VESID / ILC / Toolbox

Data Management and Consumer Record
Review Protocol

Effective April 2009

Data Management and Consumer Record Review Protocol: Word (170KB, 21 pgs.)
Data Management and Consumer Record Review Protocol: PDF (63KB, 21 pgs.)

Overview:

The Office of Vocational and Educational Services for Individuals with Disabilities (VESID) Independent Living Services Unit provides ongoing review and monitoring of Centers for Independent Living (CIL) through the review and analysis of mid year and end year statistical reports and the conduct of periodic onsite data management and case record reviews.

Purpose of the Onsite Review:

The purpose of the onsite data management and case record review is to verify data used in mid year and end of year reports, verify that Consumer Service Records (CSRs) are maintained according to New York State CIL standards, and to assure that CILs are reporting consumer demographic, disability, and service data in a consistent and accurate manner and in accordance with:

• contractual obligations;
• data collection requirements as defined in SED Office of Counsel approved Revised NYS VESID CIL Standards Performance Report and Data Collection Guide;
• performance requirements established in contract agreements.

Selection of Programs for Onsite Review:

VESID's authority allows for review based on any or all of the following criteria:

• detection of anomalies in data reporting;
• periodic and cyclical occurrences;
• turnover in management or line staff.

Procedures for Review and Monitoring:

A. Notification

• VESID expects to provide written notification 60 days prior to review for all regularly scheduled data management and case service record reviews.
• CILs are expected to submit written documentation for preview by VESID no later than 30 days prior to onsite review. See Attachment A - Preliminary Written Documentation for Onsite Review.
• VESID will provide an advance agenda 30 days prior to the review for all regularly scheduled data management and case service record reviews.
• CILs will submit a list of all VESID consumers served during the period to be reviewed for random selection of Consumer Service Records (CSRs) for review 20 days prior to the scheduled onsite review.  From the CIL list provided, VESID will select 10 percent of the consumers at random.  From the VESID list, the CIL will choose 50 percent of the selected CSRs for review.  The final selection of no fewer than 25 CSRs in total from among VESID’s random selection is left up to the CIL.

B. Time line for Report Preparation and CIL Response

• General findings are verbally presented during an exit meeting with CIL representatives.
• A written report of findings and recommendations for any relevant follow up action is sent to the CIL 30 days after completion of the onsite review.
• The CIL may provide written comment regarding the report and must provide a written plan of program improvement when necessary to address data management or case record management issues within 30 days after the written report is submitted to the CIL.

C. Recommendations and Program Improvement

• VESID provides recommendations based upon knowledge of statewide best practices in the area of independent living data management and case record management. 
• Program improvement plans must be developed with involvement of the CIL Board of Directors and organizational management. Program improvement plans require the identification of specific action steps to remedy any deficits; must specify changes in data collection, reporting and case record management; must specify strategies to reach goals through conduct of community outreach when applicable; and must describe methodologies used to project service statistics and time frames for each action step to be taken.
• Program improvement plans are reviewed by VESID and either approved or retained for additional action from the CIL within 30 days of submission. VESID will provide upon request any technical assistance to assist the CIL in developing an acceptable plan.

Scope of the Review:

Attachment A

Preliminary Written Documentation for Onsite Review

All materials noted below must be made available to the Office of Vocational and Educational Services for Individuals with Disabilities (VESID), Independent living Services Unit, no later than 30 days prior to the scheduled onsite review.

1. Job descriptions for each position funded under the VESID contract that is responsible for data management.
2. Internal CIL training manual and all forms used for Consumer Service Record maintenance and consumer data tracking and collection.
3. Data entry forms used for computerized consumer data management system and written overview of the system.
4. Written data management policies and procedures.
5. Written community outreach policies, procedures and strategies.

Please note: All documentation noted above must be made available in alternate formats upon request.

Attachment B

Consumer Tracking and Data Collection System
Review Format

Name of Reviewer: __________________________________

Date of Review: ____________________________________

Complete this form to verify compliance with data collection requirements of the NYS VESID CIL Standards, Part 2: Instructions for Direct Services and Statistical Report and to determine that service data is being maintained in a timely and thorough manner and is being accurately and consistently recorded in the data management system.

Name of CIL: _________________________________________________

Staff member(s) responsible for data management:

Name:_________________________ Title:_________________________
Name:_________________________ Title:_________________________
Name:_________________________ Title:_________________________

Check Yes or No

1. The CIL has written data management policies and procedures:
   _____ Yes _____
2. No The CIL has internal forms for consumer tracking and data collection:
   _____ Yes _____ No
3. The CIL uses a computerized consumer data management system:
   _____ Yes _____ No
   If yes, name of computer software ____________________________
   The CIL maintains information for the following data categories
4. The CIL maintains a database or log that provides an unduplicated count of demographic data for all consumers with disabilities with a Consumer Service Record (CSR) and updates age, education status and employment status annually.
   _____ Yes _____ No
5. The CIL maintains a database or log that provides for each disability category an unduplicated count of disability data for all consumers with disabilities with and without a CSR. The same consumer can select more than one disability category.
   _____ Yes _____ No
6. The CIL maintains a database or log that provides an unduplicated count of total people with disabilities (PWD) served that contains new CSRs started since October 1 of the report year, consumers with a CSR served during prior reporting years who return for services in the report year, and Information and Referral (I and R) consumers who are PWD that includes name and type of disability.
   _____ Yes _____ No
7. The CIL maintains a database or log that provides an unduplicated count of family members/significant others served that includes names, addresses, phone numbers, service data and other pertinent documentation.
   _____ Yes _____ No
8. The CIL maintains a database or log that provides an unduplicated count of other non-disabled persons served including personnel from businesses/agencies that includes names, addresses, phone numbers, service data and other pertinent documentation.
   _____ Yes _____ No
9. The CIL maintains a database or log that provides an unduplicated count of businesses/agencies served that includes names, addresses, phone numbers, service data and other pertinent documentation.
   _____ Yes _____ No
10. The CIL maintains a database or log that provides an unduplicated count of consumers served in each individual service area. The same consumer can be counted in more than one service area.
    _____ Yes _____ No
11. The CIL maintains a database or log that provides an unduplicated count of consumers receiving Information and Referral (I and R) service that includes for a person with a disability the name and type of disability and for a person without a disability only the name.
    _____ Yes _____ No
    General Comments:
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________

Attachment C

Consumer Service Record
Review Format

Name of Reviewer: __________________________________

Date of Review: ____________________________________

Name of CIL: ________________________________________________________

Complete this form for each CSR reviewed to determine compliance with CIL Standard 3 - Consumer Service Record, IL End of Year Report, Part 3: Self-Evaluation with NYS Standards

Name of Consumer: _________________________________________

The CIL maintains the following information for each Consumer Service Record:

Check Yes or No

1. Annually updates educational status and employment status data on consumer intakes/profiles.
   _____ Yes _____ No ____N/A active less than one year
2. There is a document describing rights and responsibilities as a consumer of the CIL.
   _____ Yes _____ No
   1. Document is signed by the consumer.
      _____ Yes _____ No
   2. Document is dated.
      _____ Yes _____ No
   3. Document describes the right to confidentiality.
      _____ Yes _____ No
   4. Document outlines the internal CIL appeals process.
      _____ Yes _____ No
   5. Document provides notification to the consumer of the availability of VESID to consider consumer complaints about CIL services.
      _____ Yes _____ No
      1. VESID Contact office/person is identified.
         _____ Yes _____ No
      2. VESID consumer complaint phone number is provided.
         _____ Yes _____ No
      3. VESID address is provided.
         _____ Yes _____ No
3. Identifies specific services received.
   _____ Yes _____ No
4. Identifies dates of service contact.
   _____ Yes _____ No
5. Includes relevant referral information when appropriate, provided by the CIL on behalf of consumers.
   _____ Yes _____ No
6. If a release of information is present in the CSR, then it contains:
   
   1. Appropriate and legal information.
      _____ Yes _____ No
   2. The consumer signature and is dated within 120 days.
      _____ Yes _____ No

General Comments:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

Attachment D

New York State Office of Vocational and Educational Services for Individuals with Disabilities

CIL Standards, Performance Report and Data Collection Guide

Updated March 2009

Part 2: Instructions for Direct Services and Statistical Report

Count all statistical data from all funding sources.

I. Demographic Data for People with a Consumer Service Record

Report unduplicated demographic data for all consumers with disabilities with a Consumer Service Record (CSR) served during the report year.  Include data for new consumers with a CSR started since October 1 of the report year and returning consumers with a CSR served during prior reporting years that have returned in the reporting year.  Every item of demographic data must be recorded for every consumer with a CSR unless a consumer is unwilling to provide it (in which case "unknown" should be recorded for the missing data).   Age, Education Status and Employment Status must be updated annually for each consumer with a CSR.  The six demographic categories A. through F. must agree.  These demographic categories do not need to agree with the disability data.

Reporting "unknowns" is not an option under County(s) Served. Each consumer with a CSR should have a mailing address to identify the county of residence. If a consumer lives in another state/country, give the name of that state/country.

II. Disability Data

Report all people with disabilities who received services (people with and without a CSR) during the report year.  While an unduplicated count is provided for each of the five disability categories (A., B., C, D. and F.), the disability data can reflect more than one disability category selection of A. through D. by a consumer, which would also be reported under category F.  For example, a consumer who selects both orthopedic and blindness would be reported under B. Physical, D. Sensory, and F. Multiple Disabilities.  Reporting “unknowns” is not an option under categories A. through D. The Disability category must be recorded in order to document the establishment of a CSR.  People without a CSR may be individuals receiving the service of Information and Referral (I&R) only.   These individuals have also been referred to as “casual” consumers.  In order to document the impact of CILs on people with disabilities, CILs are encouraged to request name, address and disability information from “casual” consumers.

III. Total People Served During Year

IV. Individual services - number of people served

For each service offered, report the unduplicated number of consumers receiving that service during the reporting year. The same consumer can be counted in more than one service area.

Attachment E

New York State Office of Vocational and Educational Services for Individuals with Disabilities

CIL Standards, Performance Report and Data Collection Guide

Updated March 2009

Part 2: Direct Services and Statistical Report

Name of Center:

Report Period

Count all statistical data from all funding sources.

Demographic Data for People with CSRs

Report unduplicated demographic data for all consumers with disabilities with a Consumer Service Record (CSR) served during the report year. Include data for new consumers with a CSR started since October 1 of the report year and returning consumers with a CSR served during prior report years that have returned in the reporting year. Every item of demographic data must be recorded for every consumer with a CSR unless a consumer is unwilling to provide it (in which case "unknown" should be recorded for the missing data). Age, Education Status and Employment Status must be updated annually for each consumer with a CSR. The six demographic categories A. through F. must agree. These demographic categories do not need to agree with the disability data.

II. Disability Data

Report all people with disabilities who received services (people with and without a CSR) during the report year.  While an unduplicated count is provided for each of the five disability categories (A., B., C, D. and F.), the disability data can reflect more than one disability category selection of A. through D. by a consumer, which would also be reported under category F.  For example, a consumer who selects both orthopedic and blindness would be reported under B. Physical, D. Sensory, and F. Multiple Disabilities.  Reporting “unknowns” is not an option under categories A. through D. The Disability category must be recorded in order to document the establishment of a CSR.  People without a CSR may be individuals receiving the service of Information and Referral (I&R) only.  These individuals have also been referred to as “casual” consumers.  In order to document the impact of CILs on people with disabilities, CILs are encouraged to request name, address, and disability information from “casual” consumers.

III. Total People Served During Year

IV. Individual Services - Number of Persons Served

For each service offered, report the unduplicated number of consumers receiving that service during the reporting year. The same consumer can be counted in more than one service area.