Program Review and Contract Monitoring Protocol

Effective January 1, 1997


The Office of Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR) Centers Administration Unit provides ongoing review and monitoring of Centers for Independent Living through the review and analysis of mid year and end year narrative and statistical reports, review and analysis of annual certified financial statements and the periodic conduct of onsite program reviews.

Purpose of the Onsite Review:

The purpose of the onsite program review and contract monitoring review is to verify data used in mid year and end of year reports and to assure that Centers for Independent Living are delivering services in a manner consistent with and in accordance to:

contractual obligations;

principles and philosophy of Independent Living as defined in New York State standards;

maintenance of appropriate fiscal internal controls and practices;

performance requirements established in contract agreements.

Statutory Basis for the Onsite Review: The statutory basis for the onsite review derives from sections 1121 - 1124 of New York State Education Law.

Selection of Programs for Onsite Review:

The selection of programs for onsite review is based on a combination of criteria as follows:

indicators of contractual performance;

elapsed time since last onsite review;


size and composition of program consumer population;

consistency of program delivery with program standards and contract goals.

Procedures for Program Review and Contract Monitoring:

A. Frequency

  • Review and analysis of semi annual narrative and statistical reports by Centers Administration Unit staff.
  • Onsite review a maximum of once every five years unless otherwise indicated.

B. Notification

  • ACCES-VR compiles and publicizes an annual list of anticipated onsite reviews to be scheduled.
  • ACCES-VR provides written notification of onsite review dates 90 days prior to review for all regularly scheduled program review and contract monitoring onsite reviews.
  • Centers for Independent Living submit written documentation for preview by ACCES-VR review team liaison45 days prior to onsite review, (see Attachment A - List of Preliminary Documentation for Onsite Review).
  • ACCES-VR provides written notification of onsite review team members and onsite review agenda 30 days prior to onsite review.
  • Centers for Independent Living submit list of consumers for random selection of CSR review and consumer interviews 20 days prior to scheduled onsite review.

C. Participants on the Onsite Review Team

  • The Center for Independent Living onsite review liaison may serve as contact person and coordinates CIL staff participation during the review. Individual may be the noted signatory of the contract document or their designee. ACCES-VR Centers Administration Unit staff.
  • Other ACCES-VR staff that supervise Centers Administration or serve to provide special expertise in conduct of the onsite review.
  • Any other impartial members agreed to in advance by both ACCES-VR and the CIL.

D. Time line for Report Preparation and CIL Response

  • General findings are verbally presented by the onsite review team during an exit meeting with CIL representatives.
  • A draft written report is developed for signature of the ACCES-VR Manager of Program Development and Support Services 30 days after completion of the onsite review.
  • A signed draft report is forwarded to the CIL for review and comment 45 days after completion of the onsite review.
  • The CIL provides written comment regarding the draft report 45 days after the draft report is submitted to the CIL.
  • ACCES-VR Centers Administration Unit releases final report findings and recommendations for any relevant follow up action by the CIL 75 days after issuance of the original draft report. The written comments of the CIL are appended to the final report issued by ACCES-VR.

E. Recommendations and Corrective Action

  • ACCES-VR onsite review team members provide recommendations based upon knowledge of statewide or national best practices in the field of independent living service delivery. Recommendations/best practices are provided verbally during exit meetings and in written form designated by an asterisk. Items that fall into the category of recommendations/best practices in the protocol that follows are also designated by an asterisk.
  • Corrective action plans must be proposed jointly between a board of directors and organizational leadership. Corrective action plans require the identification of specific action to remedy deficits in performance, compliance with standards or in fiscal management and time lines for each action to be taken.  Corrective action plans are reviewed by ACCES-VR and either approved or rejected within 30 days of submission. Good faith efforts made by the CIL to submit a written corrective action plan that is deemed unacceptable by ACCES-VR will be responded to by ACCES-VR in writing within 15 days with specific technical assistance and requirements. If a subsequent revised response by the CIL within 15 days remains unacceptable, ACCES-VR may take steps toward cessation of contractual obligations. In such an instance, the CIL may appeal to the ACCES-VR Deputy Commissioner level.

Scope of the Review:

A. Review of preliminary written documentation based upon Attachment A and prior year mid and end of the year report information.

B. Verification of compliance with New York State Standards for Independent Living, (see Attachment B Key Indicators of Compliance with Standards).

C. Review of 10 percent or no fewer than 15 Consumer Service Records (see Attachment C - CSR Review Format) to determine the following:

  • Documentation reflecting requirements for maintaining a CSR is revealed in the consumer file;
  • Services are delivered in a manner consistent with Independent Living principles and philosophy;
  • A range of services is being delivered to consumers.

D. Conduct of no fewer than five interviews with consumers served by the CIL using a random selection from the set of consumers served over the past 12 months, (see Attachment D for Consumer Interview format). Interviews may occur face-to-face between consumers and onsite review team members or via telephone depending upon consumer preference. All interviews will be carried out in a manner which is non-threatening to consumers and which maximizes consumer input.

E. Board of Directors Interviews, (see Attachment E for Board Interview format). Board interviews will be conducted with a majority of board members or with up to eight individuals, face-to-face, or via telephone, individually or in a group, independent of CIL staff. Interviews will aim to:

  • Understand and assess general practices of organizational governance;
  • Commitment of the board to cross-disability representation, geographic representation and ethnic representation.

F. Measurement of Performance Indicators:

The following measures of contract performance will be discussed and assessed during the onsite review:

  • Total numbers of Persons Served During the Year as a goal in comparison to actual numbers served.
  • Achievement of Community and Systems Change Goals during the preceding contract year.
  • Results of the ACCES-VR coordinated Quality and Customer Satisfaction survey.

G. Fiscal Operations: Review of CIL policies and practices of internal fiscal management (see Attachment F Review of Fiscal Operations), including but not limited to:

  • Authorization of expenditures and/or purchasing;
  • Review of internal fiscal controls;
  • Equipment inventory;
  • Budget development.

Attachment A - Preliminary Written Documentation for Onsite Review
Attachment B - Key Indicators of Compliance with New York State Centers for Independent Living Standards
Attachment C - Consumer Service Record Review Format
Attachment D - Consumer Interview Format
Attachment E - Board of Directors Interview Format
Attachment F - Fiscal Management, Budgeting and Equipment Inventory