Addendum to: Early Intervention Guidance Memorandum 2005-2
Standards and Procedures for Evaluations, Evaluation Reimbursement, and Eligibility Requirements and Determinations Under the Early Intervention Program
Referrals to the Early Intervention Program (EIP)
1. What is the purpose of having families wait for four working days after selecting an approved evaluator?
The four working day waiting period is applicable only when a family accesses an approved EI evaluator prior to the designation of an initial service coordinator. Under these circumstances the purpose of the waiting period is to ensure that the municipality has an opportunity to assign an initial service coordinator and have them meet with the parent, provide the Parent's Guide, information about the EIP, their rights and safeguards, and explain their right to select an evaluator from a list prior to the initiation of the evaluation. If a parent does select an approved evaluator prior to the designation of an initial service coordinator, the parent or evaluator must immediately notify the Early Intervention Official (EIO) and the evaluator may begin the evaluation no sooner than four working days after the EIO's receipt of written notice from the parent or evaluator. [10NYCRR §69-4.8(a)] It is the responsibility of the evaluator to confirm with the parent that a referral to the EIP has been made.
2. Who is responsible for obtaining consent for core, and/or supplemental evaluations, (e.g. evaluator, or service coordinator) and when should that consent be obtained?
Pursuant to 10 NYCRR § 69-4.8(a)(ii) the evaluator is required to obtain parental consent to conduct an evaluation prior to the initiation of the evaluation. This is applicable for both core and supplemental evaluations. There are a few acceptable ways for evaluators to obtain consent. Evaluators can inform parents of the need for consent during their first contact with them and then mail the consent to parents and request that it be returned prior to the scheduled date of the evaluation. Evaluators can also have the consent form available on the date of the scheduled evaluation and have it signed immediately prior to the evaluation. No matter how parental consent is obtained, it is the sole responsibility of the evaluator to explain the necessity of obtaining consent from parents, and ensure that written consent is received, prior to the evaluation.
3. If a parent is unavailable at the time of an evaluation, can another family member be designated to attend?
Yes, however, 10 NYCRR §69-4.8(a)(2)(iii) and (7), require that parents have the opportunity to participate in the performance of screenings, evaluations, and assessments, unless other circumstances prevent their attendance. When exceptional circumstances prevent parents from participating in the evaluation, another family member may be designated to attend in order to offer additional information about the child, and assist in the EI process. Attempts to accommodate the parent's schedule and the extenuating circumstances which prevented the family from participating in the evaluation should be documented in the child's record. Parents can share critical information about their child and are integral to the evaluation process and the importance of parental involvement in multidisciplinary evaluations cannot be overstated. Therefore, parents should be encouraged to be present and participate in the child's evaluation unless there are unavoidable circumstances as to why they cannot be present. These circumstances should be documented in the evaluation report and written summary. It should be noted that the presence of another designated family member does not relieve the evaluator of their regulatory responsibilities to:
- Offer the family the opportunity to engage in the voluntary family assessment.
- Inform parents about the evaluation process and make certain they understand it.
- Obtain parental consent to conduct the evaluation prior to the evaluation.
- Conduct a parent interview about the family's resources, priorities and concerns about the child's development and developmental progress.
- Fully share the results of the child's evaluation with parents following its completion.
- Afford the parents an opportunity to discuss the results and any concerns they may have.
4. Is it appropriate to report and use scores from a norm-referenced test that has not been standardized for a particular population?
No, the standardized instruments that are selected should be norm-referenced for the population being evaluated, including populations whose dominant language is not English. Evaluators are also responsible for ensuring that, if standardized tests are used, that they are scored, reported and interpreted as specified in the test manual, in a manner that does not violate the psychometric properties of the test or the purpose for which the test was designed. Instruments used as part of an evaluation must be reliable and valid, have appropriate levels of sensitivity and specificity; and, be sensitive to the child's and parent's culture and dominant language or other mode of communication. Evaluators should not use test scores alone to determine eligibility. Pursuant to 10 NYCRR§69-4.8(14), which delineates the requirements for performance of nondiscriminatory evaluation and assessments, no single procedure or instrument may be used as the sole criteria or indicator of eligibility.
5. Can evaluators determine eligibility using other means if there is no norm-referenced standardized instrument available for a population with a dominant language other than English?
As required by 10 NYCRR §69-4.8(a)(6), evaluators shall, in conjunction with informed clinical opinion, utilize a standardized instrument or instruments approved by the Department. If the evaluator determines that there are no appropriate norm-referenced standardized instruments available to assess a child, the evaluator may use other appropriate clinical assessments or procedures that may include standardized criterion-referenced tests, observations of the child, parent interviews, informed clinical opinion; and any other sources of information available to the team conducting the child's evaluation. The evaluator shall provide written justification in the evaluation report why such instrument or instruments are not appropriate. Results of any standardized instruments should be reported in accordance with the test manual being used and use the correct norm tables for the child's current chronological age. Regardless of whether an evaluator is using a norm-referenced or criterion-referenced test, the evaluator is required to use multiple sources of information to determine eligibility and not use test scores alone.
6. Can parents or family members serve as an interpreter?
Yes, a family member or friend may be used as an interpreter if requested or agreed to by the parent, and such a person does not compromise the effectiveness of services, violate confidentiality, and the parent has been advised that, if feasible, an interpreter is available at no cost to the family. [10 NYCRR §69-4.8(a)(9)(v)] However, parents should not be required to use family members or friends as interpreters. Use of family members and friends in the interpreter role may not provide an accurate and objective representation of the child's development and may result in a breach of confidentiality or reluctance on the part of the parent to reveal personal information important to the situation. In addition, family and friends may not be competent to act as interpreters, since they may lack familiarity with certain terminology. It is important to note that upon using an interpreter, including a family member or friend, the provider is expected to obtain parental consent for disclosure to the interpreter.
7. If there is no health assessment for a child, or recent physical exam from a primary care provider, is the evaluator responsible for arranging the medical exam?
Yes, ideally, each child will already have a primary care provider and documentation of a recent health assessment will be available for review by the multidisciplinary evaluation team. However, in circumstances where a child does not have a primary care provider and a recent health assessment and physical exam has not been done, it is the responsibility of the evaluator to ensure that a health assessment is completed. In order to receive approval to conduct core evaluations, provider agencies must demonstrate the availability of a physician in the community who will complete health assessments for the agency. If necessary, this physician may be used to conduct physician supplemental evaluations to complete the required health assessments.
If a developmental delay as defined by EIP regulation has been determined, but completion of the health assessment is delayed or the records are not available, the evaluator should submit the written multidisciplinary evaluation (MDE) report to the municipality and parent(s) and include within the report the reason(s) for the delay. The evaluator should continue to work with the parent(s) to complete the required health assessment.
It should be noted that it is not permissible to delay the initial Individualized Family Service Plan (IFSP) and the start of EI services for an eligible child if the health assessment process is delayed. This includes obtaining confirmation that a child has received blood lead tests and immunizations as per recommended schedules.
8. If a parent refuses to provide consent for a health assessment, or consent to access records of recent health assessments, may the child receive services if they are deemed eligible?
It is essential that the evaluation of a child's physical development include a health assessment including a review of the findings of a recent physical examination. The health assessment provides information about clinical conditions that may impact the services authorized on an IFSP. It also is an important mechanism for engaging a child's primary health care provider in discussions about the provision of early intervention services, especially since a physicians order or prescription may be needed for some services. The Department supports the concept that each child has a medical home at which all of their care is coordinated, and evaluators and service coordinators are expected to make ongoing efforts to assist the family in understanding the importance of and obtaining a health assessment for the child.
Ultimately, however, if a family refuses to provide consent for a health assessment, or access to records of any recent health assessments conducted for the child, and there is a developmental delay determined as defined by EIP regulations, the child is still eligible for early intervention services and must be enrolled and have an initial IFSP meeting scheduled. It is within the purview and responsibility of IFSP teams to consider the lack of a recent health assessment, or lack of access to health assessment records documenting a child's health status, when determining EI services and settings appropriate for the child, including ensuring his/her health and safety.
Municipalities must reimburse evaluators for MDEs if the health assessment has not been obtained as long as the reasons for the delay and the attempts made to obtain it have been appropriately documented.
9. If there is a need for the evaluator to ask a physician to perform a health assessment, does the physician doing the examination get paid separately from the core team, as a physician supplemental, or does the evaluator pay the physician directly from the money they receive to do a core evaluation?
If the evaluator determines that a child has no established primary care provider, or learns after the completion of the core evaluation that medical information is not available, a supplemental physician evaluation, or a non-physician evaluation by a qualified health practitioner working within the scope of his/her profession (e.g., a nurse practitioner or physician assistant), may be authorized and billed to complete the health assessment required as part of the evaluation of the child's physical development. This supplemental evaluation is paid separate from the core evaluation. In order for this to occur, the evaluation agency must have the capacity to offer a health assessment as part of the MDE, and the parent must provide consent for the supplemental evaluation. In addition, any such supplemental evaluation that is being performed to obtain a recent health assessment must include adequate information on the results of the physical examination, including vision and hearing screening, and blood lead testing that is performed.
10. What professions are able to evaluate specific developmental domains?
EIP qualified personnel completing evaluations must be trained to use appropriate methods and procedures and have sufficient expertise to complete the developmental assessment. Qualified personnel may evaluate any developmental domain that is within the scope of the recognized standards of practice for their specific discipline. If an evaluator identifies a specific area of developmental concern that is outside the scope of his or her training and expertise, he/she must arrange for a supplemental evaluation to be completed. For example, a speech pathologist may note the lack of gross motor skill development while assessing a child's communication development and request a supplemental physical therapy evaluation to further evaluate the gross motor area of development.
11. Is it possible for a special educator and a social worker on a MDE team to determine that a child meets EI eligibility requirements based upon a delay in communication and subsequently recommend services at the IFSP meeting?
10 NYCRR §69-4.8(a)(3) requires the MDE team to include two or more qualified personnel from different disciplines who are trained to utilize appropriate methods and procedures, have sufficient expertise in child development, and at least one of whom shall be a specialist in the area of the child's suspected delay or disability. If a delay in a specific area of development is known or suspected at the time of referral, qualified personnel in the area of suspected delay must be assigned to the MDE team. For example, a child referred for a speech concern should have a speech-language pathologist as a member of the MDE team and children with a gross motor concern should have a physical therapist as a member of the MDE team. It is the responsibility of the evaluator to determine the appropriate qualified personnel that will comprise the MDE team based upon the information obtained in the referral and from the parent(s). In addition, the assigned MDE team must have sufficient expertise to evaluate all five developmental domains.
If the child's area of delay is not known or suspected at the time of referral, it is permissible for a team comprised of a special educator and a social worker to determine that a child meets EI eligibility requirements based upon a delay in the communication domain. For example, a special educator can administer the Battelle Developmental Inventory which yields a standard deviation that could show a child to have a severe delay in the communication domain. Evaluators must use multiple sources of information to determine eligibility, not test scores alone to ensure that eligibility is well supported. Based on the nature of the developmental delay, a discussion of services appropriate to meet the child's needs should take place within the context of the IFSP meeting. An order/recommendation for speech therapy services must be obtained by a physician, nurse practitioner, physician assistant or speech language pathologist prior to the delivery of speech services.
Evaluation Reports and Documentation Requirements
12. Who can represent evaluators at an IFSP meeting?
One of the qualified personnel who was directly involved in the evaluation and assessment of the child is expected to attend the IFSP meeting. [10 NYCRR §69-4.11(a)(2)(iii)(a)] However, if the evaluator(s) are unable to attend the IFSP meeting, arrangements must be made for the evaluator's involvement either by telephone, having a knowledgeable authorized representative attend the meeting or by making pertinent records available at the meeting. A knowledgeable representative is considered to be an employee of the evaluation agency that is an EI qualified personnel, has expertise in completing EI MDEs and has reviewed the child's MDE prior to participating in the IFSP meeting. The representative must be prepared to discuss the child's development in all domains and must clearly understand the family's individual strengths and needs.
13. How does an evaluator document a diagnosed condition that has a high probability of delay if the condition is not on the Early Intervention list?
When an evaluator identifies a child as having a condition with a high probability of developmental delay that is not included in Appendix A of Memorandum 1999-2, Reporting of Children's Eligibility Status Based on Diagnosed Conditions With High Probability of Developmental Delay, a clear explanation and supportive documentation from the medical literature must be provided as to why the condition is considered to have a high probability of developmental delay and how and to what degree it is specifically manifested in the child. This information should be submitted as part of the child's MDE and municipalities may consult with the Department for guidance on how to evaluate and review such information when it is received. In addition, some diagnoses may not automatically qualify a child for the EIP but place a child at risk for future developmental delay. Any child who meets at-risk criteria established in EIP regulations based on medical/biological risk factors must be referred to the EIP for developmental surveillance (screening and tracking). Early intervention officials are required to provide for a system of tracking and screening such children at risk for a developmental delay [10NYCRR §69-4.3 (f) – see Appendix A)].
14. What kind of documentation is needed in the MDE report if the child is found not eligible?
An evaluation report and written summary are required for every MDE that is conducted. The evaluation report and summary must include a statement of the child's eligibility. If the results of the MDE indicate that the child is not eligible for the EIP, the evaluation report should clearly document reasons why the child is not eligible. In addition, if the child's development is within normal range or, the child is not demonstrating a significant developmental delay that meets EIP eligibility standards, the MDE team is responsible for providing clinical information and making recommendations about alternative resources or services that may be beneficial to the child and family. For children who appear to be at-risk for developmental problems in the future, the MDE team may recommend that the child be included in municipal child find activities for at-risk children (screening and tracking), with parent consent. It also could include recommendations for referrals to other service delivery systems or other early childhood programs such as Early Head Start and community-based programs.
15. Do evaluators need to provide an International Classification of Diseases (ICD) code for all eligible children? Does the ICD code need to be listed in the summary section report, or only in the MDE summary?
Yes, evaluators are responsible for ensuring the evaluation report and written summary include at least a statement of the child's eligibility which must include either a diagnosed condition with a high probability of resulting in developmental delay and associated ICD code, or a statement of developmental delay consistent with the definition of developmental delay and associated ICD code for developmental delay. Evaluators should include all known ICD codes for the child, including medical or psychiatric diagnoses not directly associated with eligibility.
Reimbursement for Screening and Evaluation
16. If a supplemental audiological evaluation is completed and the audiologist recommends further testing, can the EIP pay for the additional testing as a supplemental evaluation?
Yes, such additional testing can be reimbursed as a supplemental evaluation, if it is needed to determine the eligibility of a child for the EIP or if it is authorized on an IFSP subsequent to enrollment (e.g., to monitor a child with a hearing impairment already enrolled in the EIP). Approval from the EIO is required prior to completion of the additional evaluation. However, sedation that may be required to complete an evaluation, such as for an Auditory Brain Response (ABR) test, is considered to be medical in nature and not reimbursable through the EIP.
17. Does an MDE determine eligibility for specific services within the EI, or eligibility for the EIP?
The MDE determines eligibility for the EIP, not for specific services. The evaluation process, which includes supplemental evaluations, is not meant to "qualify" a child/family for a particular service, but rather to inform the IFSP team so that it can discuss and make an informed decision as to the appropriate services for a child/family, once eligibility for the program has been established.
18. Can counties establish specific levels of delay in specific domains to enable an eligible child to receive services?
No, municipalities cannot establish specific levels of delay in a developmental domain in order for a child to receive services which will address developmental concerns in the domain.
19. Is standardized testing a required part of the six month review or annual evaluation of the IFSP? What information is necessary and appropriate for service providers to supply as part of their six month or annual review progress reports?
No, standardized testing is not required for the six month IFSP review or the annual evaluation of the IFSP. However, ongoing assessment of a child's progress is best practice and recommended. While there is nothing in State or Federal regulation that requires the use of standardized assessment tools for IFSP reviews or annual evaluations of the IFSP, such assessments should be completed when available and appropriate for the child's age, language, culture, disability and when used consistent with the instrument's purpose and instructions.
The intent of the six month IFSP review and annual evaluation of the IFSP is to evaluate the IFSP for continued appropriateness, and if necessary, to revise its provisions. It is the responsibility of the providers of EI services to supply up-to-date information from the ongoing assessment of the child and the child's family, in order to report the child's current level of functioning in the developmental areas being serviced. The use of standardized assessments at regular intervals can provide this information. As always, all sources of information available (e.g. standardized assessment results, parent report, informed clinical opinion) need to be considered at the six month IFSP review and/or annual IFSP evaluation when discussing appropriate services for the child and family. Pursuant to 10 NYCRR§69-4.23(b), if there is an observable change in the child's developmental status that indicates a potential change in eligibility, the EIO may require a determination to be made of whether the child continues to be eligible for early intervention program services. The EIO shall not, however, require that such a determination be made sooner than six months after a child and family's initial IFSP in the program.
If standardized assessment results are submitted as part of an IFSP review or evaluation, providers can be reimbursed for a service delivery visit, or when authorized as part of the child's IFSP, as a supplemental evaluation. Ongoing assessment of the child can occur during many sessions or in only one session depending on what is an acceptable method for administering the tool. Municipalities cannot refuse payment to providers who use a visit for purposes of administering a standardized assessment needed for an IFSP review or annual evaluation of the IFSP, or require providers to also deliver additional services to the child as part of the same visit. Finally, municipalities cannot require use of standardized assessments where inappropriate for the child due to the child's language, culture, age or disability.
20. Is there a minimum amount of time that needs to lapse when using standardized instruments as part of ongoing assessments or MDEs? Can evaluators use the same tool to re-test a child?
Whether an evaluator can use a tool that was used previously depends upon factors such as the age of the child, diagnosis, type of assessment tool, and whether there are additional tools that would appropriately assess the child's development and whether it is consistent with information contained in the test manual. Evaluators are responsible for determining if the reliability and validity of a particular instrument would be compromised by the use of a tool used previously, and whether sections of a particular assessment tool should be supplemented and explained with clinical opinion. In addition, prior findings should be considered and integrated into the ongoing assessment or MDEs, to explain and investigate the difference in the performance. The tool/scores cannot be the sole criterion to determine the child's eligibility.