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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.

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Component:   6.0       Early Intervention Services and Supports

Related Policy  Component

Guidance/Procedures

Reference/Related Documents

6.1.0 General Requirements

6.1.1

  1. Other services needed to meet IFSP outcomes may include the following:
    1. SHINE (Serving Hearing Impaired Newborns Effectively) component for children with hearing impairment
    2. Blind Babies Program

Early Steps Service Code Taxonomy

SHINE Procedural Guidance

 

6.1.2

  1. While each participant in the IFSP meeting provides significant input regarding the provision of appropriate early intervention services, the ultimate responsibility for determining what services are appropriate for a particular infant or toddler, including the location and approach of such services, rests with all IFSP team members.
  2. It would be inconsistent with early intervention practice for decisions of the IFSP participants to be made based solely on preference of the family or a single IFSP team member. 
  3. Services should be tied to functional outcomes or goals that aim to increase the child’s effectiveness within their environment and family life. 
  4. When the IFSP team has difficulty reaching a decision regarding services on the IFSP, the service coordinator, as facilitator of the decision making process, should ensure that the team:
    1. Thoroughly discusses and re-considers:
      1. the concerns, priorities and resources of the family,
      2. evaluation and assessment results, and
      3. developmental outcomes expected to be achieved for the child and family
    2. Determine whether they need to reconvene to further discuss and possibly include additional individuals who have expertise to assist in the decision making process.
  5. When the IFSP meeting ends before a decision is reached, services will continue as previously authorized.
  6. The IFSP team must reach agreement regarding services as needed to meet the developmental needs of any eligible child.

 

6.1.3

  1. When a service provider has advance notice of an event (child or family related issue, holiday, vacation, jury duty, etc.) and is not able to provide services at the frequency and intensity authorized on the IFSP, it is expected that the IFSP team will plan around these events in order to serve the child. The following are possible scenarios:
    1. Sessions are usually scheduled on Monday and Thursday.  Monday is a holiday.  The Monday session is re-scheduled for Tuesday.
    2. The family is going on a two-week vacation.  Prior to the family’s departure, the provider discusses activities the family can use within the context of everyday routines during the vacation in order to address outcomes.  Service resumes at the previously authorized frequency when the family returns.
    3. The provider is called for jury duty for one week and arranges for a substitute to provide services during that week.
    4. The child will be hospitalized for one week and will have a two-week recovery time.  Following hospitalization and recovery, the IFSP team reconvenes to consider whether a modification to the frequency or intensity of services is necessary for a period of time or whether the previously authorized frequency/intensity remains appropriate.
  2. When services are missed, the team should review the child/family’s needs to determine whether a revision to the frequency or intensity of services is necessary and appropriate to address the outcomes on the IFSP.  It should not be automatically assumed that increasing the frequency or intensity of services will compensate or make up for a period when no services were provided.
  3. When a provider is not available to provide an authorized service, the IFSP team should reconvene to ensure that services are provided to meet the outcomes identified on the IFSP.
  4. LES are not responsible for ensuring the provision of services not authorized by the IFSP team, or “other services.”
  5. Services authorized by the IFSP team are reflected on Form G of the IFSP.

 

IFSP Instructions Form G

6.1.4

  1. The concept of natural environment involves everyday routines, activities and places and not just location. Following are some examples:
    1. Drinking from a cup during mealtime at a child care center.
    2. Throwing a ball during a family outing at the park.
    3. Brushing teeth before bedtime at home.

 

6.1.5

Any determination by the IFSP team that the child cannot satisfactorily achieve the identified outcomes in natural environments is based on the review of all relevant information regarding the unique needs of the child in keeping with the IFSP process.

 

 

6.1.6

It is not justification for services and/or supports to be provided in a setting other than the natural environment for reasons such as the following:

  1. Lack of providers available to serve in the natural environment.
  2. Personal preference of an IFSP team member.
  3. Existing barriers which make services in the natural environment more difficult to arrange.

 

6.1.10

The family/caregiver should be actively engaged and participate in Early Steps services and supports which may involve sharing a particular challenge with the service provider, observing the provider demonstrate a particular skill, technique or strategy before practicing the technique or strategy themselves, discussing with the service provider the effectiveness of strategies and possible alternate strategies to meet the desired outcomes.

 

6.1.12

  1. LES may enroll a child that resides outside of their assigned geographical area to meet service needs determined by the IFSP team.
  2. The receiving LES will open the child’s Early Steps record only after the sending LES has closed the child’s Early Steps record.
  3. Following are some examples of when it may be appropriate for a child and family to be served by a different LES:
    1. The family works or attends school in a different LES service area from which they reside.
    2. The child attends a child care setting or spends the day in a different LES service area from which they reside.
    3. The child is in foster care in one LES service area, but is expected to return to another LES service area.
    4. The family moved within six months of their child turning three to a different LES service area from which they previously resided.
    5. The child or family needs a specific expertise or specialty service that is only available through a LES service area other than where they reside.
    6. The child resides in a nursing facility in an area different from the family’s residence.
  4. LES may establish provider agreements with providers outside of the geographical area to meet service needs determined by the IFSP team.

 

6.1.13

Decisions regarding the frequency and intensity of services provided by Early Steps are not based on preset service guidelines or limitations. 

 

6.1.14

  1. Strategies for ensuring culturally competent services may include:
    1. Implementing strategies to recruit, retain, and promote at all levels a diverse staff and leadership that are representative of the demographic characteristics of the service area.
    2. Making reasonable attempts to offer and provide language assistance services, including bilingual staff and interpreter services, at all points of contact at no cost to families with limited English proficiency. When reasonable efforts are unsuccessful, LES may use family and friends to provide interpretation services. However, reimbursement through Early Steps is not available for interpretation services provided by family members and friends.
    3. Ensuring that Early Steps materials reflect diverse and culturally appropriate images of children and families.
    4. Maintaining a current demographic and cultural profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

 

6.1.18

  1. The child’s IFSP team can consider more intrusive, intensive or frequent supports and services only after it has been demonstrated that strategies incorporated into the child’s natural environment to achieve an identified outcome have not been successful in supporting movement toward achieving the desired outcome.
  2. Depending on the outcome, some services/ interventions may be needed for a shorter period of time or longer than others and the frequency and intensity will vary.
  3. All services, including those services accessed by the parents from non-Early Steps organizations/sources should be considered when determining services the LES must provide.

 

6.1.19

Any services that a family accesses outside the IFSP process would be included on the IFSP as “other services.”

 

6.2.0  Team-Based Primary Service Provider

6.2.1

  1. It is best practice for a consistent team to work with the family from eligibility evaluation through transition; but minimally, consistency should be maintained in team membership for service delivery, ongoing assessment, and IFSP updates. 
  2. The eligibility evaluation and assessment and IFSP development may be provided by a different team due to the provider accessibility/availability issues. 
  3. A team based PSP approach is a family-centered, capacity building method to intervention with young children with disabilities or developmental delays.
  4. Each IFSP team member shares expertise through consultation and coaching with other team members to support and strengthen the family’s confidence and competence in promoting their child’s learning and development. 
  5. The PSP is the identified lead professional on the IFSP team that works with the family/primary caregivers on a regular basis and with other members of the IFSP team providing services directly, through consultation/coaching and/or joint visits. 
  6. When a child is enrolled in a managed care plan and the service provider is not an Early Steps provider, the LES should take steps to encourage the managed care plan provider to adopt and use team-based, family-centered early intervention practices versus traditional intervention approaches, by:
    1. Informing the managed care plan provider of in-service opportunities or professional development events focusing on evidence-based approaches to early intervention which support the child/family’s participation in home and community activities in meaningful ways.
    2. Making available to the managed care plan provider articles and other resources which explain the requirements of the IDEA, Part C including the building of relationships with families and other professionals to form a team to meet the developmental needs of the child.
  7. When a child and family are receiving service coordination as the only service, designation of a PSP is not necessary.

 

6.2.2

  1. Any approved Early Steps provider may be assigned as the PSP, with the exception of service coordinators and speech therapy assistants due to the licensure requirements for supervision and their scope of practice.
  2. To decide who on the IFSP team should be a particular family’s PSP, the IFSP team should consider the following factors:
    1. IFSP outcomes and strategies.
    2. Relationship(s) with learner(s) (e.g. family members, other caregivers, other professionals).
    3. Expertise (i.e., not solely discipline) in the areas of support needed by the child and family/caregivers.
    4. Logistics (i.e., schedules, areas, availability).
  3. The PSP is chosen after outcomes, goals, and strategies are developed and services/supports are identified.
  4. Once the PSP is selected, the IFSP team determines what support the PSP needs from other IFSP team members to address each outcome and the type and amount of interactions needed to strengthen and support parents’ and other caregivers’ confidence and competence in promoting the child’s learning and development.
  5. It is acceptable and appropriate for the PSP to change based on the ongoing needs of the child/family as determined by the IFSP team.
  6. The PSP may also function in a dual role as the service coordinator when enrolled as both a service coordinator and a direct service provider.

 

6.2.3

  1. For Medicaid children, the Medicaid ITDS support and direction requirements must be met.
  2. For non-Medicaid children, support and direction of service providers (ITDS, SLP, PT, OT, nurse, etc.) will be provided by the IFSP team.
  3. For non-Medicaid children, there will be both planned (documented on IFSP) and spontaneous opportunities for support and direction.
  4. Consultation may be the mechanism by which support and direction requirements are met.

 

6.2.4

The specialists may have expertise in the following areas: hearing, vision, autism spectrum disorders, special healthcare needs, etc.  To the extent possible, the use of assessors and service providers with specialized expertise is encouraged to address the needs of children with complex medical needs or other issues.

 

6.3.0  Consultation

6.3.1

  1. Consultation may be face-to-face or by phone (when face-to-face contact is not required).
  2. Consultation between professionals on the IFSP team can occur as consultations between IFSP team members and/or as joint visits.
  3. Joint visits can be conducted one of two ways:
    1. One professional provides the service (typically the PSP) and the other(s) provide consultation and expert advice to the professional who is providing the service.
    2. A professional who is not the PSP provides a regularly scheduled session and the PSP consults for the purpose of observing and listening to the other provider’s coaching with the caregivers on how to implement strategies so that the PSP can reinforce this information on subsequent visits.
  4. When an IFSP team member consults with a daycare or preschool teacher (caregivers) it would be identified/authorized on the IFSP as an early intervention session, special instruction consultant or special instruction cooperating agency service, as appropriate.

Early Steps Service Code Taxonomy

 

6.3.2

  1. Consultation is typically between the PSP and other team members. Each enrolled Early Steps provider can bill for consultation using the form as invoice documentation.  Although they may participate in the consultation, professionals and providers who are not enrolled would not be able to bill.
  2. The original Consultation Among Service Provider Team Members form is kept in the child’s Early Steps record and participating providers use signed copies for billing.

 

6.3.3

The original Participant Documentation of Initial and Follow-up Eval/Assess/IFSP form or other form of documentation is kept in the child’s Early Steps record and participating providers use signed copies for billing.

 

6.4.0 Assistive Technology

6.4.2

When additional professionals are needed to conduct the assistive technology assessment, the individuals will participate as members of the IFSP team, even if on a short term basis.

 

6.4.4

Recommendations from the assistive technology assessment should not be driven by technology and should consider the use of low-cost alternatives.  For instance, an adapted laundry basket may be used as a seating device in the bathtub, rather than a technologically advanced device such as a bath chair.

 

6.4.5

LES and CMS offices will use whatever mechanism deemed appropriate to ensure cooperation and coordination regarding purchase of assistive technology devices.  Formal written agreements on this issue are not required.

 

6.4.6

  1. The usual and customary charge is often referred to as the list price or catalog price. 
  2. For items that are not listed as durable medical equipment, the manufacturer’s suggested retail price is to be used as the usual and customary charge.
  3. Hearing aids and (frequency modulation) FM systems are recommended to the IFSP team by the child's audiologist.

Durable Medical Equipment/ Medical Supply Services Coverage and Limitations Handbook

 

6.4.8

The IFSP should order assistive technology devices well in advance of the child’s third birthday in order to ensure that the item will be available in time for the child/family to benefit from other early intervention services which end by age three.

 

6.4.9

LES procedures regarding the lending of assistive technology devices should include guidelines regarding the family’s ability to retain a borrowed assistive technology device for a limited amount of time after the child reaches the age of 36 months.   

 

 

6.4.11

  1. An assistive technology device is authorized on the IFSP and purchased for a specific child and automatically transfers with the child when transitioning.
  2. The Assistive Technology Brochure insert may be used to inform families of their right to request that an assistive technology device be transferred with the child when transitioning or LES may create a document to serve this purpose.

Assistive Technology Brochure Insert - English

Assistive Technology Brochure Insert -Spanish

Assistive Technology Brochure Insert - Creole

6.4.12

The Request for Transfer of Assistive Technology form may be used to request the transfer of an assistive technology device or LES may create a document to serve this purpose.

Request for Transfer of Assistive Technology form - English

Request for Transfer of Assistive Technology form - Spanish

Request for Transfer of Assistive Technology form - Creole

 

6.4.13

The Assistive Technology Decision form may be used to acknowledge receipt of a written request to transfer a loaned assistive technology device or LES may create a document to serve this purpose.

 

Assistive Technology Decision form - English

Assistive Technology Decision form - Spanish

Assistive Technology Decision form - Creole

 

6.4.14

The Assistive Technology Decision form may be used to notify the requestor of approval or denial of the transfer or LES may create a document to serve this purpose.

 

Assistive Technology Decision form - English

Assistive Technology Decision form - Spanish

Assistive Technology Decision form - Creole

6.5.0 Health Services

6.5.1

  1. Health services may include the following:
    1. Cleaning intermittent catheterization, tracheostomy care, tube feeding, the changing of dressings or colostomy collection bags, and other health services.
    2. Consultation by physicians with other service providers concerning the special health care needs of eligible children that will need to be addressed in the course of providing other early intervention services.
  2. Health services do not include the following:
    1. Services surgical in nature (such as cleft palate surgery, surgery for club foot, cochlear implants, or the shunting of hydrocephalus).
    2. Services purely medical in nature (such as hospitalization for management of congenital heart ailments, or the prescribing of medicine or drugs for any purpose).
    3. Devices necessary to control or treat a medical condition.
    4. Medical-health services (such as immunizations and regular “well-baby” care) that are routinely recommended for all children.
  3. After the family’s concerns, priorities and resources are discussed and outcomes are determined, the IFSP team should consider the following in determining services and/or devices for the child/family:
    1. What is the expected outcome regarding the service/device with this child and family?
    2. How do the expected outcomes regarding the service/device relate to the developmental outcomes on the IFSP?
    3. Is the service/device:
      1. Surgical in nature?
      2. Purely medical?
      3. Necessary to enable the child to benefit from other early intervention services during the time the child is receiving those services?
    4. Is there an existing evidence base regarding this service/device that includes information regarding:
      1. The quality of the service/device?
      2. Whether the service/device:
        1. Has produced the desired results?
        2. Has worked with children/families under similar circumstances?
        3. Is considered experimental?
    5. Does the team need to include additional individuals with expertise to assist in answering the questions above?

34 CFR §303.13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.6.0 Medical Services

6.6.1

Medical services do not include services to determine etiology of a condition or for medical treatment.

20 U.S.C. 1432(4)(E)(viii)

34 CFR  §303.12(D)(5)

6.7.0 Respite

6.7.1

  1. Examples of appropriate uses of respite include: 
    1. The IFSP team of a child with a significant hearing impairment has identified American Sign Language as an appropriate means of communication for the child and family.  In order to accomplish this outcome, the IFSP team authorizes respite to allow the family the opportunity to attend American Sign Language classes.
    2. The IFSP team of a child with autism has determined that visual cues are the most effective means of communication for him and his family.  The IFSP team authorizes respite to allow the family to go to the library to access materials and software to make the necessary picture cues for their child.

 

6.7.2

  1. Respite can be provided by an organization which provides respite or a person that the family identifies. 
  2. Due to the very personal nature of the respite, it is often optimal for respite to be provided by a neighbor, friend or other acquaintance who is known to the family and child and in whom the family has confidence. 
  3. If the needs of the child require that respite be provided by a person who has specialized training (i.e. behavioral expertise) the service coordinator should provide the family with information on local resources for this need.
  4. The IFSP team will review the agreement to ensure the respite rate negotiated by the family is reasonable and necessary based on the needs of the child.

 

 

 

 

 

6.7.4

The Respite Agreement form may be used to obtain the required signed agreement statements from the family or LES may create a document to serve this purpose.

Respite Agreement form - English

Respite Agreement form - Spanish

Respite Agreement form – Creole

 

6.7.5

The Respite Documentation form may be used to obtain the required respite documentation from the family or LES may create a document to serve this purpose.

 

Respite Documentation form - English

Respite Documentation form - Spanish

Respite Documentation form – Creole

6.8.0 Early Childhood Education

6.8.1

An example of an appropriate use of early childhood education is the following:

A child has been identified as having a significant delay in social/emotional development. The IFSP team might identify interactions with non-disabled peers as a strategy to enhance the child’s social/emotional development needs.  If the IFSP team determines that supervised bi-weekly participation in an integrated child care setting with same-age non-disabled peers is the method for the service, it could specify in the IFSP that the natural environment for the service is an integrated child care setting.  In that circumstance Early Steps could assume the financial responsibility for that portion of the child care cost specifically associated with the bi-weekly interactions, as authorized in the child’s IFSP.

 

6.9.0 Plan of Care

6.9.2

  1. The IFSP or a separate document may serve as the Plan of Care. 
  2. When the IFSP is also the Plan of Care and an ITDS is providing services, the ITDS and the Licensed Health Care Professional who is providing support and direction to the ITDS must sign and date the IFSP/Plan of Care indicating that it has been collaboratively reviewed and face-to-face direction and support has been provided to the ITDS within the last six months and recorded on the child’s progress report. 
  3. If a separate Plan of Care is being used for a child receiving early intervention sessions, signatures of the ITDS and the Licensed Health Care Professional who is providing support and direction to the ITDS must be documented on the Plan of Care form.

IFSP Instructions, Form J

Florida Medicaid Memorandum, November 14, 2007

Florida Medicaid Early Intervention Services Coverage and Limitations Handbook

IFSP Instructions POC Note

IFSP Instructions POC Note

IFSP Instructions POC Note

6.11.0  Timeliness of Services

6.11.1

  1. Barriers to timely service delivery which are considered to be beyond the LES’s control are:
    1. Child issues (such as illness, child’s appointment conflict, etc.).
    2. Office closure due to hurricane or other official State of Emergency.
    3. Family/caregiver issues (such as illness, sibling child care, convenience, family appointments, transportation, vacation, work schedule, family emergencies, etc.).
    4. Family did not show for scheduled service delivery appointment.
    5. Unsuccessful attempts to contact the family to schedule service delivery (such as unreturned   phone calls to family, disconnected phone, or unable to locate family).
  2. Barriers to timely service delivery that are not acceptable reasons for delay and are considered noncompliant are:
    1.  LES capacity issue (such as no available appointment, appointment canceled due to staffing issues, inability to contact family due to staffing issues, etc.).
    2. External provider issues (such as service provider not available).
    3. Pending insurance approval.
  3. When a child or family related issue or natural disaster result in a delay of the initiation of services beyond 30 days or if the parents request a delay in initiation of services, this information must be documented in the child’s Early Steps record and the IFSP team should consider whether alternate strategies should be addressed.
  4. A lack of providers or other resources does not exempt a LES from the responsibility to make available necessary early intervention services and supports listed on the IFSP.
  5. If a particular discipline or service is unavailable, the IFSP team must reconvene to consider alternate strategies, supports and/or services that are available to address the outcome(s) on the IFSP. The service coordinator must assist the family in accessing those alternate supports/services and continuously seek appropriate supports/services.

 

6.12.0 Requirements for Children/Families With Inactive Status

6.12.1

"It would be inconsistent with Part C of the IDEA for a State to adopt a procedure that after the third time the early interventionist comes to a home for a scheduled visit and finds no one home . . . that the family receive prior written notice, along with a copy of their rights, that their child will be exited from the system unless they are able to call or write to schedule and be present for, another visit.  The State cannot assume the parent has revoked consent for services listed on the existing IFSP or that the consent provided for those services is time-limited."  [Excerpt from OSEP letter to Connecticut, October 24, 2003]

 

6.12.2

  1. The LES may designate the child/family as “inactive” when:
    1. Mail is returned and not forwarded.
    2. The phone is disconnected.
    3. The physician(s) can't locate the child/family.
    4. The provider(s) can't locate the child/family.
    5. Phone calls are not being returned and/or letters are not being responded to by the family. 
    6. Several impromptu home visits were made and the family is not home or doesn't answer the door.
  2. When entering data in the Early Steps data system:
    1. Indicate inactive status by choosing disposition code of “I” for “inactive.”
    2. Enter a disposition date of when the child became inactive.
  3. The service coordinator may attempt to contact the inactive family at least every 6 months.  The service coordinator is not required to make quarterly contact with the family and other service providers.
    Suggestions related to attempting to contact families in inactive status:
    1. The service coordinator should send a letter to the family at their last known address to attempt to reestablish contact and schedule a review of the IFSP or annual meeting to evaluate the IFSP.
    2. The service coordinator may also call the family at their last known phone number as back up.
    3. The service coordinator may contact others who have knowledge of the family for assistance in getting information to the family.
    4. The service coordinator should document, in the Early Steps record, all attempts to contact the family and file all returned mail in the Early Steps record along with the envelope.
    5. Do not send a letter to the family stating “if we do not hear from you by this date, we will terminate you from Early Steps.”

 

6.12.4

Written prior notice is required because the services are being terminated even though the child remains open in the Early Steps data system.

 

6.12.6

  1. When the family responds to the attempt to contact and/or the child turns three, the “I” disposition code should be changed in the Early Steps data system.
  2. The disposition date for when the child became inactive needs be changed to the date the family responds to the attempt to contact or the date child turns three.

 


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