.  Grantees  generally  did not  document 
important  events--such  as family contacts  and  semices  provided  to the  family--in 
a manner  that  is conducive  to follow-up.  Grantees  commonly  used  logs to 
document  contacts  rather  than  inserting  specific  notes  and  documentation  into 
the  childs file. 
	 It was impossible  to track  individual  parents  participation  in the  program 
during  the  school  year.  The  only source  of this information  was cumbersome 
in-kind  report  documentation. 
.	 Education,  health,  social  services,  and  special  needs  files remained  separated, 
even  after  the  school  year  ended.  A grantee  might  have  three  or four  different 
files for one  child, all in different  locations. 
15
 RECOMMENDATIONS 
THE  SECRETARY  SHOULD  CONVENE  A TASK  FORCE  TO  CONDU~  A 
FORMAL  AND  THOROUGH  REVIEW  OF THE  MANAGEMENT  OF THE 
HEAD  START  PROGRAM 
Because  of (1) inadequate  grantee  record  keeping,  (2) the  lack of specificity  in the 
Head  Start  performance  standards,  and  (3) the  fact that  many grantees  disregard  ACF 
policy guidance,  we are  unable  to determine  if the  program  and  performance  data 
weaknesses  that  we found  reflect  serious  deficiencies  in the  quality  of services 
provided  by Head  Start.  This,  when  considered  with the  organizational  and 
programmatic  concerns  expressed  by grantees  in the  companion  report  entitled  Head 
Start  Expansion:  Grantee  Experiences  and  anticipated  major  future  expansions,  leads 
us to recommend  that  the  Secretary  convene  a task force  to conduct  a formal  and 
thorough  review  of the  management  of the  Head  Start  program.  The  task  force 
should  analyze  the  respective  roles  and  functions  of the  Head  Start  Bureau,  ACF 
regional  offices, grantees,  and  delegates.  It should  review  how the  Head  Start 
program  is currently  organized  and  managed  and  how it can  best  be  structured  to 
administer  the  current  and  anticipated  expansions.  The  task  force  should  examine  the 
planning,  distribution  of funds,  grants  management,  oversight,  technical  assistance, 
management  information  systems,  and  performance  standards  that  are  currently  used 
to manage  the  program. 
The  Secretary  has  initiated  a comprehensive  examination  of Head  Start  with a 
particular  emphasis  on quality  and  accountability.  The  Secretarys  initiative  includes 
(1) immediately  identifying  poorly  performing  grantees,  designing  corrective  actions, 
providing  technical  assistance,  and  ensuring  that  grantees  that  provide  high quality 
services  receive  program  funds  and  (2) conducting  an in-depth  review  of the  program 
with the  help  of an  intellectually  diverse  expert  study panel  and  using the  results  to 
design  the  Head  Start  program  of the  future.  This  plan  addresses  our  concerns  and  is 
consistent  with our  recommendation.  We anticipate  that  the  examination  will consider 
all of the  issues  that  we have  identified  as well as the  following  recommendations: 
THE  ACF  SHOULD  CREA~  DISTRIBU~  AND  MANDATE  SPECIFIC 
RECORD  KEEPING  AND  CHILDRENS  FILE  MAINTENANCE  INSTRUCIIONS 
FOR  GRANTEES 
Standardized  record  keeping  and  file maintenance  would assure  easy access  to 
childrens  files.  Grantees  could  identifj  missing semices  or needed  follow-up  more 
readily,  and  on-site  reviews  could  be completed  more  expeditiously. 
16  THE  ACF  SHOULD  STRENGTHEN  ITS MONITORING  OF  GRANTEES  TO 
BETTER  IDENTIFY  AND  ADDRESS  PROBLEM  AREAS 
Although  Head  Start  directors  and  PIR  data  indicate  that  grantees  are  in compliance 
With Ifit  prtimmmce  stzmbwti,  we identified  on-going  deficiencies  in tne neatin and 
social  services  components.  Although  we did not  conduct  a review of ACFS on-site 
monitoring  process,  we believe  that  ACF  should  consider  restructuring  and  condensing 
its on-site  program  reviews so that  more  time  and  resources  can be  devoted  to 
monitoring  and  providing  technical  assistance  to the  most  needy  grantees.  By 
conducting  a condensed  OSPRI,  ACF  could  reduce  the  time  normally  required  to 
complete  an  on-site  review.  The  time  and  resources  saved  could be  used  to conduct 
follow-up  activities  and  to provide  technical  assistance  to grantees  that  are  having 
difficulty  providing  quality  services.  Furthermore,  ACF  should  randomly  sample  PIR 
data  to assure  its validity. 
THE  ACF  SHOULD  DEVELOP  A MODIFIED  FNA  FORM  THAT  SHOULD  BE 
REQUIRED  OF  ALL  HEAD  START  GRANTEES 
Fewer  than  40 percent  of grantees  use the  Model  FNA.  Grantees  do not use  the 
Model  FNA  because  it is cumbersome,  requires  too  much  staff time  to administer,  and 
is not  conducive  to an open  dialogue  with the  family.  The  Model  FNA  should  be 
revised  to reflect  these  comments.  The  ACF  should  require  grantees  to use  the 
revised  FNA  throughout  the  school year  to track  and  follow up on family needs. 
AGENCY  COMMENIX 
AS discussed  in the  first recommendation,  the  Secretary  has initiated  a comprehensive 
review  of the  management  of the  Head  Start  program. 
We  received  written  comments  on the  draft  report  from  ACF,  ASPE,  and  ASMB. 
The  ACF  generally  concurred  with our  recommendations  but was concerned  about  the 
presentation  of some  of the  data  and  conclusions  in our  findings.  They were 
particularly  concerned  about  the  immunization  and  social services  findings.  We found 
their  comments  helpful.  As a result,  we have  revised  the  immunization  section  and 
presented  additional  data  to explain  and  clarify our  finding.  In addition,  we have 
provided  a detailed  response  to all of ACFS comments,  including  immunizations  and 
social  services,  in appendix  C.  The  ASPE  and  ASMB  provided  editorial  and  technical 
comments  and  suggestions  which have  been  incorporated  in the  final report.  The 
complete  text  of the  ASPE  and  ASMB  comments  can  be found  in appendix  D.  APPENDIX  A

PERFORMANCE  DATA  COLLECTED 
To  collect  information  on some  of the  performance  indicators,  we reviewed  files for 
children  who  had  participated  in the  program  during  the  1988-89 (pre-expansion)  and 
1991-92 (post-expansion)  school  years.  We requested  that  each  of the  80 sampled 
grantees  send  us rosters  of children  enrolled  during  February  1989 and  February 
1992, in all program  options  so that  we could  select  a random  sample  of 20 students 
per  grantee  for each  school  year.  To  replace  children  who were  in the  program  less 
than  120 days or whose  files were  incomplete,  we actually  selected  30 children  for 
each  school  year. 
We  reviewed  each  childs medical,  social  services,  education,  special  needs,  and  other 
files.  overall,  we reviewed  files for  1,598 children  for the  1991-92 school year  and 
1,573 children  for the  1988-89 school  year. 
We  also conducted  a review  of attendance  records  to evaluate  average  daily 
attendance,  actual  enrollment,  and  percent  of full enrollment.  To  accomplish  this, we 
requested  that  grantees  send  us a list of their  classes.  We  produced  a set of tables 
that  allowed  the  reviewer  to randomly  select  20 class-days  for each  year.  For  each 
selected  class-day,  we recorded  the  funded  enrollment,  actual  enrollment,  and  the 
number  of children  who attended  class that  day. 
To  collect  information  on the  other  performance  indicators,  we interviewed  directors 
of all 80 grantees  and  obtained  management  and  performance  data.  These  data 
included  menus  for February  1989 and  February  1992, staffing  tallies,  budget  and 
expansion  figures,  parent  training  and workshop  documentation,  and  Federal  matching 
(in-kind)  records. 
At the  completion  of the  fieldwork,  we weighted  all data  to project  to the  universe  of 
Head  Start  grantees  and  delegates  that  expanded.  We determined  statistical 
significance  by assessing  overlapping  confidence  internals.  APPENDIX  B

HOW  HEAD  START  PROGRAM  PERFORMANCE  CHANGED 
ACCORDING  TO  THE  OIG  PERFORMANCE  INDICATORS 
INDICATOR  #1:  Percent  of children  medically  screened 
SOURCE:  Childrens  health  file review 
Percent  of ~  children  who:  1988-89  1991-92  Difference 
received a medical screen within 90 days of  74.4  70.2  -4.2 
enrollment 
received a medical screen after 90 days of  8.6  11.4  +2.8 
enrollment 
did not a receive a medical screen during  17.0  1s.4  +1.4 
the current school year 
percent  of fl  children  who  did not  1988-89  1991-92  Difference

receive  a medical  screen  because:

:.,

.,...

they received one during previous  8.4  10.1  +1.7 
12 months 
parent  refused treatment  1.8  0.7  -1.1 
screening was not required because child  0.1  0.6  +0.5 
was currently receiving treatment 
No Documentation  5.7  5.2  -0.5 
Other  1.1  1.8  +0.7 
B-1
 Out  of children  who  received  a medical  1988-89  1991-92  Difference 
screen,  percent  who received  each  of 
following  assessments  as part  of the 
screen 
charted height/weight assessment  82.0  76.4  -5.6 
immunization assessment  97.6  98.4  +0.8 
vision screening  92.1  93.2  +1.1 
hearing screening  91.0  93.3  +2.3 
hemoglobin/hematocrit screen  86.9  88.5  +1.6 
tuberculosis test  57.6  60.3  +2.7 
speech assessment  77.9  84.5  +6.6 
special needs identification  46.2  48.5  +2.3 
:. 
percent  of ~  children  who received  a  1988-89  1991-92  Difference 
~ctimplete  medical  screen: 
Annual requirements**  55.0  53.8  -1.2 
Annual and biennial requirements**  43.8  45.7  +1.9 
According  to the Head  Start Performance  Standardsy the required elements  include 
(a) growth, speech, and  immunization  assessments  and special needs identification 
annually  and  (b) vkion  testing, hearing testing, and hemoglobin  or hematocrit 
determination  eveiy 2 years.  Because  of the different  methods  that grantees use to 
identifi  special neeak, we omitted  this from  our M  of required elements. 
B-2  INDICATOR  #2:  Percent  of children  receiving  the  needed  medical  treatment 
SOURCE:  Childrens  health  file review 
.:& 
ent  of need  for medical  follow-up:  1988-89  1991-92  Difference 
Out of children who received a medical 
screen, percent who had medical needs  24.4  24.2  -0.2 
identified 
.: 
.out  of children  who  had  medical  1988-89  1991-92  Difference 
needs, percent  for whom: 
i 
grantees met all medical needs  I  74.9  I  76.2  I  +1.3 
grantees met some medical needs  9.4  5.5  -3.9 
grantees met no medical needs  15.7  18.2  +2.5 
B-3  INDICATOR  #3:  Percent  of children  receiving  dental  exams 
SOURCE:  Childrens  health  file review 
Percent  of ~  children  who:  1988-89  1991-92  Difference 
,. 
received a dental screen within 90 days of  63.6  67.6  +4.0 
enrollment 
received a dental screen after 90 days of  17.6  17.1  -0.5 
enrollment 
did not receive a dental screen  18.8  15.3  -3.5 
,,. 
Ptxcent  of&l  children  who did not  1988-89  1991-92  Difference 
~receive a dental  screen  because: 
.. 
. . 
parent  refused treatment  1.4  0.5  -0.9 
parent  missed appointments  1.0  0.7  -0.3 
appointment  scheduled, not yet completed  0.2  0.6  +0.4 
dental needs were checked only during  0.8  0.3  -0.5 
medical screen 
provider was unable to complete screen  1.6  0.3  -1.3 
No Documentation,  but child received  3.7  3.7  0.0 
screen during previous year in Head Start 
No Documentation  10.1  9.3  -0.8 
B-4
 INDICATOR  #4:  Percent  of children  receiving  the  needed  dental  treatment 
SOURCE:  Childrens  health  file review 
. 
Ektent  of need  for  dental  follow-up:  1988-89  1991-92  Difference
:..,:, 
Out  of children  who received  a dental  42.9  37.6  -5.3 
screen,  percent  who had dental  needs 
,. 
Out  of children  who  had  dental  needs,  1988-89  1991-92  Difference

:percent  for whom:

::

:,:,,

grantees met all dental needs  83.3  66.6  -16.7

grantees  met some  dental  needs  I  5.3  I  7.4  I  +2.1 
grantees met no dental needs  I  11.3  I  26.0  I  +14.7 
INDICATOR  #5:  Percent  of children  fully immunized 
SOURCE:  Childrens  health  file review 
E:..k,tent  of immunizations:  1988-89  1991-92  Difference
... 
.,. 
Percent of ~  children fully immunized  I  39.9  I  43.5  I  +3.6 
B-5
 INDICATOR  #6:  Grantee  provides  nutritious  meals  and  snacks 
SOURCE:  Grantee  menu  analysis 
Percent  of grantees  that  meet  Head 
19s8-89  1991-92  Difference 
,,Start nutrition  requirements,  by 
[program option: 
... 
.. 
Overall, all grantees  89.1  88.8  -0.3 
Part-day grantees  100.0  100.0  0.0 
Full-day grantees  60.9  59.8  -1.1 
,Percent  of grantees  that  meet  Head  1988-89  1991-92  Difference 
$tart  nutrition  requirements,  by meal:
;,.:.  .
,,:.:
,, 
Breakfast, all grantees  100.0  100.0  0.0 
Snack, all grantees  72.9  79.2  +6.3 
Lunch, all grantees  100.0  100.0  0.0 
B-6    INDICATOR  #7:  Percent  of children  for whom  the  teacher  has entered  in the 
childs folder  observational  comments  at least  once  a month 
(center-based  only) 
SOURCE:  Childrens  education  file review, teacher/education  component  files 
,,...,:
::...,
::.: .
~went  of observational  comments:  1988-89  1991-92  Difference
.:::,,, .....,...,
Percent of all center-based children for

whom teacher made observational  28.3  34.3  +6.0

comments in childs file at least once a

month

INDICATOR  #8:  Average  class size 
SOURCE:  Enrollment  data,  attendance  record  sample 
:,::. 
.... 
,,..,..,A.:....:,.,,. :.v.,:erage  class size:  1988-89  1991-92  Difference
Funded enrollment  (number of children)  17.9  17.8  -0.1 
per class 
Actual enrollment  (number of children)  17.5  17.6  +0.1 
per class 
B-7
 INDICATOR  #9:	 Percent  of families  for whom  a family needs  assessment  has been 
completed 
SOURCE:  Childrens  social  service  file 
:, 
Percent  of alI families  for whom  1988-89  1991-92  Difference 
!grantees:   
conducted a Family Needs Assessment  62.7  73.7  +11.0 
completed a family profile  92.1  89.5  -2.6 
identified family needs and/or goals  51.3  61.9  +10.6 
:. 
Percent  of all families  for whom  1988-89  1991-92  Difference

gtiantees:  

:...

:,

developed a full Family Assistance Plan  12.6  20.7  +8.1 
developed a partial Family Asistance  Plan  14.4  18.3  +3.9 
developed no Family Assistance Plan  24.1  23.0  -1.1 
identified no needs, therefore  did not  48.9  38.0  -10.9 
develop a Family Assistance Plan 
B-8
 INDICATOR  #10:  Percent  of families  with identified  needs  for whom  the  Head  Start 
program  has attempted  to meet  these  needs 
SOURCE:  Childrens  social  services  file review,  social services  component  log and 
file review 
Out  of families  with  identified  needs,  1988-89  1991-92  Difference 
percent  for whom  grantees: 
attempted  to meet all or most needs  39.4  46.8  +7.4 
attempted  to meet some needs  27.8  22.7  -5.1 
attempted  to meet few or none of the  24.0  26.9  +2.9 
needs 
deemed no action necessary to meet needs  8.8  3.7  -5.1 
:., .
!%)ut of families  with identified  needs,  1988-89  1991-92  Different 
~percent for  whom  grantees:
:.:::.....:.:...:,.., .
furnished information about available  52.7  60.6  +7.9 
community services 
gave referrals to community agencies  43.6  46.1  +2.5 
provided direct services  20.8  19.2  -1.6 
followed-up  25.2  30.7  +5.5 
B-9  INDICATOR  #11:  Percent  of parents  volunteering  at  least  50 hours  per  year 
SOURCE:  Grantee  interviews,  volunteer  and  in-kind  file review 
*  Although  we reviewed parent  volunteer files,  they were not organized to track 
individual  parents ) volunteer participation.  We asked program directo~  whether 
the percent  of parents  volun~eenngat least 50 houns per year  (or 6 houns per 
month)  had  increased, decreased, or s~ayed the same. 
:,. 
.Percent  of grantees  reporting:  Percent
:..:
>,.,:. 
an increase in parent volunteering since 1988-89  42.6 
no change in parent volunteering since 1988-89  34.8 
II I 
a decrease in parent volunteering since 1988-89  22.6 
INDICATOR  #12:  Percent  of full enrollment 
SOURCE:  Enrollment  data,  attendance  record  sample  review 
1988-89  1991-92  Difference 
II I  I  II 
Percent of full enrollment  98.0  99.*1  +1.1 
The  OIG report, Head Start Expansion:  Grantee Experiences found  that  13 
 
percent  of grantees were unable  to enroll all additional  children planned  under 
expansion.  The funded  enrollment jigures used to compute  percent  of full 
enrollment  in the above table do not include  children  who could not be enrolled 
because  of problems  witit expansion. 
B-10  INDICATOR  #13:  Average  vacancy  time 
SOURCE:  Grantee  inte~iews,  attendance  data  review 
,,, , 
Percent  of grantees  reporting  that  their  1988-89  1991-92 
average  vacancy  time  is: 
one week or less  61.2  72.3  +11.1 
8 to 14 days  13.6  12.4  -1.2 
15 to 30 days  14.0  13.7  -0.3 
Dont know  11.2  1.7  -9.5 
INDICATOR  #14:  Grantee  is not  at fiscal or program  high risk 
SOURCE:  ACF  regional  office  data 
None  of the grantees that  we vkited  were at f~cal  or program high rzkk. 
INDICATOR  #15:  Child-to-staff  ratio  (based  on actual  enrollment) 
SOURCE:  Grantee-provided  staff tally, enrollment  data 
;;:,,, 
.,..,,.. 
f:,.,i,ldren  per:  1988-89  1991-92  Difference
.,.,... ,.. .,
teacher, not including teaching assistants  19.5  18.8  -0.7 
teacher,  including  teaching  assistants  9.8  9.4  -0.4 
social service staff person  91.2  94.5  +3.3 
health  staff person  202.2  186.8  -15.4 
parent  involvement  staff person  165.1  150.5  -14.6 
B-II  INDICATOR  #16:  Number  of volunteer  trainings  and  parent  workshops 
SOURCE:  Grantee  interviews,  volunteer,  training,  and  in-kind  file review 
UNABLE  TO  DETERMINE.  Grantee files  were not conducive  to analysis. 
INDICATOR  #17:  Average  number  of contacts  with each  parent 
SOURCE:  Childrens  social services  file review,  social  semices  component  log and 
file review 
UNABLE  TO  DETERMINE.  Grantees record parent  contacts  differently.  Our 
reviewen  had  limited  success attempting  to quantifi  parent  contacts. 
INDICATOR  #18:  Average  daily attendance 
SOURCE:  Attendance  data  review 
,: 
...C hildren  present  divided  by funded  1988-89  1991-92  Difference 
~enrollment 
r 
Average daily attendance  I  84.3  I  86.3  I  +2.0 
B-12  APPENDIX  C 
ACF  COMMENTS  ON THE  DIL%171REPORT  AND 
DETAILED  OIG  RESPONSE 
c-l  DEPARTMENT  OF HEALTH & HUJMAN SERVICES 
ADMINISTRATION  FOR CHILDREN AND FAMILIE! 
Officeof the Assistant Secreta~, Suite 600 
370 LEnfantP romenade, S.w. 
Washington,  D.C. 20447 
. 
m 
Apti  7,  1993 
TO: 
Inspector  General 
FROM : 
Acting  As~istant  Secretary  for 
Children  and  Families 
M!rls am 
/
SUBJECT:  Office  of  Inspector  General  Draft  Report,  Evaluating 
Head Start  E@ansion  Through  Performance  Indicatorstg 
(OEI-09-91-O0762) 
The  Administration  for  Children  and  Families  (14CF)  appreciates 
the  opportunity  to  review  and  conumrk  on  the  Office  of  Inspector 
Generalts  (OIG)  draft  Report.  While  there  are  clearly  sexvice 
~allty  problems  in  some  programs,  ACF  believes  that  the  large 
majority of  Head  Sta~  p~~ams  are  ~roviclin~  th#r  qlled 
children- and  famili&-win*  good quallty  servlce~  and arestriving 
to  be  responsive  to  tieir  needs,  to  improve  program  management 
and  to  meet  Head  Starts  Performance  Standards.  The  problem  is 
not  that  service  quality  is  low  in  any  general  sense  but,  rather, 
that  it  is  uneven.  While  Head  Start  programs  at  the  high  end  of 
the  quality  spectrum  are  excellent,  it  is  evident,  based  on  ACWS 
own  experience  managinq  the  program,  that  some  local  programs  do 
not  fully  comply  with  important  elements  of  the  Head  Start 
Performance  Standards. 
ACF  program  officials  are  aware  of the variability  in  quality 
among  local  ?lead  start  programs  and  a  Variety  of  steps  have  been 
and  are  being  taken  to  correct  deficiencies.  These  include  the 
strengthening  of  ACFQS  program  monitoring  capacity, modifying 
Head  Startts  training  and  technical  assistance  delivery  system, 
providing  additional  funding  to  local  programs  for  service 
~ality  mprovement,  providln~  training  for  Head  Start  directors, 
zmprovlng  management  informatlcm  systems  and  promulgating  needed 
regulations  and  guidelines. 
TO  the  extent  that  the  OIGCS  study  helps  to  identify  areas 
requiring  further  attention  it  is  a  useful  contribution  to  our 
own  efforts  to  upgrade  Head  Start  service  quality.  However,  our 
overall  reaction  to  the  draft  Report  is  mixed.  On  the  one  hand, 
we  believe  that  the  Report  correctly  points  to  ~portztrlt  issues 
related  to  specific  program  components  and  to  local  Head  Start 
recordkeeping  and  reporting  tha~  clearly  require  further 
examination  and  action.  The two most  prominent  of  these  program  Page 2 - Bryan  B.  Mitchell 
We  also  believe  that 
components  are  health  and  social  services.  which broadly 
a  full-scale  management  review of  the  pro~={ 
that  may  be associated  with  the
examines all of  the  factors 
unevenness  in  service  quality  found  among  Head  Start  progrms,  is

an appropriate  step  toward  addressing  the  problem  and  zs

welcomed.

we  believe  that  the  Report  overstates

On the  other hand,  however, 
the  magnitude  of  the  problems  identified  and  that  it  is

misleading  --certainly  with  respect  to  ~unlzatlon and  to  some

In  ?dd+tlon,  despite  the  Reportts

extent  in  other  areas  as  well. 
cautionary  lan~a~e  regarding  the  dlst+nctlon  between.

and  actual  service  quallty  deficits,  the

recor-eepin?  deficits 
are  discussed  and  interpreted

manner  in  which  the  OIG  study  data 
betray  at  least  a  partial  disposition  toward  concluding,tiat  what

may  be  recor~eeping  problems  are,  in  fact,  servxce  dellverY,

negatxve  and  conclusive

problems.  This  gives  the  Report  a  more 
tone  than  may  be  warranted  or  intended. 
and 
.  Outlined  b~-low~M  greater detail are  ACF~s  ~specif~c  concerns 
co-ents  on  thelRep~rtts  findings  and  reco~endatlons.
: 
OIG  Report Findinqs 
leave

1)  Children may not be fully immunized before they 
he Head Start  Program 
The  ACF  believes  that  the  data  and  conclusions  presented,in the 
immunization  of  Head  Start  children 
OIG  Report  relative  to  the 
only  43.2  percent  of 
are  misleading.  The  Report  states  that 
children  were  fully  immunized  as  defined,by  Head  Start 
idelines.t*  While  97  percent  of  all  children  were  fully 
?%  unized  for  MKR and  90  percent  had  received  the  HIB 
immunization,  the  Report  states  that  chil~en  fre~ently  did  not 
receive  needed  DPT  and  polio  immunizations. 
 Head Start guidelines 
To be considered fully immunized, four-

recommend 5 doses of DPT and 4 doses of polio vaccine for 
year-olds and 4 doses of DPT and 3 doses  of pollo vacczne for 
three-year-olds.  However, the guidelines make allowances for  . 
children  who  were  not  immunized  as  infants  and  ellmlnate  me 
fifth  DPT and fourth polio vaccine doses for children whose 
vaccines were  given  after  the  clnldts 
previous doses of these 
The  Head  Start  guidelines  also  provide  a 
fourti  birthday. 
schedule  which  indicates  the  timing  and  spacing  of  the 
vaccinations. 
be  a  shoticoming  in  the  ~unization 
To  the  extent  that  there  may 
of  children,  it  is  largely  related  to  children  not  recelvln9  tie 
for DPT and polio and not to a 
last  in  the  series  of doses 
general disregard of immunization requlr-ents.  On the contra~~ 
c-3 
.  . 
. 
. 
. 
Page 3  - Bryan  B.  Mitchell 
according to  the  OIG%  findings,  98.4  percent  of  all  Head  Start 
children  were  assessed  for  current  immunization  status (not 80 
percent as stated on page 9; see table on page B-2), 97 percent 
received the MM? immunization and 90 percent received the HIB 
immunization.  These data strongly suggest that Head Start 
programs recognize the importance of immunization and argue for 
the exercise of caution before concluding that Head Start is 
grossly deficient in immunizing children. 
Part  of  the  problem  associated  with  the  OIG  Reportts  analysis  may 
lie  in  the  differing  interpretations  of  what  is  required in the 
serial immunizations for DPT and polio.  Head Start guidelines 
notwithstanding, some States, including the study States of 
Michigan and Washington for example, do not require that children 
receive  a  fifth dose of OPT vaccine andjor a fourth dose of polio 
vaccine, and Head Start programs and their  health  service 
providers  typically  do  not  provide  children  with  these  final 
doses. 
Another  source=  ?f  confusion  is  the  reporting  specifications  of 
the  Head  ~tart$&ogr&m  In~ormation  Report  (PIR);  tie  annual 
survey  instrument  on  which  Head  Start  programs  provide 
information  about  their  operations.  As  the  OIG  Report  itself 
notes, the PIR does not reference a fifth dose of DPT vaccine or 
a fourth  dose  of  polio  vaccine  as  a  requirement  for  reporting 
four-year-olds  as  having  completed  their  immunizations.  Rather, 
for reporting purposes, Head Start programs are instructed to use 
4  doses of DPT  and  3  doses  of  polio  vaccine  as  the  threshold  for 
a  child  having  satisfied  immunization  requirements,  irrespective 
of  whether  the  child  is  three  or  four  years  of  age. 
Using  the  4  doses  of DPT/3 doses of polio vaccine threshold 
specified in the PIR instructions, Head Start programs reported 
that 88 percent of  their enrollees were fully immunized.  Based 
on verbal communications with OIG study team staff, we were 
informed that using this service standard the OIGCS study data 
are very close to the PIR data:  88 percent immunized according 
to the PIR and 84 percent immunized according to the OIG study 
team@s data. 
BY  using Head Startgs 5 DPT/4 polio vaccine dose guideline as the 
standard to be met by all four-year-olds in Head Start, the 
Report exacerbated the  apparent  discreparwy  which  the  Study  found 
between  the  data  rep~rtecl  by  Head  start  pro~arns  on  the  plR  and 
the data collected  on  site  by  the  OIG  study  team.  Since 
approximately  63  percent  of  the  Head  Start  children  are  four
year-olds,  the  manner  in  which  they  are  dealt  with  is  critical  in 
any  assessment  of  humanizations  in  Head  Start. 
c-4  . 
Page 4  - Bryan B. Mitchell 
ACF will need to  examine the issue  of  what threshold should be 
used for reporting childrens immunization status  on  the PIR, 
recognizing  that  programs  in  some  States  may  not  meet  the  5  DPT/4 
polio  vaccination  guideline  for  four-year-olds  and  also  that  some 
four-year-olds  should  not  receive  these  final  boosters.  It 
should  also  be  noted  that  using  the  more  st~ingent  5  DPT/4  polio 
standard  for  reporting  four-year-old  children  as  fully  immunized 
on  the  PIR  is  not likely to alter immunization practices.  The 
principal result is likely to be that more  children  are  reported 
as  Up-to-date  as  opposed  to  having  coxnpleted  immunizations. 
Finally, we wish to point out that, apart from the issue of what

constitutes fully immunized,1the Report gives the impression

that large numbers of Head Start children are not up-to-date in

their immunizations.  It  asserts  that  Approximately  69.4  percent 
of  the  children  who  required  polio  immunizations  during  the 
program  year  did  not  receive  all  they  needed,  58.6  percent  of  the 
children  who  requhed  DPT  immunizations  during  the  program  year 
did  not  receive  all  they  needed  (page  9). 
Acc&~*ing ;&;th&Head ,Startguideline&~=ch~ic@en{shoulbde
gin 
immunizations @u~ingzZnfancy  and  should  ha~?received  4 doses of 
DPT  and  3  doses  of  polio  vaccine  by  their  Isth  month  and  another 
dose  of  each  vaccine  between  the  ages  of  4  and  6.  HoWeV=,oSO~e 
children,  especially  in  low-income  communities,  do  not  receive 
immunizations  on  time  and  must  be  immunized  according  to  a 
revised  schedule  which  is  also  specified  in  the  Head  Start 
guidelines.  For  example, a three-year-old entering Head Start 
without any prior immunizations receives his first shots in 
August.  The child should receive DPT-1, polio-l, MMR and HIB. 
Two months later, in October, the child should receive DPT-2 and 
polio-2.  Then, in December, the child should receive DPT-3.  The 
child should  not  receive  another booster until the period  between 
June  and  December  of  the  following  year.  Thus,  the  child  should 
not  have  more  than  3  doses  of  DPT  and  2  doses  of  polio  vaccine 
during  the  Head  Start  year.  Additional doses of vaccine during 
that time period would be of no benefit.  The same schedule would 
apply to a four-year-old with no prior immunizations. 
NO data are presented either in  the  body of the OIG Report or in 
Appendix B concerning how OIGS analysis took into account the 
childs age of first vaccination, the child~s age and vaccination 
status upon entry into Head Start and the child~s length of stay 
in the program before concluding that children did not receive 
all they  needed    by  way  of  immunizations. 
For  the  reasons  cited  above,  we  recommend  a  full  and  careful 
reanalysis  of  the  OIG  study  data.  The  reanalysis  should  present 
immunization  rates  for  four-year-olds  using  the  immunization 
c-5  8 
. 
Page 5 - Bryan B. Mitchell 
thresholds in  both  the  Head  Start  guidelines  and  the  PIR.  In 
determining  whether  the  children  are up-to-date  in  their 
immunizations,  the  reanalysis  should  make  appropriate  ad]ustrnents 
for  childrens  ages at first immunization and other relevant 
factors.  We also recommend that all of the data used in the 
analysis be presented in the Report along with such explanations 
of methodology as are necessary to understand how the data were 
compiled and analyzed.  Absent this, we recommend that the 
finding that  only  43.2 percent of Head Start children were fully 
immunized be dropped from the Report and that the immunization 
section be recast to reflect only what can be asserted with 
confidence. 
2)  ~  ect  ormation in 
childrenls health records. 
The ACF has several suggestions related to this finding.  First, 
the tables on page B-1, which provide some of the information 
used to illustrate this conclusion, should be modified~  The 
first table-is misleading in representing 18.4 percent of Head 
Start ~ildren  as not having receive-da medical screen.  The  -. ..
information in the  second table indicates that 10.1 percent  did 
not  require  screening because they had been screened during the 
previous 12 months and an additional 0.6 percent did not require 
screening because they were under treatment.  The data on these 
two categories of children should be removed from the second 
table and included in the first table so as to clearly show that 
only 7.7 percent of  the  children who required a medical screening 
did not receive it.  The fact  that  92.3  percent  of  all  Head  Start 
children  received  a  medical screen and that only 7.7 percent did 
not should be highlighted on page 8 along with the other 
information presented. 
Second, it would be helpful if the Report provided additional 
information regarding how it was determined that only 53.8 
percent of Head Start children received growth, speech and 
immunization assessments (pages 8 and B-2).  More information 
about this  aspect of Head Start program performance might shed 
some light on why this figure is so much lower than, and in 
apparent conflict with, the data on assessments presented in the 
table on the top of page B-2.  The data on page B-2 show that 
76.4 percent of children received height/weight assessments, 84*5 
percent received speech assessments and 98.4 received 
immunization assessments.  We also suggest the need for 
clarification of the note at the bottom of page B-2 which seems 
at variance with the notation on page 8 regarding the threshold 
for determining whether a child had received all appropriate 
tests.w 
C-6 
.  Page 6  - Bryan  B.  Mitchell 
3)  Grantees freuuentlv do not identifv or address 
families  social  service  needs. 
The OIG Report indicates that 26.3 percent of families 
participating in Head Start did not receive a family needs 
assessment (FNA).  It also states that, in some cases, Head Start 
programs only partially completed FNAs, used scaled do~  fo~s 
to accelerate the needs assessment process or substituted intake 
or application forms for a formal FNA.  TWO points related to 
these observations are unclear:  First what criteria did the OIG 
study team use to determine what constitutes an acceptable FNA? 
Might not at least  some  Head Start programs believe that the 
family profile1forms completed for 89.5 percent of enrolled 
families (see table on page B-8) contain sufficient information 
to serve as family needs assessments?  Second, how detrimental is 
the use of locally developed forms and protocols which may be 
less comprehensive  and  elaborate  than  the  model  FNA  developed  by 
the  Federal  government?  It  should  be  noted  that  the  use  of  the 
model  FNA  is  not  required.  Head  Start  guidance  merely  indicates 
that  programs  should  use  some  form  of  FNA.19 
7 
W*&  re~~ct  to  lieaci  Start  programs  efforts  to-actually  address 
family  needs,  we  suggest  that  the  tables  on  the  top  of  page  B-g 
and  on  page  13  be  modified  and  made  consistent.  The  table  on 
page  B-9  indicates  that  the  percent  of  families  with  identified 
needs  for  whoxa  Head  Start  prograxns  attempted  to  meet  few  or  none 
of  the  needst  was  26.9  percent.  No  definition  is  given  for  what 
is  meant  by  few  . . .of  the  needs  or  how  these  families  were 
distinguished  from  the  preceding  category  on  the  table,  f-ilies 
on  whose  behalf  programs  attempted  to  meet  some  of  the  need~en 
Unless  satisfactorily  distinguishable,  we  suggest  that  farnilles 
in  the  few-needs-met  category  be  iriclucied  with  the  families  in 
the  some-needs-xnet  category  and  that  the  26.9  percent  figure  be 
adjusted  downward  to  reflect  only  those  families  who  apparently 
received  no  assistance. 
A corresponding modification should be made to the table on page 
13 Please note in this connection that, as it stands, the table 
 
on page 13 is inconsistent with the table on page  B-g  in  that  it 
acknowledges no Head Start program efforts whatsoever on behalf 
of the 26.9 percent of families with identified needs. 
4)  Grantees ~ files and records freuuentlv are incomplete. 
inconsistent and difficult to review. 
This finding provides an important contextual consideration 
within which the entire OIG Report  Should  be  viewed  and  has  Z1 
material bearing on each of the other three major findings.  As 
noted in the Report itself, and as apparent  in  our  own  review  of 
it, the  OIG study team found it difficult in many instances to 
determine whether a problem identified during the review was an 
. 
. 
c-7   
Page  Bryan B. Mitchell 
7  -
actual service delivery weakness or the result of inadequate 
record keeping.  Since the issue of records and record keeping 
permeates so much of the Report, we suggest that this finding be 
presented first. 
As  indicated  earlier  in  this  memorandum,  we  also  suggest 
modifying  some  of  the  language  used  to  present  findings  and 
conclusions  which  is  inconsistent  with  the  Reports  own 
cautionary  note  regarding  the  study  teamts  inability  to 
determine  if  the  program  and performance data 
weaknesses. ..reflect serious  deficiencies  in  the  quality  of 
senices  provided  by  Head  Startg  (pages  ii  and  7).  A  few 
examples  of  language  which  appear  to  clis~egarci  this  caveat  are: 
Grantees  are  not  completing  the  minimum  health  requirements  to 
the  extent  reported...  (page  7)  ;  apparently...  percent  received 
no  follow-up  treatment (page 8); Approximately  140@0--or  26=3 
percent  --families  participating  in  Head  start  nationally  did  not 
receive  an  FNA~  (page  10);  and  made  no  attempt  to  meet  family 
needs  (page  13).  In  these and  other  instances,  it  would  be  more 
appropriate  to  use  language  such  as  the  study  team  could  find  no 
documentation  that...tt  or  local  Head  Start  program  records  were 
inadequate/incomplete  with  respect  to...,  etc. 
Finally, we also recommend that the Report include information on 
the results of the OIG study  tearn~s  follow-up  interviews  with 
selected  programs  which  are  mentioned on page 5.  The purpose of 
these interviews was to ascertain the reasons for the apparent 
discrepancies between the  data collected by the study teams on 
site  and  the  PIR  data.  Since  the  reliability  of  the  PIR  data  is 
presented  as  an  issue  in  the  Report,  it  would  be  helpful  to  knOW 
the  results  of  this  follow-up,  including  the  perceptions  of  the 
programs  whose  operations  were  the  subject  of  the  OIG  review. 
Our own informal discussions about immunizations with 18 of the 
programs reviewed by the OIG study team indicate that these Head 
Start programs do not consider their records to be inadequate and 
that they believe that the PIR information which they submit at 
the end of the program year is accurate.  However,  several 
programs indicated that, although services may have been 
provided, an individual childts health record might be incomplete 
because of several factors:  the  lag-time  associated  with  several 
centers  reporting  to  central  recardkeeping  locations;  the 
difficulty  of  obtaining  actual  copies  of  medical  records  from 
physicians not reimbursed by the Head Start program itself; and 
the fact that all of a child~s records may  not  be  in  the  master 
file  for  each  child  prior  to  the  actual  Close-out  of  tie  program 
year. 
C-8   
 
Page 8 - Bryan B. Mitchell

OIG Report Recommendations

1)  The Secretaq  of HHS should convene a task  force  to 
conduct  a  tormal  and  t borough  review  of the management 
of  t he  Head  Start  program. 
The ACF believes  that  a  management review of Head Start would be 
useful in helping to identify and address issues bearing upon

pro~am  quality.  In a March 31, 1993 letter to Senator Kennedy,

Chazrman of the Senate Labor and Human Resources Commttee,  the

Secretary indicated that she has asked for a top-to-bottom looktt

at the program.  The review would be undertaken with the help of

an expert study panel and the results used to design an improved

Head Start program.

2)	 The  ACF should create, distribute and mandate specific 
recordkeeplnq and children Bs tzles maintenance 
lnstructzons for grantees. . -
r	 *,+    El 
1.8 
 The  ACF  believes this recommendation  has  merit.  The  agency  has 
already  begun  work  on  the  implementation  of  new  recordkeepxng  and 
reportzng  protocols  for Head  Start,  entitled  the  Head  Start 
Family Information System (HSFIS).  The new system WZU  xnclude 
tiformation on the services provided to individual Head Start

children as well as on family needs and how  they  are  being 
addressed.  As  envisioned,  HSFIS  would  meet  the  recordkeeping 
needs  of  local  Head  Start  programs  and  also  facilitate  their 
reporting  of  information  to  ACYF.  A  request  for  clearance  to 
field  test  HSFIS in 22 Head Start programs is currently at the 
Office of Management and Budget for approval.

grantees to 
3)	 The ACF should strengthen its monitoring of 
better ~dentlfy and address Problem  areas. 
The ACF agrees with the suggestion under this recommendation that 
the PIR data should be checked for validity on a sample  ~asiq. 
However, other aspects of this recommendat~on, as ~pl~fled  m 
the text on page 15 which follows it, are problematic. 
First, although we a~ee  that we need to continue to stren~en 
our monitoring capacity, it is not clear what the Report means 
when it states that ACF should consider restructuring and 
condensing its on-site pro~am  reviews.  The OIG%  study  did not 
e%amzne how monitoring viszts are conducted, and the Report 
itself presents no findings or analyses concerning on-site 
monitoring. 
c-9  . . 
I 
Page 9 - Bryan B. Mitchell

Second, while we agree with the intent of the suggestion that ACF

should devote more time and resources to monitoring and providing

technical assistance to the most problematic ~antees~  tiere ~e

severe  constraints  related  to  its- implementat~on.  The  Head  Start 
legislation  requires  that  ACF  cenduct  an  on-site  monitoring  visit 
to  one-third  of  the  Head  Start  grantees  each  year  (approximately 
460  programs),  that  all  newly  established  programs  be  visited 
early  in  their  second  year  of  operation  and  that  follow-up  visits 
to Head Start a~encies be conducted when appropriate.  Currently

available staffng  and travel resources are barely adequate to

meet these statutory requirements, particularly the follow-up

visit requirement.  In so far as existing resources permit

follow-up visits, they are already being targeted on programs

identified as havinq significant Problems.  Any expansion of on-

site  monitoring  to  ~ddi~ional  pro~ams  would  requfie  more 
resources  than  are  currently  available. 
We suggest that this recommendation focus on validating  the  PIR 
data and that the topic of ACPS  monitoring processes and 
priorities be examined as part of the larger management review of 
Head Start envisioned by  the  Reports  first  recommendation. 
4)	 The ACF should develop a modified FNA form that should 
be  re qulred ot all Head  tart grantees. 
We believe that the HSFIS will satisfy the intent of this

recommendation.

If you have any questions about our comments or if we can be of 
further assistance, please do not hesitate to call. 
c-lo  OIG  RESPONSE  TO  ACFS COMMENTS 
ACF  CO MMENT  (Page  1):  While there are clearly service quality problems  in some 
programs, ACF  believes that  the laqp  majority of Head  Start programs  are providing  their 
enrolled children  and families  with good quality services and are stnvingto be responsive 
to their needs., to improve program  management  and to meet Head  Starts Performance 
Standards.  The problem  h not that service quality is low in any general sense but, rathe~ 
that  it is uneven.  While Head  Start programs at the high end of the quality spectrum  are 
excellent,  it k  evident,  based on A CFk  own expenencemanaging  the program,  that some 
local programs  do not fully  comply  wi~h important  elemenls  of the Head  Start 
Performance  Standards.  
ACF program  oficials  are aware of the variability in quality among  local Head  Start 
programs  and  a variety of steps have been and are being ~aken [o corect  deficiencies. 
These include  the strengthening  of ACFk  program monitoring  capacity, modi~ing  Head 
Starts training and  technical  assistance deiivery system, providing  additional funding  to 
local programs for service quality improvement,  providing training for Head  Start directo~, 
improving  management  information  ~stems  and promulgating  needed  regulations and 
guidelines.  
OIG  RESPONSE:  Based  on our  experiences  while conducting  on-site  visits, we 
generally  agree  with ACFS assessment  that  some  grantees  provide  better  and  more 
complete  services  than  others.  Given  the variation  in quality,  we believe  that  certain 
grantees  require  greater  technical  assistance  and  oversight  than  others.  This was the 
reason  that  we recommended  that  ACF  concentrate  its resources  on the  most  needy 
grantees,  rather  than  on the  ones  that  provide  high quality  services  already  (who could 
receive  a condensed  on-site  review).  Although  we did not  conduct  a tull study of 
ACFS on-site  review  process  and  we recognize  that  there  may  be legislative 
constraints,  we believe  that  ACF  should  consider  this optiom 
ACF  COMMENT  (Page  2):  tOn tileo{iwr hand,  however,  we believe iha~ the Repoti 
overstates the magnitude  of lhe problems  identified  and dlat it is misleading--certainly 
with respect to immunization  and to some  extent in other areas as well.  In addition, 
despite the Reports cautionary  language regarding [he dhtinction  between  record keeping 
deficits  and  actual  service quality deficits, the manner  in which the  OIG study data are 
discussed  and interpreted betray at least a partial deposition  ~oward concluding  that  what 
may  be record keeping problems  are, in fact,  service delivery problems.  Thk  gives the 
Report  a more negative and conchisive  tone than may be warranted or intended. 
OIG  RESPONSE:  While  the  report  includes  many  references  to the  poor  file 
maintenance,  we cannot  reject  the  probability  that  many grantees  are  not  providing 
the  services  required  by the  performance  standards.  The  immunization  problem,  in 
particular,  should  not  be dismissed  as merely  a record  keeping  problem,  since we 
found  conflicting  ACF  immunization  @delines  and  learned  that  many  grantees 
disregard  ACF/CDC  immunization  guidance,  anyway. 
C-11  Given  the  inconsistency  and  poor  condition  of tiles  maintained  by many  grantees,  it is 
impossible  for  any reviewer,  including  ACF  staff, to ascertain  whether  grantees  are 
adequately  providing  services  to children  and  families.  The  OIG  reviewers  conducted 
extensive  file reviews  of all available  information,  including  logs that  were  maintained 
by the  grantees.  They  also gave grantees  the  benefit  of the  doubt,  whenever  possible. 
ACF  COMMENT  (Page  2):  The ACF  believes that the data  and conclusions presented 
in the  OIG  Report  relative to the immunization  of Head  Start cilildren are mideading. 
17te Report  states that  only 43.2 percent  of c}lildren were fully  immunized  as defined  by 
Head  Start guidelines.  W}lile 97 percent  of all children  were fully  immunized  for MJ4R 
and  90 percent  had  received the HIB  immunization,  the Report sta[es tha~ children 
frequently  did not receive needed  DPT and polio  immunizations. 
To be considered  ~uhyimmunized,  Head  Start guidelines  recommend  5doses of DPT 
and  4 doses of polio  vaccine for four-year-olds  and 4 doses of DPT and 3 doses of polio 
vaccine for  three-year-olds.  However,  t}le guidelines  make  allowances for  children who 
were not  immunized  as infants  and eliminate  the fif(h  DPT  and fourth  polio  vaccine 
doses for  children  whose previous  doses of these vaccines  were given after the childh 
fourth  birthday.  Tile Head  Start guidelines  also provide  a schedule  which  indicates the 
hmingand spacing of the vaccinations.  
OIG  RESPONSE:  Our  analysis  took  all of these  factors  into  consideration. 
ACF  COMMENT  (Page  2):  To the extent that [here may be a shortcoming  in the 
immunization  of children,  it is la~ely  related to children not receiving the last in the senes 
of doses for  DPT  and polio  and not [o a general disregard of immunization  requirements.  
OIG  RESPONSE:  We  agree  that  most  children  who are  not  fully immunized  require 
only DPT  andior  polio  immunizations.  We tound,  however,  that  children  sometimes 
required  more  than  simply  the  last  in the  series  of immunizations.  We have  added 
additional  narrative  and  tables  in the  report  to  clarify  this  and  provide  additional 
information  for  ACF. 
ACF  COMMENT  (Page  3):  On t}le contrary, according to the  OIGS findings, 
98.4 percent  of all Head  Start children were assessed for  current immunization  status 
(not 80 percent  as stated  on page  9; see table on page B-2)... 
OIG  ItESPONSE:  The  ACF  did not  interpret  the  tables  correctly.  The  narrative  on 
page  9 of the  draft  report  referred  to the  percentage  of all children  who  received 
immunization  assessments.  Therefore,  children  who  did not  receive  medical  screens 
were  included  in this computation.  The  table  on page  B-2 refers  to the  percentage  of 
the  children  who  received  medical  screens  and  received  an  immunization  assessment 
as part  of the  screen.  This  excluded  children  who did  not  receive  medical  screens. 
C-12  ACF  COMMENT  (Page  3):  These data strongly suggest that Head  Start programs 
recognize the importance  of immunization  and a~ue  for lhe exercise of caution  before 
concluding  that Head  S~art is grossly deficient  in immunizing  children.  
OIG  RESPONSE:  In no section  of the  report  did we conclude  or imply that  Head 
Start  is grossly deficient  in immunizing  children.  At  the  same  time,  the  data  do not 
lead  us to conclude  that  all Head  Start  grantees  are  vigilant  in ensuring  that  children 
obtain  all immunizations  as required  by Head  Starts  published  guidance.  We have 
added  additional  narrative  and  tables  to the  report  to clearly  document  the  extent  to 
which  children  have  not  received  all required  immunizations. 
ACF  COMMENT  (Page  3):  Part of tile problem  associated  wi[h the  OIG  Report k 
analysis may  lie in lhe differing interpretations  of whu~ is required in ~he serial 
immunizations  for DPT  and polio.  Head  S[art guidelines  notwithstanding  some  States, 
including  ~he study Sta[es of Michigan  and  Washington for  example,  do not require that 
children  receive a fifth  dose of DPT  vaccine  and/or a fourtil  dose of polio  vaccine, and 
Head  Start programs  and their heal~h service providers typically do not provide  children 
wi~h these final  doses.  
OIG  RESPONSE:  We agree  that  grantees  use  different  standards  to determine  how 
many  DPT  and  polio  immunizations  are  required.  However,  ACFS reference  to 
Michigan  and  Washington  using lower  standards  is somewhat  inappropriate.  In fact, 
almost  half  of the  Michigan  and  Washington  grantees  were  above  the  mean  in terms 
of children  fully immunized  according  to Head  Starts  published  guidance.  In addition, 
senior-level  ACF  staff commented  during  meetings  that  the  presence  of less-stringent 
State  standards  would  not be  an appropriate  rationale  for grantees  to obtain  fewer 
immunizations  than  those  published  in ACFS guidance.  The  ACF  should  clarify what 
is expected  of grantees  and  assess compliance  with the  performance  standards  based 
on clear  and  consistent  guidelines. 
ACF  COMMENT  (Page  3):  Ano[hcr source of con.h.sion is [he reporting specifications 
of the Head  Start Program Information  Report  (PIR),  the annual  survey instrument  on 
which Head  Start programs provide  information  about  (}~eiroperations.  As  [he OIG 
Repofl  itself notes,  the PIR does ]lot refere~lce u Jfth  dose of DPT  vaccine or a fourth 
dose of polio  vaccine  as a requirement for  reporting four-year-okis  as having completed 
their immunizations.  Rather, for reporting purposes, Head  Start programs are instructed to 
use 4 doses of DPT  and 3 doses of polio  vaccine  as dle threshold for  a child having 
satisjied  immunization  requirements,  irrespective of whether the child h  three or four yearn 
of age. 
Usingthe 4 doses of DPT/3  doses of polio  vaccine  threshold specified  in the PIR 
inshuctions,  Head  Start programs reported (hat 88 percent  of their enrollees were fully 
immunized.  Based  on verbal communicatio]ls  widl OIG study (earn staff,  we were 
informed  that  using this service s[andard (}w OIGs study data are very close to dle PIR 
data:  88 percent  immunized  according [o the PIR  and 84 percent  immunized  according 
to the  OIG study team h da~a. 
C-13  OIG  RESPONSE:  We  agree  with ACFS assessment.  This  also  indicates  that 
grantees  immunization  records  are  fairly accurate.  From  this, we can conclude  that 
grantees  are,  to a large  extent,  disregarding  the  ACFS immunization  guidance,  and  our 
statement  that  43.5 percent  are  fully immunized  m measured  by ACFS guidance  is 
accurate. 
ACF  COMMENT  (Page  3):  By using Head  Starts 5 DPT/4  polio vaccine dose 
guideline  as the standard  to be met by all four-year-olds  in Head  Start, the Report 
exacerbated  the apparent dhcrepancy  which the study found  between  the data reported by 
Head  Start programs  on the PIR  and the data collected  on site by the OIG study team. 
Since  approximately  63 percent  of the Head  Start children are four-year-olds,  the manner 
in which  they are dealt  with is cn[icalin any assessment  of immunizations  in Head  Start. 
OIG  RESPONSE:  We  agree  that  the  percent  of children  fully immunized  as 
tabulated  by ACF  and  OIG  are  not  comparable.  This  discrepancy  was caused  by 
conflicting  ACF  criteria  for determining  full immunization.  While  its guidance 
suggests  that  5 DPT  and  4 polio  are  necessary,  ACFS published  data--the  88 percent 
stated  in ACFS Statistical  Fact  Sheet--uses  the  less stringent  PIR  criteria.  In addition, 
ACF  does  not  validate  PIR  data.  Our  random  sample  of children  is a clear,  accurate 
measure  of the  extent  of immunizations  that  Head  Start  grantees  provide. 
ACF  COMMENT  (page  4):  ACF will need lo examine  [he issue of what threshold 
should  be used for reporting c}iildrcnk immunization  status on the PIR,  recognizing that 
programs  in some  States may  no[ meet the S DPT/# polio  vaccination  guideline for four
year-olds  and ako  that some four-year-olds  should  not receive these Jinal boostem  It 
should  ako  be noted  that using the more s[ringenl 5 DPT14 polio  standard for repofling 
four-year-old  children as jidly  immunized  on [he PIR  is not likely to alter immunization 
practices.  The principal  result is likely to be that more children  are reported as up-to-date 
as opposed  to having completed  immunizations. 
OIG  RESPONSE:  We  agree  that  ACF  should  examine  its criteria  for reporting  full 
immunization  on the  PIR.  This  is far less important,  however,  than  clarifying  its 
guidance  to grantees  on  how many immunizations  each  child  should  receive.  If ACF 
believes  that  grantees  should  have  the  option  of ignoring  the  guidelines  created  by the 
Centers  for  Disease  Control  and  distributed  by ACF  in favor  of State  or other 
standards,  then  it should  issue formal  guidance  to grantees  that  states  this policy. 
ACF  ~wNT  (page  4):  Finahy,we wikh lo poinl  OLUlhat, apart from  the ksue  of 
what constitutes  @llyimmunized,  )the Repor~gives !Ile impression  t}lat la~e  nurnben  of 
Head  Start children are not  up-to-dale  in llleir immunizations.  11 asserts that 
Approximately  69.4 percent  of the chi[dren who required polio  immunizations  during the 
program year did not receive all ihey needed,  58.6 percent  of the children  who required 
DPT  immunizations  during [he progr~imyear did not receive all [hey needed  (page 9). 
According 10 the Head  Star{ guiddines,  chi[dren shou!d begin immunizations  during 
infancy  and should  have received 4 doses of DPT  and 3 doses of polio  vaccine by lheir 
C-14  18th month  and  another  dose of each vaccine between  the ages of 4 and 6.  Howeve4 
some  children,  especially in low-income  communities,  do not receive immunizations  on 
time  and must  be immunized  according [o a revised schedule  which is also specified  in 
the Head  Start guidelines.  For example,  a three-yeur-old  en~eringHead  Start wit}~outany 
ptior  immunizations  receives his first sho!s in August.  Tile c}lild should  receive DPT-1, 
polio-l,  MMR  and HIB.  Two months  late~ in Oc[obe~ the child should  receive DPT-2 
and polio-2.  T/len, in Decembe~  the c}lild should  receive DPT-3.  T}le child should  not 
receive anot}ler booster until the period between June  and December  of the following year. 
Z4us, the child should  not have more than 3 doses of DPT  and 2 doses of polio  vaccine 
during the Head  Start year.  Additional  doses of vaccine  during that time period  would be 
of no benefit.  Tile same schedule  would apply to a four-year-old  with no pnor 
immunizahons.  
OIG  RESPONSE:  As we commented  during  meetings  with ACF,  we were  unable  to 
determine  whether  underimmunized  children  were  indeed  up-to-date  in their 
immunizations.  The  up-to-date  measure  would  represent  a very small  percentage  of 
Head  Start  children  who were  severely  underimmunized  when  entering  Head  Start 
and  could  not  receive  all required  immunizations  during  the  school  year.  Clearly,  very 
few children  come  into  Head  Start  as underimmunized  as the  one  used  by ACF  as an 
example.  In fact,  OIG  reviewers  were  unable  to recall  a single  instance  in which a 
child  had  no immunizations  when  entering  Head  Start.  In addition,  ACF  data  indicate 
that  only 8 percent  of all Head  Start  children  are  up-to-date  rather  than  fully 
immunized  or not  fully immunized.  Even  assuming  that  8 percent  of our  sample  was 
up-to-date  (rather  than  not  fully immunized),  approximately  half of all Head  Start 
children  still are  not  fully immunized  or up-to-date  as defined  by Head  Starts 
published  guidance. 
We  have  revised  the  report  to exclude  references  to children  receiving  all 
immunizations  they need.  The  final report  focuses  on whether  children  who are  not 
fully immunized  received  ~  of their  needed  immunizations  during  the  school year. 
We  believe  that  this gives grantees  the  benefit  of the  doubt,  given that  it is possible  for 
a child to receive  as many  as 3 DPTs  and 2 polios  during  the  school  year. 
ACF  COMMENT  (Page  4):  No data  am presented  either in the body of the OIG 
Report  or in appendix  B concerning how  OIG b analysis took  into account  lhe childs age 
of jkst  vaccination,  the cilildh  age and  vaccination  ~[utus upon  entry into Head  Start and 
the childh  length of stay in the program before concluding  tha~ children did not receive 
all they needed  by way of immuniza~ions. 
OIG  RESPONSE:  We  have  revised  the  final report  to include  more  information 
about  how we assessed  immunizations.  We ascertained  whether  each  child  received 
his first DPT  and  polio  immunizations  by the  time  she was 4-months-old.  In addition, 
we used  this and  the  childs age to determine  how many  immunizations  were 
necessary.  All children  were  in the  program  for at  least  120 days. 
C-15  It should  be  noted  that  only 39 percent  of children  who required  DPT  immunizations 
received  at least  one  and  only 34 percent  of children  who required  polio 
immunizations  received  at least  one  during  the  school year.  The  final  report 
incorporates  this information. 
AC.F COMMENT  (Pages  4-5):  For[he reasons cited above,  we recommend  a full  and 
careful reanalysti  of the  OIG study data.  The reanalysis s}lould present  immunization 
rates for four-year-olds  wing  the immunization  thresholds in both  the Head  Start 
guidelines  and the PIR.  In determining  whelher the children are up-to-date  in their 
immunizatiom,  the reanalysh  s}lould make  appropria~e adjustments  for  children b ages at 
fint  immunization  and other relevant factors.  We also recommend  that ali of the data 
used in the analysis be presented  in ~}leReport along with such  explanations  of 
methodology  as are necessary lo understand  how the data  were compiled  and analyzed. 
Absent  t}u$ we recommend  that the finding  [hat onb  4.?.2percent  of Head  Start c}lildren 
were fully  immunized  be dropped from  t}w Report and lhat the immunization  section  be 
recast to rejlect only what can be asserted wi(h confide rice. 
OIG  RESPONSE:  The  immunization  finding, as written,  presents  clear,  accurate 
information  about  the  extent  of immunization  among  Head  Start  children.  We  have 
revised  the  report  to  address  ACFS concerns,  but  our  main  concerns  remain: 
1.  43.5 percent  of children  are  fully immunized  as defined  by Head  Start 
guidelines  (the  draft  report  figure  was 43.2 percent).  These  guidelines  are  the 
same  as those  published  by CDC  and  many other  organizations.  Using  the  PIR 
reporting  guidelines,  84.0 percent  are  fully immunized.  We  are  unaware, 
however,  of any policy that  states  that  grantees  should  use PIR  reporting  as the 
standard  requirement  for immunizations. 
2.  Grantees  do not  have  clear  instructions  about  how many  immunization  they 
should  obtain  for children.  The  PIR  and  Head  Start  published  guidance  are  in 
conflict. 
3.  Many  children  participating  in Head  Start  are  missing key immunizations,  and 
some  need  several  immunizations  to be fully immunized. 
4.  Many  children  did not  receive  immunizations  during  the  program  year,  although 
they  needed  them,  according  to ACF/CDC  guidelines.  Less than  40 percent  of 
children  who required  DPT  and/or  polio  immunizations  received  ~  during  the 
1991-92 school  year. 
ACF  COMMENT  (Page  5):  T/le A CFS PIR da[a do not accurately reflect information 
in children k health  records.  Tile A (3F has several suggestions related to this finding. 
Fimt, the tables on page B-1, wilic}l provide some  of the information  used to illustrate thk 
conclusion,  should  be modi~ed.  Tile Jirst table is mtileading  in representing 18.4 percent 
of Head  Start c}lildren as not ho ving received a medical  screen.  The information  in the 
second  table indicates  that  10.1 percent  did not require screening because  they had been 
C-16  screened  during the previous  12 months  and an addi~ional 0.6 percent  did not require 
screening because  they were under treatment.  Tlw data  on t}lese two categories of 
children should  be removed from  the second  table and included  in the first table so as to 
clear~ show  t}lat only  7.7 percent  o! the children who required a medical  screening did 
not receive it.  Tlw fact  that  92.3 percent  of ull Head  Start c}lildren received a medical 
screen and  that  only  7.7 percent  did nol should  be highligh~ed on page  8 along with the 
other information  presented.  
OIG  RESPONSE:  We  have  modified  the  table  on page  B-1 to indicate  that 
18.4 percent  of Head  Start  children  did not  receive  a medical  screen  during  the 
current  Vear.  While  we understand  that  ACF  does  not  require  grantees  to obtain 
screens  for second  year  participants,  we found  no documentation  or guidance  that 
would  allow grantees  to do this.  The  performance  standard  guidance  states  that 
screening  tests  should  be  carried  out  for all the  Head  Start  children  (page  17).  In 
this regard,  we believe  the  distinction  in the  table  on Page  B-1 is appropriate.  We 
found  that  some  model  grantees  obtained  health  screens  for all children,  regardless  of 
whether  they  had  one  the  previous  year. 
A broader  concern  that  ACF  does  not  address  is the  lack of complete  health  screens. 
Only about  half  of the  children  in Head  Start  received  all three  required  annual 
assessments  during  their  screens  (growth,  speech,  and  immunization--we  gave  grantees 
the  benefit  of the  doubt  for the  special  needs  assessment).  This  does  not  include  the 
biennial  assessments  (vision testing,  hearing  testing,  and  hemoglobin  or hematocrit 
determination).  If we used  complete  health  screens  as the  measurement  for whether 
children  received  a health  screen,  grantee  performance  would  be  much  lower. 
ACF  COMMENT  (Page  5):  Secotul, i~ would be hclpfid  if the Report provided 
additional  information  regarding how it was determined  tilat only S3.8 percent  of Head 
Start children  received growth, speech and immunization  assessments  (pages 8 and B-2). 
More  information  about  this aspect of Head  Start program performance  might shed some 
light on  why d~ti figure  h so much  lower ~han, and in apparent  con.ict  with, the data  on 
assessments presented  in ~he table on (he [op or page B-2.  Tile data on page B-2 show 
that  76.4 percent  of children received height/weig}lt assessmen~s, 84.S percent  received 
speech  assessments  and  98.4 received immunization  assessments.  We ako  suggest the 
need for  clarification  of [he note at the bottom  oJpage B-2 which seems at vanance with 
the notation  on page  8 regarding {he ihreshold for determining  whether a child had 
received  all appropriate tests.  
OIG  RESPONSE:  We  clarified  the  wording  of the  tables  in the  final  report.  The 
53.8 percent  refers  to the  percent  of ~  Head  Start  children  who received  a full health 
screen.  This  includes  children  who did not  receive  any screen.  The  table  on page 
B-2 refers  to the  assessments  received  by children  who received  a health  screen.  We 
also have  revised  the  report  to ensure  that  the  footnotes--which  describe  the  criteria 
for determining  whether  a child received  a complete  health  screen--are  consistent. 
C-17  AC!F COMMENT  (Page  6):  Grantees frequently do not zdentifi or address families 
social service needs.  Tile (2IG Report  indicates  tilat 26.3 percent of families  participating 
in Head  Start did not receive a family  needs assessment  (FNA).  It also states that, in 
some  cases, Head  Start programs only partially  completed  FNAs,  used  healed down) 
forms  to accelerate  the needs assessment process or substituted  intake  or application forms 
for  a formal  FNA.  Two points  related [o [hese observations are unclear:  Fint  what 
criteria did the  OIG study team  use to determine  wha[ constitutes  an acceptable  FNA ? 
Might  not  at least some  Head  Start programs  believe ~ha~the  ~amily profile forms 
completed  for  89.5 percent  of enrolled families  (see table on page B-8)  contain  su.cient 
information  to serve as family  needs assessments? 
OIG  RESPONSE:  We  used  ACFS performance  indicator  guidance  to determine  the 
intent  of the  FNA  process.  The  guidance  states:  The FNA  will identi~  the  interests, 
desires,  goaks, needs  and  strengths  of the  family, and  will help  the  Social  Sewices  staff 
determine  how Head  Start  can best  work with the  family to maximize  and  maintain  its 
strengths,  while  strengthening  areas  of need  and/or  concern.  ln addition,  we 
examined  each  component  of ACFS Model  FNA,  which is described  on page  12 of 
the  report.  While  we did not  assess grantees  forms  against  the  model  FNA, we 
looked  for  an  attempt  to identi~  needs  and  goals  at a minimum. 
The  family  profiles  we saw merely  list family members  and  ages.  We frequently  found 
that  this information  was part  of the  enrollment  application,  rather  than  part  of a 
social  sexvices file.  If a family profile  contained  an assessment  of family needs,  we 
considered  it to be  an FNA  (as well as a family profile).  However,  we did not  deem  a 
listing  of family  members  and  ages  as a suitable  substitute  for an assessment  of the 
reasons  the  family  is in poverty  and  the  services  it requires. 
We would  consider  it a severe  program  weakness  if ACF  found  grantees  in 
compliance  with social  service  requirements  if they systematically  failed  to ascertain 
parents  needs  for  income  supplements,  education,  job  assistance,  medical  and  mental 
health  services,  and  other  assistance. 
In addition,  we found  little  evidence  that  grantees  used  and  updated  FNAs  throughout 
the  year.  This  is critical  because  families  may be hesitant  to share  their  needs  and 
problems  during  intake.  Overall,  grantee  efforts  to identify  needs  are  clearly  a 
problem. 
ACF  COMMENT  (Page  6):  ..,Iww dc[rimental  is [he use of locally developed fomns 
and protocols  which may  be less comprehensive  and  elaborate than  the model  FNA 
developed  by the Federal government?  It should  be noted  that the use of the model  FNA 
b not required. Head  Start guidance  merely indicates  that programs should  use  some 
form  of FNA.  
OIG  RESPONSE:  The  report  does  not  state  that  grantees  development  of forms  is 
detrimental.  However,  ACF  should  be aware  that  some  grantees  have  developed 
forms  that  clearly  make  no attempt  to identi$  family  needs  or goals  or develop  action 
C-18  plans.I nadditioOnI,G
  reviewers  often  found  that  enrollment  forms  were  used  as 
FNAs  and  contained  few or none  of the  elements  in the  Model  FNA.  Some  model 
grantees  have  developed  scaled-down  forms  that  comprehensively  identi&  family needs 
and  help  develop  a framework  to address  these  needs. 
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ACF  COMMENT  (Page  6):  Wi~h respect to Head  Start programs efforts to actually 
address family  needk,  we suggest that the tables on the top of page B-9 and on page 13 be 
modified  and made  consistent.  The table on page B-9 indicates  that  the percent  of 
families  with identified  needs for  whom Head  S[art programs  at~empted [o meet few  or 
none of the needs was 26.9 percent.  No deflni[ion  is given for  what is meant  by ~ew...of 
the needs or how  [Ilesefamilies  were distinguislw.i from  tile preceding  category on the 
table, families  on whose bella~prograrns  cit[empted to meet  some of the needs. )  Unless 
sat~actotily  dtitinguishable}  we sugges~that f~~miliesin [hefew-needs-met  catego~  be 
included  with the families  in the some-needs-met  categoy  and that  the 26.9 percent figure 
be adjusted  downward  to rejlect only [hose families  who apparently received no 
assistance.  
OIG  RESPONSE:  The  data  in the  two tables  are  consistent.  We  have  modified  the 
category  names  to ensure  that  they  are  not  misunderstood. 
The  OIG  reviewers  examined  the  extent  to which  grantees  attempted  to  meet  each 
familys  needs.  We  excluded  families  who  had  no identified  needs.  If a family had 
needs,  we considered  any documented  effort  by the  grantee  to  address  the  need-
including  providing  direct  semices,  making  a referral,  or even  simply  making  a 
telephone  call--to  be  an attempt  to meet  the  need. 
The  ACFS comments  indicate  that  it is unaware  that  grantees  are  not addressing 
family  needs  to a large  extent.  We found  clear  evidence  that  many  grantees  do not  or 
are  unable  to  address  ~  family needs  due  to excessive  social  service  staff caseloads, 
general  staff  overload,  lack of available  community  services,  and  other  reasons.  The 
few or none  category  was one  category.  lf we found  absolutely  no attempt  to meet 
the  familys needs,  we judged  the  effort  to be an attempt  to meet  few or no needs.  If 
a family had  many  serious  needs  and  the  grantee  made  minimal  efforts  to address  only 
one  or perhaps  two--with  no follow-up--we  determined  that  they  had  met  few or 
none. 
During  training,  we instructed  reviewers  that  moderate  attempts  to meet  a portion  of 
family  needs  should  be judged  as an attempt  to meet  some needs.  The  ACF  should 
note  that  we also  combined  most and  all into  one  category,  which  makes  this 
categorys  data  somewhat  higher  than  if we had split  them.  ACI? COMMENT  (Page  6):  A corresponding modi~cation  should  be made  to the table 
on page  13.  Please note  in ~hk connection  that, as it stands,  the table on page  13 h 
inconsistent  with the table on page B-9 in [hat i~ acknowledges  no Head  Start program 
efforts whatsoever  on behalf  of t}w 26.9 percent  of families  with identified  needs 
OIG  RESPONSE:  We  have  revised  the  table  on page  13 so that  made  no attempt  to 
meet  family needs  is replaced  by attempted  to meet  few or no family needs. 
ACF  COMMENT  (Page  6):  Gran[eesfiles and records frequently  are incomplete 
inconshtent  and dificult  to review.  T}u3finding  provides  an important  contextual 
consideration  wit}lin which  the entire OIG Report s}tould be viewed and has a material 
bearing on each  of the other three major jindings.  As  noted  in tile Report itse~  and as 
apparent  in our own review of it, the OIG study team found  it diflcult  in many  instances 
to determine  whether a problem  identified  during the review was an actual service delivery 
weakness  or the result of inadequate  record keeping.  Since  the issue of records and record 
keeping permeates  so muc}l of [he Report,  wc suggest tilat ibis finding  be presented ftnt.  
OIG  RESPONSE:  We  believe  that  the  lack of documented  evidence  that  children 
received  the  required  health  and  social services  is the  most  important  finding.  The 
ACF  should  examine  the  issue of inadequate  record  keeping  under  the  context  that 
serious  service  delivery  problems  may exist.  Each  finding  refers  to record  keeping 
problems,  if these  indeed  exist and  influence  the  findings. 
ACF  COMMENT  (Page  7):  As indicated  eorlier in this memorandum,  we also suggest 
modifiing  some  of the language used to present findings  and conclusions  which is 
inconsistent  with the Reports own cautionav  note regarding the study team k inability  to 
determine  if the program  and performance  do[u weaknesses... re~ect serious deficiencies  in 
the quality  of services provided  by Head  S[urt (pages ii and  7).  A few  examples  of 
language  which  appear to disregard (his caveat  [ire: Grantees are not completing  the 
minimum  health  requirements  10 the ex[en( reported... (page 7); apparently...percenl 
received no follow-up  treatment  (page 8); Approximately 140,000--or 26.3 percent-
families  participating  in Head  Sturt nationally  did not receive an FNA  (page IO); and 
made no attempt  to meet family  needs (page 13).  In these and other instances,  it would 
be more  appropriate to use language such as the study team  couid find  no 
documentation  t}lat... or local Head  S[art program  records were inadequate fincomplete 
with respect to..., etc.  
OIG  RESPONSE:  As it is written,  the  report  emphasizes  that  some  grantees  were 
unable  to provide  documentation  or data  to prove  that  certain  services  had  been 
provided.  In other  cases,  OIG  reviewers  concluded  that  selvice  delivery  problems 
exist, and  the  problems  are  not solely related  to record  keeping  problems. 
we  areunable  to  conclude  that  the  absence  of documentation  is related  to  file 
incompleteness.  The  absence  of documentation  could  also  indicate  that  the  services 
were  not  provided.  The  finding  states  that  it frequently  was  difficult  to  review  and 
C-20  verify performance  indicator  data.  Other  grantees  were  exemplary  in their  internal 
recordkeeping. 
The  OIG  reviewers  frequently  found  blank  FNAs  in childrens  files.  To  a large  extent, 
we found  underimmunized  children  who did not  receive  any immunizations  during  the 
year,  according  to the  charts  in their  files.  We  found  health  screen  documentation 
that  clearly  showed  that  certain  assessments  were  not  completed.  The  ACF  should 
understand  that  these  service  delivery weaknesses  clearly  exist.  We  are  unable  to 
ascertain  the  extent  of these  weaknesses,  however,  because  of some  grantees  poor 
record  keeping. 
ACF  COMMENT  (Page  7):  Finally, we also recommend  tilat the Report include 
information  on the results of the OIG study teams follow-up  interviews with selected 
programs  which are mentioned  on page 5.  T}le purpose  of these interviews was to 
ascertain  the reasons for  tile apparent discrepancies  between  the data  collected by the 
study teams  on si[e and  the PIR data.  Since  the reliabilip  of the PIR  data k presented  as 
an zksue in the Repor~, i~ would be helpJhl to know  lhe results of this follow-up,  including 
the perceptions  of ~heprograms  whose opero[ions were the subject  of the OIG review. 
Our own informal  discussions  aboul  immunizations  with 18  of the programs reviewed by 
the  (21G study team  indicate  that [hew Head  Start programs  do not consider their records 
to be inadequate  and that  they believe !ha[ [he PIR  information  which they submit  at the 
end of the program year h accurate.  
OIG  RESPONSE:  We  have  incorporated  information  obtained  during  follow-up  calls 
in the  final  report.  We  also found  that  grantees  believe  that  their  files are  adequate. 
This  clearly  indicates  the  need  for ACF  to take  leadership  to provide  file maintenance 
guidelines. 
We would  expect  grantees  to assert  that  their  PIR  information  is accurate.  Without  a 
process  to  audit  or otherwise  validate  PIR  data,  neither  ACF  nor  OIG  could  verify  its 
accuracy. 
ACF  COMMENT  (Page  7):  ...severai programs indicated  that, al~hough services may 
have  been provided,  an individual  child?  heaith  record might  be incomplete  because  of 
several factotx  the lag-time  associated with several centers reporting to cen[ral record 
keeping  locations;  the dificulty  of obtaining  actual  copies of medical  records from 
physicians  not reimbursed  by the Head  Start program itself  and  the fact  that all of a 
childs records may not be in the master file for  each child prior to the actual  close-out  of 
the program year.  
OIG  RESPONSE:  We  contacted  the  grantees  well before  our visit and  provided  them 
with  the  names  of the  children  whose  files  we  wished  to  review.  We  clearly  instructed 
them  to  obtain  all ap ProPriate  files  including  health.  social  semices,  enrollment,  s~ecial 
needs,  education,  and  anv  other  files  related  to  the  child  or  familv.  When  we  found  a 
pattern  of  missing  information,  we  coded  it as missing  in  our  analysis  and  removed 
these  children  from  the  statistical  calculations.  In addition,  all  grantees  should  have 
C-21  been  able  to provide  complete  198&89 files.  We  found  that  grantees  performed 
similarly  in 1988-89 compared  to  1991-92, and  the  issues  of concern--medical  and 
dental  follow-up,  immunizations,  and  social  services  among  others--have  not  changed 
since  1988-89. 
RECOMMENDATION  #1:The SecretaorfvHHS shouldconvene a task force to 
conduct a formal and thorougrhevieowfthemana~ementoftheHead starPtroaam. 
ACF CO MMENT:  The ACF  believes that u management  review of Head  Start would 
be useful  in helping to identifi  and address issues bearing upon program quality.  In a 
March  31, 1993 letter to Senator Kennedy,  Chairman  of t}le Senate  Labor  and Human 
Resources  Committee,  the Secretary indicaled  that she has asked for  a top-~o-bottom 
look at t}~eprogram.  The review would be undertaken  with the help of an expert study 
panel  and  the results used to design an improved  Head  S~artprogram.  
OIG  RESPONSE:  No response  is necessary. 
RECOMMENDATION  #2:  The  ACF  should  create.  distribute  and  mandate  specific 
record  keeping  and  childrens  files maintenance  instructions  for aantees. 
ACF  COMMENT:  The A CF believes (Ilis recommendation  has merit.  The agency has 
already begun  work on the implementation  OJnew record keeping  and reporting protoco~ 
for Head  Start, entitled  die Head  Start Family Information  System  (HSFIS).  The new 
system  will include  information  on the services provided  to individual  Head  S~art children 
as well as on family  needs and how t}ley are being addressed.  As  envisioned,  HSFIS 
would  meet  the record keeping needs of local Head  Start programs and  also facilitate 
their reporting of information  to A CYF.  A  request for  clearance  to field  test HSFIS  in 
22 Head  Start programs k  currently al [he OJJke of Management  and Budget for 
approval.  
OIG  RESPONSE:  We  have  not reviewed  the  HSFIS  and  do not  know if it should  be 
a mandated  record  keeping  system for all grantees. 
RECOMMENDATION  #3:  The  ACF  should  strengthen  its monitorin~  of grantees  to 
better  identifv  and  address  problem  areas. 
ACF  COMMENT:  The ACF  agrees with [he suggestion under this recommendation 
that the PIR  data should  be checked f~x-validity on a sample  basis.  However,  other 
aspects of this recommendation,  as amplified  in [he {CX[on page  15 which follows  it, are 
problematic.  
First,although  we agree that  we need [o continue  to strengthen  our monitoring  capacity, 
it k  not  clear what the Report means  when it states lhat A CF should  consider 
restructuring and condensing  its on-site program reviews. T}le OIG h study did not 
examine how rnonitoting  visits are conducted,  and  the Report  itself presents no findings  or 
analyses concerning  on-site rnoni[oring. 
c-22  Second, while we agree wi[h [he intent  of the suggestion that ACF  should  devote  more 
time  and  resources to monitoring  and providing technical  assistance to ~hemost 
problematic  grantees, there are severe constraints re!a~ed to its implementation.  Tile Head 
Start legti[ation requires that ACF  conduct  an on-site monitoring  visit to one-t}lird of the 
Head  Start grantees each year  (approximately  460 programs),  that all newly established 
programs  be vbited  early in their second year of operation and  that follow-up  vkits  to 
Head  Start agencies be conducted  when appropriate.  Cuvently  available stajjing  and 
travel resources are barely adequate  to meet  these statutory requirements, particularly the 
follow-up  visit requirement.  In so far  as exbting resources permit follow-up  vikits, they are 
already being targeted on programs identified  as having significant problems.  Any 
expansion  of on-sile monitonng to additional  programs would require more resources than 
are currently available.  
We suggest that  this recommendation  focus  on validating the PIR  data  and that the topic 
of ACF?  monitoring processes  and priorities be examined  as part of the laiger 
management  review of Head  Start envisioned  by the Report k first recommendation.   
OIG  RESPONSE:  We  do not  believe  that  a review of the  on-site  review  process  is 
necessary  in order  to suggest  that  ACF  focus its resources  to target  and  provide 
technical  assistance  and  oversight  to the  grantees  that  are  having  the  most  problems. 
Clearly,  some  grantees  require  more  assistance  than  others.  We suggest  that  ACF 
consider  conducting  a scaled-down  on-site  review to assess  a grantees  general 
performance.  Based  on ACFS findings, further  review and  technical  assistance  could 
be  provided,  depending  on the  grantees  need.  This would  also avoid  wasting  time 
andresourcecsonductinag thorougohn-sitreevieowfagranteweithexcellent 
performancaendcleandocumentation. 
We  are  not  suggesting  that  ACF  expand  its on-site  review  program.  Conducting  a 
scaled-down  initial  on-site  review would  allow ACF  to continue  to  meet  its 
requirement  to visit all new grantees  and  all existing grantees  every  3 years.  Initial 
visits could  be  completed  in a fraction  of the  time  that  ACF  currently  spends  at each 
grantee.  This would  allow  more  time  for follow-up visits. 
We  agree  with ACF  that  this issue should  be  addressed  during  the  review  of the 
management  of Head  Start  made  in Recommendation  #1. 
RECOMMENDATION  #4:  The ACF  should  develop  a modified  FNA  form  that 
should  be  required  of all Head  Start  ~rantees. 
ACF  COMMENT:  We believe that HSFIS  will satisfy the intent  of this 
recommendation.   
OIG  RESPONSE:  As mentioned  above,  we have not  reviewed  the  HSFIS.  If ACF 
mandates  it and  it includes  a modified  FNA,  it would satisfj  the  intent  of the 
recommendation. 
C-23  APPENDIX  D 
ASPE  AND  AS~  CO-NTS  ON THE  Dm  REPORT 
D-1  .. . . 
EB19@3 
To:	 Bryan  B. Hitchell 
PrincipalDeputyInspectorGeneral 
PROM:	 Acting  Assistant  Secretq 
forPlannhg and  Evaluation 
s~JECT  :	 OIG  Draft  Report  Evalua&g  Head  Start  Expansion 
Through  Perfo~ce  lndicat~rs,  OE1-09-91-00762  --
CONCURRENCE 
Thank  you  for  the opportunity  to  review  this  draft  repoti.  AS my
Staff  and  1  have  noted  in  previous  discussions,  this  repotiand 
itscompanionreporton granteeexperiencehsi ghlighta numberof
issues  which  will  become  central  to  pltig  forfuture 
expansions  of  the  HeadStartProgr-. 
I commendtheworkyour
staffhave  done  in  prepaing  both  repo~. 
s

Ow

Shl

.  We look forward  to  wox~g  closely  with  your  staff  on  upc~g 
xepoxtsas  well.  I  believe  the  prmess  of  dismssfig  a  working
draft  prior  to  this  clearance  document  was  beneficial  and,  from 
our  stand~intat least,  clears  the  way  forquickapproval  of 
this  version. 
,I .-r
.

-4  ..

*
 = 
-
k
. 
4 
D-2
 To:  Bryan  B. Mitchell 
. 
Principal Deputy  Inspetior Geneml 
1 
% 
=x:  Elizabeth  M.  ~ames   
ent  and  Budget 
Acting  Assistmt  Secre  ry  fOr  Man 
~  ~ansion 
Tp  uating  He 
Smm:  OIG  Draft  Repoti:  n 
1-09-91-00762

Through Perfo~nce  Indicatorsn,
 
Thti  yo.u for the oppo~ity . to reviewtPehrefdor~anfc tre e  caters.
aluatlnaHead Start  ~on  ~rauqh 
two  other cmapartlon  repo~  on  Head 
This  repofi  as  well  as  OIGtS 
Start expansion will be very valuable to the pro- at this 
point in its histoq.  I  have  seve=l  specific  comments 
concemtig  this  repofi. 
Page ii and  Page 9  - Finding  Chiltien  may not be fully immunized 
before  they  leave  the  Head Stati Progr~.t$  Children who,mter 
Head Stan  without any previous  immunizations  or  are  seriously 
behind  with  their  serial  immunizations  cannot  be ftily 
suggested
immunized  by  the  time  they  leave Head  Start. 
m~~~en my not  be fully  ~unized~  or
replac=ent  sentence: 
before  they  leave  the  Eead 
up-to-ate  with  their  imniunizatio=, 
sia*  Program. 
 
p.2- We reco=end  replacing the COL- AdditionalExp-lon 
The currentcal
Rxnding~ with CO~/Quali~  Improv-ent.c
shows the COLA and QualitYImprov-at  alongwi~  T=in~g  ~~ 
TechnicalAssis~ce.  We believe that the Training and Technical 
Assist=ce  number shouldnot be included because these **  are

not as directlyrelatedto imprmtig a grantee qualityas tie

Also, pleaseverifYfinal  

COLA or Quality Improv-at  fun~ are. 
colm  numberswith the Head St- Bureau.

.

Suggested  replac-at  column: 
n 
COLA/QualitY

Impravemmt  .

Expansion I
 $49,000,000 
. 
mansion  11  ~ 
.
..* 
Expansion  III  $195,000,000  .
Expansion IV
 $108,535,000 
Expansion  V  $189,828,000 
P.3- Please revise the firstsent=ce in the first pasruagggreaspthetdo


reflect the change in the table on the previo=  page.

identified on

replacmmts  The COLA/QualitY Improv=-t  funds,
were set-aside funds given to

the cha~  on the preceding page~
D-3  ,+ 
-*:* 
Page 2 - Bryan B. Mitchell 
.  .-  
If you have any questionsor con~ 
please  con~ Karen  S&afar  (690-6238) 
. 
5 
.  .  .
.-,- -
..  ,.  .0 . . 1 
. : ., 
D-4  ? 
Department  of  Health  and Human  Sefices 
OFFICE  OF 
INSPECTOR  GENERAL 
EVALUATING  HEAD  START EXPANSION 
THROUGH  PERFORMANCE  INDICATORS 
MAY  1993  OFFICE OF IIWPE~OR  GENERAL  . 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Semites (HHS) programs as well 
as the health and welfare of beneficiaries served by those programs.  This statuto~  mission is carried 
out through a nationwide network of audits, investigations, and inspections conducted by three OIG 
operating components:  the Office of Audit Semites, the Office of Investigations, and the Office of 
Evaluation and Inspections.  The OIG also informs the Secretaxy of HHS of program, and management 
problems, and recommends courses to correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations 
in order to reduce waste, abuse, and mismanagement and to promote economy and efficiency 
throughout the Department. 
OFFICE OF INVESTIGATIONS 
The OIGS Officx of Investigations (01) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of 01 lead to criminal convictions, administrative sanctions, or civil 
money penalties.  The 01 also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECIIONS 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and 
the public.  The findings and recommendations contained in these inspection reports generate rapid, 
accurate, and up-to-date information on the efficienq, vulnerability, and effectiveness of departmental 
programs.  This report was prepared in the San Francisco regional office under the direction of Kaye 
D. Kidwell, Regional Inspector General, and Paul A. Gottlober, Deputy Regional Inspector General. 
Project staff included: 
SAN FRANCISCO  HEADQUARTERS 
Jemifer  Mallen, Co-Project Mder  Wm. Mark Krushat, SC.D.,Mathematical Statistician 
Brad Rollin, Co-Project Leader  Alan Levine, Program Specialist 
Elizabeth Bell 
Kathy Dezotte  ATLANTA  CHICAGO 
Robert Gibbons 
Deborah Harvey  Betty Apt  Suzanne Johnson 
Ellen Kotler  Ron Kalil 
Donald Loeb  Chris Koehler 
Brian Pattison 
Alicia Simon  OFFICE OF INVESTIGATIONS 
BOSTON  Baldur Krahl  Jose Munoz-Caro 
Timothy Corbett  AID lXl FAMILIES WITH DEPENDENT  CHILDREN 
Lori Rutter 
Agustin Quiles-Ocasio 
Irelys Ramirez-Ramos 
For additional copies of this report, please contact the San Franciscoofficeat (415)556-6830.