Why are EC audits conducted?

Improve educational results and functional outcomes for all students with disabilities

What are the 6 core components of a state EC Audit?

• Student Record Review • Interviews: EC Process • Service Verification • Related Services Verification • LEA Resources • Licensure

How many records will be audited in BCPS?

Approximately 25 records ; 6 schools; 30 records for secondary transition

What information will be needed at the school level?

School bell schedule, school map, student schedule with PowerSchool ID #, EC staff roster, related service provider schedule; student attendance, student discipline log, student grade report, student achievement on state assessments (Student Profile sheets will be used to collect data)

What about the interview?

Interviews, regarding EC Process, will be conducted with LEA administrators, including EC Directors/Coordinators; EC teachers and related services providers at the selected school sites. Responses will be scored on average for each group and across schools using the Interview Rubric. Items measured the working knowledge of Child Find, Discipline, Transfer Students, and Secondary Transition.

Tell about the CHILD FIND process

o Response to notification: 30 days o Used to identify students suspected of a disability and in need of specially designed instruction o Includes children advancing from grade to grade/highly mobile (migrant) children o Meets requirement to determine whether or not to refer the student to special education o Parent referral procedures

Tell the key elements that must be considered in the DISCIPLINE of students with disabilities.

o Change of placement/patterns of removal/10-day rule o Manifestation Determination o Requirement to provide services o FBA/BIP o Special Circumstances

Describe the TRANSFER PROCESS for students transferring from OUT-OF-STATE with a current IEP

o Comparable Services o Initial Process-Evaluation o Initial Process-Consent for the provision of services o Adopt or develop a new IEP o Request for Records

Describe the TRANSFER PROCESS for students transferring from IN-STATE with a current IEP

o Comparable Services o Review and Revise the IEP (if needed) o Request for Records o Parent/Teacher Conference/ IEP Team Meeting o Review Records for Compliance

Describe the key elements of SECONDARY TRANSITION

o Transition Assessments o Transition Goals o Transfer of Student Rights o IEP Team Meeting: Outside Agencies/Student o Transition Activities

What other LEA information is collected during a state EC audit?

Post Secondary Record Review, Special Education Service and Related Service Verification, Review of LEA resources, Verification of Special Education staff licensure

Does the audit deficit sheet look familiar?

The Program Compliance Review - Deficit Sheet looks just like the audit sheet used in BCPS audits!

How does the Special Education Service Verification work?

In order to verify that services were provided in accordance with the IEP, the monitor will select one service from each student's IEP, identify the timeframe would be delivered according to the EC teacher's schedule and observe the instruction at the school site.

How does Related Service Verification work?

Related service logs and schedules are reviewed for the last completed grading period.

What happens at the end of the state EC audit?

• discuss preliminary findings with LEA; • explain the correction process; • review available resources; and • collaborate with the LEA to develop next steps to ensure correction of all noncompliance

When are all the corrections due?

All areas of noncompliance MUST be corrected within one year.

Program Compliance Review (PCR)

7.015 Hand Hygiene: Practice observation of hand hygiene compliance via the use of a hand hygiene survey tool to be reviewed quarterly at the QAPI committee. (Chapter 10.14 Handwashing & Surgical Antisepsis) Continue infection control education through ongoing orientation to center staff routinely and annual mandatory in-service. Continue to promote hand hygiene awareness for patients and staff by means of educational materials placed throughout the center which references the CDC/WHO guidelines. Needle-stick Injuries: (Refer to Exposure Control Plan) Use of designated safety engineered needles for injections (safety glide needles for injection and autoguard IV catheters) and blood draw. New employee and annual clinical competency for injections will be provided to all staff. The staff will be trained yearly on OSHA, blood borne pathogens and PPE. 7.016 Hand Hygiene Quality in the ASCs: based on AORN (Association of periOperative Registered Nurses) Standards and guidelines Policy: All ASC staff, including physicians, nurses, and other healthcare workers, are required to perform hand hygiene before and after any direct contact with patients, before and after any procedure, and after any contact with potentially contaminated items or surfaces. Hand hygiene must be performed using either an alcohol-based hand rub or soap and water. The alcohol-based hand rub must contain at least 60% alcohol. Staff members must ensure that their hands are free of debris and visible dirt before performing hand hygiene. Hand hygiene must be performed for a minimum of 20 seconds, and hands must be dried thoroughly after washing. Staff members must be trained on proper hand hygiene techniques and will be educated on a regular basis to ensure compliance with this policy. All staff members must comply with this policy and demonstrate compliance during inspections by ASC management and regulatory agencies. Any staff member who fails to comply with this policy will be subject to disciplinary action. ASC management will monitor compliance with this policy through regular inspections and audits and will take appropriate action to address any noncompliance issues. The ASC will maintain records of staff compliance with this policy as part of its infection control program. The ASC will review and update this policy on an annual basis or more frequently as needed to ensure that it remains current with the latest guidelines and standards for hand hygiene quality.

7.03 Patients with Infectious Disease The center adheres to infection control policies to ensure the safety of patients, physicians, and staff members. Patients who are currently being treated for an infectious disease or condition that is transmitted via the contact route may not be treated at the center. Patients with disease spread via droplet (e.g. influenza) or airborne (e.g. tuberculosis, measles) routes will reschedule their procedures in consultation with their physicians. The infection control nurse, in consultation with the infection control consultant, will determine whether the patient requires isolation or other additional precautions. If a patient with current Clostridium difficile-associated diarrhea is treated at the center, all rooms where the patient was housed, even briefly, should be cleaned by housekeeping under supervision of the staff at the center. Physicians must document relevant information in their pre-admission documentation. Standard Precautions will be followed in the care of all patients. Cigarroa Interventional Institute establishes policies to ensure compliance with infection control policies for the care of patients with drug-resistant organisms. The physician will screen patients through the medical history review prior to scheduling a patient at the center. During the pre-operative (pre-op) phone call or interview, a pre-op screening of the patient will be conducted. Strict isolation policies are required to treat patients with active MRSA, VRSA, or tuberculosis. Since this facility has no provisions for strict isolation, those patients with active infections will be referred elsewhere for treatment. Patients who are undergoing or completed a course of antibiotic therapy, are colonized and/or are not actively infected may be treated at the center. Patients with active infections requiring transmission-based precautions are not appropriate candidates for this facility and will be referred to another facility or rescheduled. Procedures cannot be scheduled for patients currently undergoing an infection with transmission based precautions. The patient must finish the course, and they will be rescheduled. Definitions and Standards: The following definitions and standards are provided for informational purposes only: Airborne Transmission and Precautions: This mode of transmission occurs by the spreading of either airborne droplet nuclei (small particle residue of 5 microns or smaller), of evaporated droplets which contain microorganisms that remain suspended in the air for long periods of time) or dust particles containing microorganisms. Patients must be isolated in private rooms with special air handling and ventilation, and the door must remain closed. Patient transport should be restricted to essential transport only. Respiratory precautions must be taken when in the presence of patients with active tuberculosis, including respiratory masks. Droplet Transmission and Precautions: Droplets are transmitted from the host source by coughing, sneezing, talking, or during procedures such as suctioning or bronchoscopy. Patients must be isolated, and a distance of 3 feet maintained between the infected patient and others. Caregivers within 3 feet of the patient should wear a mask. Patient transport should be minimized. Contact Transmission and Precautions: Direct contact transmission involves direct body surface to body surface contact with physical transfer of microorganisms between a susceptible host and an infected person. Indirect contact transmission involves contact with an intermediate object (usually inanimate) and a susceptible host. Patients should be isolated as much as possible. Gloves and hand washing are essential for all contact with the patient and contact with objects, which come in contact with the patient. Gloves should be changed after each contact. Reportable Condition If the patient is determined to have a reportable condition at any time during pre-admission, the Director of Operations/Nurse Manager will be notified. The procedural physician will be contacted and the case will be canceled. The Department of Health will also be notified the same day following state regulations regarding Reportable Communicable Diseases. To report a disease or condition, contact: The City of Laredo Epidemiology 24/7 Reporting Line: (956) 763-2915, if unable to report locally, call The Texas Departmrent of Health Services epidemiology program: 24/7Number for Immediately Reportable – 1-800-705-8868

PROGRAM

Program Evaluation

Program, process and threads

Program variables

Program Perpaduan Masyarakat Madani

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