During our audit period, EEC did not consistently complete group care program licensing visits within required timeframes. From our sample of 366 group care program licensing visits, 59 (16%) were not conducted by the established deadlines. On average, EEC conducted licensing site visits 55 days after the established due dates in LEAD. Licensing visits that are not completed within required timeframes prevent EEC from ensuring that programs operate safe and healthy environments.
Under 606 CMR 3.03, group care programs are licensed for two years and are still considered licensed until EEC completes its license renewal visit. Until September 2017, EEC had no documented policies or procedures for frequency of license renewal visits. According to EEC management, required licensing site visits were conducted at license issuance and renewal, and additional licensing site visits were only required for licensing changes.
In September 2017, EEC implemented the Differential Licensing Handbook. However, group care programs were not phased in to the differential licensing model and subjected to the requirements of the handbook until after the first licensing renewal that occurred after September 27, 2017.
The handbook states,
Scheduled visits are conducted at license renewals. . . .
Renewal of a [program’s] license will occur every two (2) years. . . .
The Monitoring Visit will be conducted [by EEC] annually approximately 12 months after the Full Licensing Review Visit, within a four-month window
Reason for Noncompliance
The due date for licensing site visits is automatically generated by LEAD and set 14 months after the previous licensing site visit. This automatically generated due date is part of the new business processes in EEC’s differential licensing model. Although LEAD automatically generates the site visit due dates, EEC had not yet phased its group care programs in to the new model, so they were not visited by the due dates in LEAD.
- EEC should phase its group care programs in to its new model as soon as possible.
- EEC should meet its deadlines for licensing visits.
As noted in the audit report, the Licensing Education Analytic Database (LEAD) system automatically generates a “deadline” for program monitoring visit annually based on predetermined settings in the technology. This date is an internal benchmark and is not dictated by any statute or regulation. In practice, residential program visits are regularly conducted by EEC staff for many reasons including but not limited to, a new license application site visit, a new program site visit where existing programs already exist, a license renewal, an investigation, focused monitoring or technical assistance. These visits are tracked separately in the LEAD system and are not marked as satisfying the “licensing visit” deadline in the LEAD system unless an EEC staff member makes a manual adjustment, which is time consuming and cumbersome in the system. EEC continues to align the data tracking [in] the LEAD system through additional technical enhancements in LEAD to account for this practice. EEC is currently working with DCF and the Department of Elementary and Secondary Education (DESE) to improve coordination of monitoring visits and help identify appropriate strategies for improving licensing monitoring of Residential Programs and Placement Agencies specifically.
During our audit period, EEC did not consistently complete group care program licensing visits within required timeframes; this could result in delays in addressing any problems. It appears from its response that EEC is taking measures to improve this process.
|Date published:||May 5, 2020|