Title IV-E Foster Care Eligibility Review Program Improvement Plan

Title IV-E Program Improvement Plan

Instructions and Template

This document guides Title IV-E agencies on developing a Program Improvement Plan (PIP) in response to findings of their Title IV-E Foster Care Eligibility Review (IV-E Review). These instructions add to the guidance included in Chapter 6 of the “Title IV-E Foster Care Eligibility Review Guide” (IV-E Review guide). The IV-E Review guide and the Children’s Bureau Regional Office must be consulted for additional information on PIP requirements, content, and format.

PIP Requirements

Federal regulations at 45 CFR § 1356.71(i) require the development of a PIP when a Title IV-E agency is not in substantial compliance in a primary review of its foster care program administered under Title IV-E of the Social Security Act. The Title IV-E agency must develop its PIP in consultation with the Children’s Bureau and must address each area the IV-E Review identified as needing improvement. The Title IV-E agency must consult with the Children’s Bureau Regional Office for guidance and technical assistance throughout the PIP development and implementation processes.

The Title IV-E agency must submit its PIP to the Children’s Bureau Regional Office for approval within 90 calendar days from the date the Title IV-E agency receives written notice from the Children’s Bureau that it is not operating in substantial compliance [45 CFR § 1356.71(i)(2)]. The Children’s Bureau may extend the submission deadline an extra 30 calendar days when the Title IV-E agency requests more time to send the Children’s Bureau Regional Office additional documentation to support eligibility of error or other improperly paid cases resulting from the IV-E Review. The Title IV-E agency submits periodic progress reports to the Children’s Bureau Regional Office and a cumulative report after the PIP completion date. The Children’s Bureau Regional Office and Title IV-E agency determine a reporting frequency that is confirmed in the PIP approval letter. The Title IV-E agency emails its PIP documents and reports to the Children’s Bureau Regional Office working with the Title IV-E agency.

The time frame for completing PIP implementation may not exceed 12 calendar months from the date approved by the Children’s Bureau [45 CFR § 1356.71(i)(1)(iii)]. Not all PIP elements require this length of time. The 12-month period for implementation is an outside time limit for those elements requiring more extensive planning and action. The Children’s Bureau may extend the 12-month period when the Title IV-E agency requires legislation to implement corrective action to accomplish a PIP goal.

PIP Contents

The PIP must include the following elements, as noted in federal regulations at 45 CFR § 1356.71(i):

• Specific goals for improvement

• Action steps needed to correct each identified weakness or deficiency

• Time frames for completing each action step

Additional content essential to PIP development and approval is discussed later in this document. The PIP must provide sufficient detail and context to ensure the Children’s Bureau Regional Office and Title IV-E agency can work in partnership to monitor PIP progress in implementing and completing the PIP.

Suggested PIP Format

The Children’s Bureau does not require a Title IV-E agency to use a particular format when developing its PIP, but we encourage use of the standard template below to help the agency prepare PIP documents for initial submission and for periodic reporting of progress to the Children’s Bureau Regional Office. Use of this template will facilitate ease of review, approval, and tracking of PIP activities. Also, the template is designed to meet the requirements of § 508 of the Rehabilitation Act (meaning it can be posted to the Children’s Bureau’s website in a format accessible to those using assistive technology).

The suggested PIP template allows Title IV-E agencies to enter information by broad strategy categories to address key performance areas needing improvement as described in the Title IV-E agency’s Final Report of IV-E Review findings. Additional key concerns affecting agency performance identified through planning and development of the PIP and program evaluation also should be included in the PIP.

The suggested PIP template consists of three major components: (1) a general information section that summarizes program issues and root causes, (2) a PIP implementation section that details primary strategies for corrective action and program improvement, and (3) a progress evaluation and reporting section that summarizes the progress made toward plan completion. Regardless of the format used, the PIP submitted must include the same scope of information as is outlined in this template.

The standard template has tables for up to four program performance issues (areas needing improvement). If there are more than four such issues, the Title IV-E agency should copy and paste a blank table and update the numbering in cells A and B of the table (for example, “Program Performance Issue #5”) to reflect the correct number of identified areas needing improvement. The cells will expand in height to allow for several action steps. The Title IV-E agency should copy the table framework as many times as necessary so that all of the identified outcome items that contributed to noncompliance are addressed.

Instructions

Title IV-E agencies are strongly encouraged to use the standard format in preparing the PIP document and subsequent progress reports for submission to the Children’s Bureau Regional Office. The standard template begins immediately following these instructions.

Introductory Information

At the top of the PIP template, enter information to identify your agency; check the box next to the type of report being submitted (PIP or Periodic Report); enter the date of the reporting period for an initial PIP or for the periodic report; and enter the date the PIP document is submitted. Also provide general contact information for agency personnel responsible for overseeing PIP development, implementation, and monitoring activities.

Section 1. General Information

This section explains the reason(s) for the PIP and provides a summary of the program performance issues identified in the IV-E Review’s Final Report and through your program evaluation and PIP planning processes. The narrative should include an analysis of the root causes of key systemic and case-specific performance issues that will be addressed in Section 2 of the PIP. The narrative also should describe how improvement efforts will be integrated with other systematic program strategies that have a bearing on key IV-E program issues affecting performance.

Section 2. Program Improvement Plan Implementation

This section details your agency’s work plan to strategically direct and carry out sound program improvements. For each program performance issue, your agency is expected to set clear goals, design effective strategies, identify objective measures to track performance outcomes, and periodically report performance achievement. The following is information about each cell in the suggested template.

1. Program Performance Issue (area needing improvement). Record, in a sentence or two, the overall performance area needing improvement as described in your agency’s Final Report or identified through your program evaluation and PIP planning processes. Each program performance issue serves as the foundation for improvement goals, action steps, and measures of performance toward achieving desired program results.

2. Program Goal. Describe the overall performance outcome that is to be achieved through action steps to address the identified area needing improvement based on the Final Report and your agency’s program evaluation and PIP planning processes. The PIP is expected to address these areas through short-term goals (plans to immediately minimize the negative effects on program operations; for example, ensure correct claiming through case-specific payment adjustments) and/or long-term goals (plans for lasting reforms; for example, ensure correct claiming through system code changes).

3. Action Step. Delineate specific action steps your agency will undertake to complete the target goal and create improvements to correct an identified weakness or deficiency. The steps, procedures, or activities must relate directly to the target goal, must be easy to understand, and must be consistent with the level of effort required to improve performance and achieve improvement goals. They also must be measurable so that performance indicators can be set to track progress toward achieving the intended result. Title IV-E agencies should not overly rely on training and policy changes as action steps to correct program weaknesses or deficiencies. Title IV-E agencies are advised to develop strategies for supporting systemic change and sustaining the improvement effort.

4. Responsible Party. Identify the person(s) or category of persons responsible for carrying out specific action steps to achieve, or for directing achievement of, each target outcome.

5. Target Completion Date. Indicate a date or period when each action step will be completed. Set realistic time frames for implementing action steps and achieving goals.

6. Performance Indicator. Establish performance indicators that will measure achievement and describe how the Children's Bureau Regional Office will know an action step has been completed. The performance indicator is a quantitative or qualitative factor to measure program results against the program goal. Program goals and performance indicators are different. Program goals describe what must be achieved and performance indicators are measurements that demonstrate whether the goals are achieved. A performance indicator shows to what extent the intended results have been accomplished.

7. Status Update or Evidence of Completion. Leave blank for approval of proposed PIP and complete after PIP approval to report periodic updates on, or completion of, an action step. Before an action step is completed, use this cell to give a brief update on the status of each action step due during the reporting period. (Section 3 of the PIP template is used to provide specific details on progress toward completing an action step). After completing an action step, briefly describe the evidence that demonstrates that an action step has been achieved. Evidence of completion can be a unit of measure, a specific document, a report, or other evidence of achievement demonstrating progress toward and eventual completion of the action step. Evidence of completion must be submitted to the Children’s Bureau Regional Office (see Section 3).

8. Completion Date. Enter the date an action step is completed.

Section 3. Progress Evaluation and Reporting

For PIP approval, enter in this section a description of how progress toward goal achievement will be evaluated and reported to the Children’s Bureau Regional Office, including methods, tools, frequency, and format of evaluation procedures.

After PIP approval and during PIP implementation, use this section to report periodically to the Children’s Bureau Regional Office on the status of each action step due during the reporting period. The periodic status report should include a detailed description of barriers preventing progress. It also may include additional details to support or explain information recorded in Column G of the tables in section 2 of the PIP and any supplementary information relevant to the completion of the PIP. Proof/documentation of any action step completed during the reporting period also must be submitted with the progress report. The periodic status reports, followed by a cumulative summary at PIP completion, are submitted according to the reporting schedule noted in the PIP approval letter. The periodic status and cumulative reports must provide sufficient detail and context to ensure that the Children’s Bureau Regional Office can monitor PIP progress and completion for successful results.

Title IV-E Program Improvement Plan

for ________________________

Type of Report (please check one): Program Improvement Plan:  Periodic Report: 

Reporting Period: Date Submitted:

Agency Contact:

Section 1. General Information

Provide a summary of the findings of the IV-E On-Site Review, including area(s) needing improvement identified in the Title IV-E agency’s Final Report and through the program evaluation and PIP planning processes. Also discuss root causes of key systemic and case-specific performance issues that will be addressed below in Section 2 of the PIP.

Section 2. Program Improvement Plan Implementation

1. Program Performance Issue #1:

2. Program Goal Issue #1:

C. Action Step	D. Responsible Party	E. Target Completion Date	F. Performance Indicator	G. Status Update or Evidence of Completion	H. Completion Date

Section 2. Program Improvement Plan Implementation

1. Program Performance Issue #2:

2. Program Goal Issue #2:

C. Action Step	D. Responsible Party	E. Target Completion Date	F. Performance Indicator	G. Status Update or Evidence of Completion	H. Completion Date

Section 2. Program Improvement Plan Implementation

1. Program Performance Issue #3:

2. Program Goal Issue #3:

C. Action Step	D. Responsible Party	E. Target Completion Date	F. Performance Indicator	G. Status Update or Evidence of Completion	H. Completion Date

Section 2. Program Improvement Plan Implementation Issue

1. Program Performance Issue #4:

2. Program Goal Issue #4:

C. Action Step	D. Responsible Party	E. Target Completion Date	F. Performance Indicator	G. Status Update or Evidence of Completion	H. Completion Date

Section 3. Progress Evaluation and Reporting

For PIP approval, enter below a description of how the Title IV-E agency will evaluate progress and report it to the Children’s Bureau Regional Office, including the frequency and format of the evaluation procedures. During PIP implementation, provide a summary and evaluation of the status of progress made toward goal achievement, barriers preventing progress, and any additional information relevant to the completion of the PIP. Also submit evidence of an action step completed during a reporting period.

Title IV-E Program Improvement Plan Page 3