Data Management and Consumer Record Review Protocol
Updated April 2013
The Office of Adult Career and Continuing Education Services Vocational Rehabilitation (ACCES-VR) 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 ACCES-VR CIL Standards Performance Report and Data Collection Guide;
- performance requirements established in contract agreements.
Selection of Programs for Onsite Review:
ACCES-VR’s authority allows for review based on any or all of the following criteria:
- random rotation through the list of CILs;
- detection of anomalies in data reporting;
- periodic and cyclical occurrences;
- turnover in management or line staff.
Procedures for Review and Monitoring:
- ACCES-VR 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 ACCES-VR no later than 30 days prior to onsite review. See Attachment A - Preliminary Written Documentation for Onsite Review.
- ACCES-VR 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 Consumer Service Records (CSRs) served, regardless of funding source, during the period to be reviewed for random selection of CSRs for review 20 days prior to the scheduled onsite review. From the CIL list provided, ACCES-VR will select 10 percent of the consumers at random. From the ACCES-VR 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 ACCES-VR’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 Program Improvement Plan (PIP) 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
- ACCES-VR 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 ACCES-VR and either approved or retained for additional action from the CIL within 30 days of submission. ACCES-VR will provide technical assistance to assist the CIL in developing an acceptable plan.
- If a center fails to develop a PIP, or fails to carry out a PIP subsequent to the development of an ACCES-VR approved plan, the contract may be terminated. For information on contract performance expectations, see the ACCES-VR Contract Enforcement Guidelines.
- For information on submitting a Program Improvement Plan, see the NYS CIL Standards, Performance Report and Data Collection Guide, Part 3: Instructions for Attachments available online at the ACCES-VR website in the ILC Toolbox under Standards (Updated October 2015).
Scope of the Review:
- Review of preliminary written documentation and prior reporting period mid year and end of the year statistical report information. See Attachment A - Preliminary Written Documentation for Onsite Review.
- Verification of compliance with data collection requirements of the SED Office of Counsel approved Revised NYS ACCES-VR CIL Standards Performance Report and Data Collection Guide. See Attachment D - Part 2: Instructions for Direct Services and Statistical Report and Attachment E - Part 2: Direct Services and Statistical Report.
- Review of CIL consumer tracking and data collection system to determine its capacity to capture unduplicated counts, it includes all required information, and the level of maintenance for all required data categories. See Attachment B - Consumer Tracking and Data Collection System Review Format.
- Review of 10 percent or no fewer than 25 Consumer Service Records (CSRs)to determine that CSRs contain all appropriate components, that complete demographic information is being maintained and updated appropriately, and that service data is being maintained in a timely and thorough manner and is being accurately and consistently recorded in the data management system. CSR review only involves a review of the case file and ACCES-VR does not contact consumers during the onsite review. See Attachment C - Consumer Service Record Review Format.
- ACCES-VR’s review does not require access to personal health information records or other medical and/or treatment documentation. These records should be maintained separately in compliance with Health Insurance Portability and Accountability Act (HIPAA) and other applicable confidentiality requirements. Independent Living services are not to be misconstrued as “medical” in nature even if funded with Medicaid or Medicare, and therefore, documentation of Independent Living services must be maintained in accordance with New York State CIL standards for Consumer Service Record (CSR) maintenance.
- Since ACCES-VR requires centers to report all statistical data from all funding sources, all Consumer Service Records (CSRs) served, regardless of funding source reported, are subject to review to determine compliance with the NYS CIL Standards. To fully comply with the Standards, a center must maintain in consumer files for any program not funded by ACCES-VR all the components of a CSR as defined in the NYS CIL Standards.
- Discussion and assessment of the following measures of contract performance:
- Total numbers of persons projected to be served during the year as a goal in comparison to actual numbers served;
- Total numbers of persons served during the prior year meets the ACCES-VR contract baseline and is appropriate in consideration of the State funding level and the size and composition of consumer population that may be served.
Attachment A - Preliminary Written Documentation for Onsite Review
Attachment B - Consumer Tracking and Data Collection System Review Format
Attachment C - Consumer Service Record Review Format
Attachment D - Part 2: Instructions for Direct Services and Statistical Report
Attachment E - Part 2: Direct Services and Statistical Report