Back to Early Steps Policy Index | CMS Home

Early Steps Operations Guide
7/1/2010

This document does not include guidance/procedures for each policy in the Early Steps Policy Handbook.  Guidance is included only as necessary to explain how to implement a policy, outline steps, or recommend actions to support implementation.

All files on this page are under 2.3MB
All links open in a new window

Component:   12.0     Data Collection/Reporting and Record Keeping

 

Related Policy  Component

Guidance/Procedures

Reference/Related Documents

12.3.0 Early Steps Data System - Child/Family Information

12.3.2

A.      The referral date in the Early Steps data system should not be changed except for correction of an error, even if the child is closed and then re-referred.

B.     Data regarding “child’s race” and “child’s gender” are reported to U.S. DOE/OSEP

C.     Local Early Steps should make every effort to accurately identify and enter the child’s race.

D.     Parent report of race is acceptable. 

E.     Very few children should be labeled as “unknown” for race. 

F.      Data regarding income and family size are tracked by Early Steps State Office and used to determine the number of children who may potentially be eligible for Medicaid.

 

12.3.3

A.      The initial contact date which is entered in demographics is the date that the LES made contact with the family.

B.     First face-to-face contact date is the date that the LES met with the family in person for the first time.  The first face-to-face contact date is reflected in interventions with the designation of the face-to-face status code for the service provided.

 

12.3.4

Entering evaluation data such as tests used and scores is optional.

 

12.3.5

A.      If the initial IFSP does not take place within 45 days of receipt of the referral by the LES, the reason for delay must be documented in the child’s record and entered as a barrier in the Early Steps data system.  Barrier codes for the initial IFSP are as follows:

1.   Barriers considered to be beyond the LESs control:

C - Child issues (such as illness, appointment conflict, etc.)

D - Office closure due to hurricane or other official state of emergency

F - Family/caregiver issues (such as illness, child care, convenience, family appointments, transportation, vacation, work, emergencies, etc.)

N - Family did not show for scheduled evaluation and/or initial IFSP

U - Unsuccessful attempts to contact to schedule first contacts activities, evaluation/assessment and/or initial IFSP meeting (.e.g. unreturned phone calls, disconnected phone, or unable to locate family)

R - Re-referral (Child was enrolled previously, closed, and re-opened)

2.   Barriers that are not an acceptable reason for delay and are considered noncompliant.

E - LES capacity issue (such as no available appointment, appointment canceled due to staffing issues, inability to contact family due to staffing issues, etc.)

I - Insurance approval pending for evaluation/ assessment

P - External provider issues (e.g. team not available)

B.     All authorized early intervention services should be entered into the Early Steps data system, regardless of payor.

C.     Initial, periodic review, and annual evaluation of the IFSP data are directly related to two compliance indicators, so it is critical that this data be correct.

D.     Data regarding whether or not service location is the natural environment are directly related to a performance indicator, so it is critical that this data be correct.

E.     It is not necessary to authorize IFSP consultation, screenings, evaluations, assessments, provider travel,  transition conferences, service coordination (targeted case management or case management) and service coordination travel time.

F.      Authorization dates for the same service may not overlap or exceed six months.  However, the original authorization date can be extended if the service remains the same at the time it is reauthorized.

 

12.3.10

A.      A transition conference barrier code can and should be used in the Early Steps data system when a transition conference is late or never held.

B.     If the transition conference does not take place within the required timeframe, the reason for delay will be documented in the child’s record and entered as a barrier in the Early Steps data system.  Barriers for the transition conference are as follows:

1.      Child issues (such as illness, appointment conflict, etc.) prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

2.      Family/caregiver issues (such as illness, child care, convenience, family appointments, transportation, vacation, work, emergencies, etc.) prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

3.      Office closure due to hurricane or other official state of emergency prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

4.      Family did not show for scheduled transition confer­ence which prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

5.      Inability to contact the family after appropriate and reasonable attempts to schedule the transition con­ference (.i.e., unreturned phone calls, disconnected phone, or unable to locate) prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

6.      The family declined to participate in a transition conference.

NOTE: This barrier should not be used when the family declines pursuing services with IDEA, Part B. In this case, the transition conference still needs to be held no later than 90 days prior to the child's third birthday.

7.      The child was determined eligible for Early Steps 90 days or less prior to the child's third birthday, which prevented the transition conference from occurring at least 90 days prior to the child's third birthday. 

8.      LES capacity issue (such as no available appointment, appointment canceled due to staffing issues, inability to contact family due to staffing issues, etc.) prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

NOTE: This barrier is not an acceptable reason for delay and is considered noncompliant.

9.      Local school district representative issues (such as unavailability of local school district representative, appointment canceled by local school district repre­sentative, local school district representative did not show for conference, etc.) prevented the transition conference from occurring at least 90 days prior to the child's third birthday.

NOTE: This barrier is not an acceptable reason for delay and is considered noncompliant.

C.     The date in the “transition conference date” field in the Early Steps data system should be left blank when a transition conference is never held.

D.     The “transition conference date” field in the Early Steps data system indicates when the conference is actually held, not when it is due, scheduled, or anticipated to occur.

IFSP Instructions, Form I

 

12.3.11

A.      The date of closure is the date that child exited Early Steps which should be the same as the date noted on the written prior notice and should not be later than the child’s third birthday. 

B.     The date of closure is not necessarily the same date that the data is being entered into the Early Steps data system, since LES have up to ten days to enter the closure data.

C.     When reopening a closed child in the Early Steps data system, delete the previously entered disposition date and code. Record previous closure information and re-refer/open date in the “Note” field for future reference, and check the “Closed Before” box in the Early Steps data system.

D.     Following are the possible reasons for closure:

1.      Attempts to contact unsuccessful - Children for whom Early Steps personnel have been unable to contact or locate before the child and family have been determined eligible and have an IFSP developed.

2.      Attempts to contact unsuccessful - Children who Early Steps designated as “inactive” in the Early Steps data system and turned three years old.

3.      Deceased - Children who died on or before their third birthday.

4.      Completion of IFSP prior to reaching age 3 - Children who have not reached age 3, have completed their IFSP and no longer require services under Early Steps.

5.      Transfer to Other Center/District - Children whose family has moved to another LES region for contin­ued service and for whom contact has been made with the receiving LES.

6.      Not eligible for IDEA, Part B, exit with referrals to other programs - Children who reached their third birthday, were evaluated and determined not eligible for IDEA, Part B, and were referred to other programs, which may include preschool learning centers, Head Start (but not receiving IDEA, Part B services), and child care centers, and/or were referred for other services, which may include health and nutrition services, such as (Women, Infants and Children)WIC.

7.      Not eligible for IDEA, Part B, exit with no referrals - Children who reached their third birthday, were evaluated and determined not eligible for IDEA, Part B, but were not referred to other programs.

8.      Withdrawal by referral or guardian prior to IFSP -Children whose parents declined all services prior to IFSP development.

9.      Withdrawn by parent or guardian after IFSP - Children whose parents declined all services after an IFSP was in place, as well as children whose parents declined to consent to IFSP services and provided written or verbal indication of withdrawal from services.

10.  IDEA, Part B eligible, exiting IDEA, Part C -Children determined to be eligible for IDEA, Part B who exited (or will soon exit) IDEA, Part C. This includes children who receive IDEA, Part B services in conjunction with Head Start.

11.  Moved out of state - Children who moved out of state before their third birthday. Do not use this category for a child who moved within state (i.e., from one program to another).

12.  Not Eligible for Early Steps services - Children deter­mined to NOT meet IDEA, Part C /DEI eligibility criteria at initial evaluation or based on review of relevant collateral information.

13.  Not considered for IDEA, Part B - Children who reached their third birthday and were not referred to IDEA, Part B.  This category may be used to report children whose parent did not consent to an IDEA, Part B referral.

14.  IDEA, Part B eligibility not determined - Children who reached their third birthday and their IDEA, Part B eligibility has not been determined. This category includes children who were referred for IDEA, Part B evaluation, but for whom the eligibility determination has not yet been made or reported.

 

 

12.4.0  Early Steps Data System - Provider Information

 

12.4.3

A.      The use of a non-enrolled provider should be the rare exception and not the rule.

B.      When the LES must use a provider not enrolled in the CMS Provider Management System due to the circum­stances described in Policy Handbook 12.4.3, the LES should provide information and assistance to such provider on enrolling in the CMS Provider Management System.

C.     The requirements of Policy Handbook 6.1.4 supersede the use of a family’s insurance provider.

 

 

Policy Handbook 6.1.4

 

12.5.0 Early Steps Record

 

12.5.1

  1. The LES will not maintain separate or shadow Early Steps records.
  2. LES may use the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records.
  3. If LES choose to use the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records, the following actions should be taken by the LES:
    1. Distribute the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records to all LES staff and instruct staff to:
      1. Write out words/phrases rather than using abbreviations/acronyms in documents that are routinely shared with families, providers, and others (i.e. IFSPs).
      2. Use approved abbreviations/acronyms rather than writing out words/phrases in documents that are primarily kept within the LES (i.e. case notes).
      3. Use abbreviations/acronyms exactly as listed on the approved list.
      4. Use only the abbreviations/acronyms that appear on the list, or other locally recognized abbreviations/acronyms for local agencies or public places that do not conflict with or duplicate those that are listed on the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records document.
    2. Ensure that a legend of any locally recognized abbreviations/acronyms used is kept in the Early Steps record so that reviewers, auditors, families, or others will be able to understand what is written in the Early Steps record.
    3. Ensure that hard copy of the Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records document is kept in each child’s Early Steps record so that reviewers, auditors, families, or others will be able to understand what is written in the Early Steps record.
  4. The Early Steps record may exist in electronic format.
  5. The Early Steps record should be in the following format with all items in chronological order per section with the most recent items on top:
    1. Front of Record:  Log of Access to Confidential Record:
      1. Form DH-CMS 1063 , Log of Access  to Confidential Record
    2. Section 1: Notes/Service Implementation:
      1. Service Coordination/Targeted Case Management Notes
      2. Documentation of the substance of all contacts with or related to the child/family including telephone contacts, home visits, office visits, meetings, emails, and etc.
    3. Section 2: Intake/Referral:
      1. Referral form
      2. Intake forms
      3. Demographic information
    4. Section 3:  Medical: (This section primarily includes collateral information obtained from medical providers outside Early Steps.)
      1. Medical Progress notes
      2. Nursing notes
      3. Physical examination reports
      4. Growth charts
      5. Discharge summaries
      6. Birth history/delivery records
      7. Radiology/Laboratory reports
      8. CMS clinic reports
      9. CMAT medical information
    5. Section 4:  Evaluation/Assessment/Eligibility:
      1. Evaluation and assessment reports
      2. Evaluation and assessment protocols
      3. Collateral information/reports used for eligibility determination
      4. Therapy prescriptions and care plans (Physical Therapy - filed together, Occupational Therapy - filed together, Speech Therapy - filed together)
      5. Hearing screens and evaluations
      6. Vision screening information
      7. Progress reports generated by service providers (therapy, special instructions)
    6. Section 5:  Individualized Family Support Plan:
      1. Individualized Family Support Plans and updates
    7. Section 6:  Consent/Legal:
      1. Consent for Release of Information form
      2. Consent for Release of Special Confidential Information form (as needed)
      3. Court documents (custody orders, treatment orders, etc.)
      4. Consent for Evaluation and Use of Insurance form (CMS ES Form 1064)
      5. Permission to video/photograph, if appropriate
    8. Section 7:  Financial/Data:
      1.   Documentation of Insurance/Medicaid
      2. Medicaid eligibility information
      3. Service/payment authorization, when applicable
      4. Invoices and billing information (may be in a separate child-specific file)
      5. Early Steps data forms - not required (Interventions/Appointments/Referrals)
    9. Section 8:  Correspondence/Miscellaneous:
      1. Prior notification letter/forms
      2. Copies of correspondence sent out by Early Steps, record requests, notification of meetings/ appointments/missed appointments, referrals to services (to implement Individualized Family Support Plan or for transition from Early Steps)
      3. Copies of correspondence received by Early Steps: responses to referrals, requests for information, etc.
  6. If there is concern for the foster parent(s) who have provided consent, the names and personally identifiable information can be redacted from the IFSP or other related documents in the records before being released to the natural parent(s).

Early Steps Abbreviations/Acronyms Approved for Use in Early Steps Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CMS ES Form 1064 – Spanish

CMS ES Form 1064 - Creole

 

 

 

 

 

 

 

 

 

 

Operations Guide 8.5.1

12.5.2

A.      There may be limited items in the Early Steps record for children for whom contact is not successful, eligibility is never determined, or an IFSP is never developed.

B.     While considered a part of the Early Steps record, invoices and billing information may be kept in a separate place.

C.     Any information relayed via email that is related to screening, evaluation and assessment, eligibility determination, development and implementation of the Individualized Family Support Plan, provision of services, individual complaints dealing with the child, and any other area under IDEA, Part C related to the child or the child's family, should be printed and filed in the Early Steps record.

 

12.5.3

Progress reports summarize the services provided during a reporting period. Service documentation describing each encounter and service provided to an Early Steps child or family member are different from progress reports.

 

12.6.0 Data Reporting Requirements For Early Steps Providers

12.6.1

A.      To ensure timely and accurate data, LES should have mechanisms in place for the following:

  1. Resolving discrepancies or data errors or omissions when identified.
  2. Entering and reviewing exception records and making appropriate staff aware of problems with excessive or inappropriate exception records.
  3. Reviewing and making appropriate corrections to data fixes reports.
  4. Ensuring Medicaid numbers are consistently entered into the Early Steps data system for all Medicaid eligible children.
  5. Assuring that each child entered into the Early Steps data system has an assigned service coordinator, including utilizing data reports to ensure compliance.
  6. Requiring in the contract, memorandum of agree­ment or interagency agreement with LES providers that the start date for a service is reported to the service coordinator within a specific timeframe.

 

12.6.2

A.      The Natural Environment Travel Log serves two primary purposes:

1.      Statewide uniform documentation of travel paid to providers with contract funds.

2.      Statewide uniform billing documentation for provider travel.

B.     Travel is not reimbursable for providing traditional therapy sessions at the provider’s official place of business.

C.     Travel is reimbursable for a provider to travel from their official place of business to the first destination for service delivery, and each subsequent destination for service delivery, and back to the provider’s official place of business.  A provider’s official place of business could be their home; however, the provider cannot claim more than one official place of business.

D.     The Natural Environment Travel Log is designed to print on one page, front and back.

E.     The state approved Natural Environment Travel Log - EXCEL version calculates minutes/ mileage/ charge)

F.      The LES can determine which fields, in addition to the minimum required fields, the provider will complete, depending on the process the LES will use to verify/audit travel payments to providers.

 

12.7.0 Data Reporting Requirements - ESSO to U.S. DOE/OSEP

12.7.1

A.      ESSO will report on the number of infants and toddlers, ages birth through 2 (children who have not yet reached their third birthday), and their families receiving early intervention services under IDEA, Part C accord­ing to an individualized family service plan (IFSP) in place on a specific date.  Data are collected for each individual age and for each racial/ethnic category. 

B.     ESSO will report on the number of infants and toddlers, age birth through 2, and their families receiving early intervention services under IDEA, Part C according to an individualized family service plan (IFSP) in place on a specific date, according to the primary setting of the services. 

C.     ESSO will report on the number of infants and toddlers with disabilities, ages birth through age 2, who exited IDEA, Part C services during a 12-month reporting period.  All children who reached their third birthday while still receiving IDEA, Part C services should also be reported as exits.  Only infants and toddlers who had an active individualized family service plan (IFSP) in place at some time during the State-determined 12-month reporting period are to be reported. 

WESTAT Questions and Answers on the Part C Child Count Data Collection Document

WESTAT Questions and Answers on the Part C Settings Data Collection Document

WESTAT Questions and Answers on the Part C Exiting Data Collection Document

 


Back to Early Steps Policy Index | CMS Home