Chapter II

Technical Assistance Services

Since the late 1960s, the Department of Public Health has been required by law to "provide consultative services to licensees and applicants for licenses to assist them to attain and maintain the standards established in regulations" (C.G.S. Sec. 19a-82.) This provision only applies to child care centers and group day care homes, not family day care homes. The committee found DPH, through its Division on Community Based Regulation, provides their technical assistance services to all types of child care facilities.

Terminology

Although the statutes require the public health department to provide "consultative services," DPH uses the term "technical assistance" to describe its efforts. The department believes technical assistance more aptly represents its present role in helping child care providers. The statutory purpose of these services, whatever term is used, remains: to assist providers to attain and maintain regulatory standards.

The department does not have a formal, written definition of technical assistance for use by its licensing specialists or the broader child care community. The lack of a standardized definition of technical assistance appropriately communicated to the licensing specialists and to licensed providers could lead to increased confusion on part of licensing specialists and providers about what technical assistance means, what form it takes, and how it fits into their other licensing responsibilities.

Licensing specialists within the Division of Community Based Regulation's Licensing Unit are responsible for inspecting child care facilities. As part of the inspections, the specialists are instructed not to act as "consultants" offering absolute solutions to providers' concerns. Instead, the specialists are responsible for providing assistance and options to providers on matters relating to current state licensing regulations. The committee believes this practice is appropriate and helps clarify the role of the licensing specialist as it relates to implementing C.G.S. Sec. 19a-82, as long as it is properly communicated to specialists and providers.

For purposes of this study, the following definition of technical assistance is used:

advice and guidance provided to an applicant or licensee with the purpose of enabling him or her to attain and maintain compliance with state child care licensing requirements.

The above definition is adapted primarily from C.G.S. Sec. 19a-82. A similar definition describing technical assistance is used by the National Association of Regulatory Administration (NARA). NARA is a national organization whose purpose is to promote excellence in human care and service regulation. As part of its efforts, the association offers a training curriculum for use by regulatory personnel, such as DPH, which includes information on licensing and technical assistance.

The committee determined DPH technical assistance services for child care providers occur at various stages throughout the child care licensing process. Technical assistance can be given in group settings and to individual on site. A description of the types of technical assistance services offered to prospective and licensed child care providers by DPH, as described in this chapter, include:

• new providers information packets;
• Helpdesk;
• workshops and statewide forums;
• on site visits to family day care providers;
• office meetings to address violations; and
• services provided in the course of inspections and site visits.

Lack of plan. One of the most significant findings made during this study, and a common theme highlighted in the narrative below, is the public health department's lack of a technical assistance master plan for child care providers. No centralized scheme exists detailing important guidelines and procedures such as 1) what is technical assistance, 2) how it should be implemented, 3) when it should occur, and 4) what service providers can expect to receive to help them attain and maintain state regulations. The current technical assistance "system" within the DPH child care regulation division is an uncoordinated set of practices without a centralized design. The department's technical assistance structure for child care providers lacks a well-defined approach that is fully-communicated and adequately monitored.

New Provider Information Packets

Within the past year, the Division of Community Based Regulation developed resource information packets for prospective child care providers. The packets are distributed during the initial inspection phase conducted after the prospective provider's application has been reviewed by the division.

Separate packets are available for center and family-based facilities. The packets include resource material, copies of required forms, and descriptions of various programs available to providers and parents.

The information packets were reviewed for both centers and family day care homes and finds each to contain practical information for providers. The packets also serve as an important means of communication with providers, which is vital to ensuring compliance with child care regulations.

During site visits with licensing specialists (discussed below), committee staff observed providers were receptive to the information packets. Staff accompanied licensing specialists on three initial inspections where distribution of the packet was mandatory, and observed the packets were given to the providers in all three instances.

Although each provider commented during the site visits the information packet was important to have and welcomed the material, in some instances the packets for the same type of facility (i.e., family day care home) contained differing information. Licensing specialists said the information is generally the same depending on the type of facility it is given, but licensors may include additional resource material they have collected over time. This may prove useful to the providers receiving the information, but is inconsistent if all providers do not receive comparable material.

The committee believes the resource information packets offer newly-licensed providers important and helpful information. The division, however, needs to make sure the material included in the packets is consistent, timely, and appropriate to the type of facility receiving the information.

Helpdesk

A telephone "Helpdesk" for child care providers has been maintained by the department for the past several years. A toll-free telephone number and one local number are established for providers to ask application and licensing questions. The telephone lines are staffed by a licensing specialist who rotates daily. The committee was told the Helpdesk averages approximately 60 calls per day.

The committee was also told if the Helpdesk licensing specialist does not know the answer to a question, either another specialist or a supervisor is consulted and a return call is made to the provider. According to a committee survey of providers (detailed in Chapter V), the response time of the Helpdesk is a basic concern among providers and needs to be quicker. Other observations made by the committee regarding the Helpdesk include:

· a system of logging either the number of calls or the types of questions received by the Helpdesk no longer exists -- DPH cites large volume of incoming calls as the reason for discontinuing tracking the calls; and

· since calls are not tracked, the Helpdesk is not formally used as management tool for performance information, such as gauging providers' concerns or tracking the time it takes the unit to return calls if answers are not provided during the initial call.

A separate line to receive complaints about child care providers has been established, because calls about complaints are handled differently than technical assistance calls. The Investigations Unit within the community based regulation division is responsible for receiving complaints. No Investigations Unit staff are used to assist with the Helpdesk. The desk is only staffed with specialists from the Licensing Unit.

Workshops and Statewide Forums

DPH conducts workshops for groups of child care providers on topics of providers' choosing. Of the log maintained by the Licensing Unit, the topics mostly include reviewing regulations and licensing processes with providers

Workshops are offered for groups of at least 10 people and presented by child care licensing specialists, supervisors, and sometimes managers. The workshops are conducted at a site chosen by the provider(s).

Figure II-1 shows the number of workshops held by the division for child care providers in FYs 98-01 based on the written log maintained by the Licensing Unit. The number of workshops has increased steadily since FY 98, except for FY 99. Twelve workshops were conducted in FY 98, increasing to 41 in FY 01. The unit's log also attempts to track workshop attendance, but the information is too inconsistent for meaningful analysis.

The committee believes the increase in workshops indicates a direct effort by DPH to offer technical assistance to child care providers throughout the state. In reviewing the workshop process, however, some deficiencies were found.

· Program review survey results (see Chapter V) indicate providers are not fully aware the department offers workshops, and some providers commented more should be done to communicate the technical assistance activities offered by DPH. The Licensing Unit told the committee attempts to inform providers are made. For example, an article announcing the workshops appeared in the Winter issue of the quarterly statewide publication "All Children Considered" distributed to each provider, which the committee confirmed. The department also noted providers were notified workshops were available in a mass-mailing dated April 10, 2001.

· During its site visits, committee staff noted licensing specialists were not consistent in telling providers the workshops are available nor did the information left with providers refer to the workshops.

· Some providers indicated individual assistance is lacking because the workshops are conducted in large sessions. The providers also expressed skepticism about asking questions in workshops because of their group settings. DPH said providers can call the Helpdesk or their licensing specialist if more individual attention is required.

Forums. The Division on Community Based Regulation conducted five forums at different sites throughout the state during FY 00. The forums were designed to offer information to child care providers about the state's licensing and enforcement processes. The forums were held in Hartford, North Haven, Norwalk, Norwich, and Waterbury with a total attendance of approximately 400. Presentations were made by the division director and various child care regulation managers and supervisors.

Committee staff did not attend any of the forums given their timing, but obtained copies of the presentations made at them by the licensing and enforcement managers. The presentations outlined the child care regulatory functions within DPH and the efforts being made by DPH to inform providers about various licensing and enforcement rules and processes. The division did not, however, solicit formal feedback from providers attending the forums, as well as the workshops described above, to gauge their opinions on the overall usefulness of the programs.

On-Site Technical Assistance Visits for Family Providers

The community based regulation division implemented a new technical assistance program for family day care providers at the beginning of 2001. The program offers an individual technical assistance visit for all newly-licensed family providers. The technical assistance visits are not mandatory and may be declined by providers. Although the program began in 2001, the division said it is offering on-site visits to family providers licensed as of July 1, 2000.

The new program is designed to offer assistance to newly-established providers outside of the normal inspection process. The program allows the licensing specialist to determine whether a provider's home has any deficiencies that would normally be cited as violations during a routine inspection. Unless the deficiencies are of a grievous nature, nothing is formally noted on an inspection form or put into the provider's file. The licensing specialist will inform the provider of potential violations and try to answer any questions the provider has during the visit. DPH views this as a way to bring new providers into full compliance with licensing regulations, rather than waiting until their first unannounced inspection, which could be several years after licensure.

Visit protocol and data. A set of general written procedures was finalized for the FDCH technical assistance program in late February 2001, and put into a protocol document. The document, distributed to each licensing supervisor and specialist, is to be used by licensing specialists as a guide in implementing the program.

Under protocol, licensing specialists are to set up appointments with providers for technical assistance visits within the first three months after the provider is licensed. The protocol is silent, however, as to when the visit should actually occur following licensure. The division said its standard is to complete visits within the first six months of licensure, although it is not in the protocol document.

A data base for family day care providers is maintained within the community based regulation division. Among other information, it includes the dates initial technical assistance visits occurred.

The data base was examined for basic performance indicators, such as: 1) the time elapsed between licensure and when initial appointments were made; 2) the time from licensure to the technical assistance visit; and 3) the number of providers declining visits. The analysis, however, is limited because:

· several important dates are not captured, including the date calls are made to providers to set up appointments and whether providers declined the technical assistance visit; and

· the data base is only current through March 2001 - roughly a month after the program's protocol was finalized. Data base information is scheduled to be updated every six months, has not been updated since March 2001, and was due for updating after the data base was examined in early September.

Although the division's data base contains limited information, analysis of existing data shows the following:

· family day care providers licensed or relicensed between July 1, 2000, and March 31, 2001, totaled 228;

· a total of 144 providers were contacted by DPH to set up a technical assistance visit;

· a total of 114 providers received a technical assistance visit from a DPH licensing specialist; and

· the time between the licensure date and technical assistance visit averaged 185 days, or six months.

Additional data need to be captured for adequate management analysis of the program. For example, the division needs to know the date providers were contacted to set up visits in order to determine if the program timeframe protocol is being followed. The data base is also not designed to capture whether a provider declines a visit, which may also be useful program analysis information.

Office Meetings

Office meetings between the Licensing Unit and individual providers are used as a way to encourage providers to attain and maintain licensing regulations. The purpose of the meetings is to assist providers and help bring them into regulatory compliance before referrals are made for enforcement. The meetings are mostly triggered by providers' insufficient actions to correct previously identified problems.

Another type of "office meeting" is used at the beginning of the application process. The Licensing Unit said it is available to providers who have questions during the application process. Committee staff attended one such meeting whereby a provider applying for a center license met with DPH licensing staff to discuss the particular layout of the center. In addition to a general discussion about the regulatory requirements, blueprints were given to a licensing supervisor and specialist for review before the final application was made by the provider.

Site Visits

Technical assistance can also occur during the course of inspections and other site visits. In their role as inspectors, licensing specialists serve as the primary source of technical assistance on a daily basis to child care providers throughout the state. According to the Licensing Unit, 21 licensing specialists annually inspect roughly 1,220 family day care homes and 860 center-based facilities. The specialists also assist with the relicensure of 1,830 family day care homes and 860 centers and group day care homes.

Committee staff accompanied licensing specialists on various types of site visits. The purpose of the visits was to observe firsthand the types of technical assistance offered, any similarities or differences among licensing specialists in providing assistance, and providers' reactions to the assistance given.

As shown in Table II-1, committee staff accompanied a total of 11 licensing specialists. The specialists were chosen based on the type of facilities they inspect (family or center/group) and their experience level as licensing specialists. Committee staff wanted to observe licensing specialists at both ends of the experience spectrum to observe their approaches to technical assistance.

The visits included initial licensing inspections, unannounced spot inspections of family day care homes, unannounced six-month and routine inspections of centers, and general technical assistance visits. In total, 17 visits were made, as shown in the table.

The committee staff makes the following observations resulting from its site visits. It should be noted, the observations only deal with technical assistance matters, and not inspection or licensing issues.

• Although the focus of most visits was on the regulatory/inspection aspect, some form of technical assistance was offered by licensing specialists during each visit when appropriate, such as providing alternatives to fixing problems, distributing information about outside resources, or explaining DPH processes.
• An exit interview was held during each visit whereby the licensing specialist summarized the inspection findings, answered providers' questions, and told providers the specialist was available if additional questions arose.
• Although some licensing specialists informed providers about DPH technical assistance services such as the Helpdesk and workshops, the information was not provided during each visit.
• Informational handouts were provided during each of the initial licensure/technical assistance visits, although the information varied somewhat among licensing specialists for the same type of facility inspected.
• No vast differences existed in how technical assistance was offered among the various licensing specialists based on their experience levels.
• Licensing specialists more familiar with a provider and/or facility seemed to offer more in-depth assistance based on their knowledge of past inspections of the facility or discussions with the provider.

Notification Methods

DPH uses various methods to communicate its technical assistance programs to child care providers. As mentioned above, mass-mailings and articles in a statewide child care publication sent to all providers are two examples of the department's efforts. DPH is also represented on several statewide child care forums, including the statutorily-established Child Day Care Council. The department said such forums are used to communicate the department's child care technical assistance services.

The department has also established a website that includes a page for child care regulation ( http://www.state.ct.us/dph/BRS/Day_Care/day_care.htm). The webpage became operational in February 2001.

The committee believes the website is comprehensive, but needs to be more user-friendly and providers need to become fully aware it exists. For example, improvements could include a "Frequently Asked Questions (FAQ)" page based on areas deemed most important by the licensing, enforcement, and complaints units. A first aid course description page organized by town would also be easier to search for courses according to their location than the current alphabetical format. In improving its child care website, the department should seek feedback for improvements from providers.

Overall, the committee believes providers need to be notified of technical assistance programs through as many means as possible, including mass-mailings, as part of the application process, during inspections, during calls to the child care regulation units, through statewide child care associations and publications, and as a part of a formal feedback process recommended below. It is evident from the committee's survey results in Chapter V providers are not fully aware of the range of technical assistance services offered by DPH, despite the department's efforts.

Targeted notification for centers. DPH developed a targeted technical assistance notification initiative for newly-licensed centers and group day care homes in mid-2001. The initiative informs providers of the various types of technical assistance services available and gives them the opportunity to request specific technical assistance child care regulation division.

A formal letter explaining the division's various technical assistance programs is now being included in the new provider resource information packet and given to providers at their six-month inspections. The letter includes a registration form specifying the type of technical assistance, the specific format the provider is interested in, and a preferred date and time.

The committee believes this initiative is a positive attempt by the department to directly offer technical assistance to child care providers, and should be considered for all licensed providers. Such services should also be based on providers' technical assistance needs and be fully and regularly communicated to internal staff and the external child care community.

Required Consultants

State law requires centers and group day care homes to contract with various licensed professionals to serve as additional resources to the providers. Providers are also required to develop and implement a written plan for such services. Centers and group day care homes must have the following consultants available for technical assistance:

• early childhood educational consultant;
• physician, physician assistant, advanced practice registered nurse, or registered nurse consultant;
• dentist or dental hygienist;
• social service; and
• registered dietician.

During the site visits, licensing specialists asked providers if they used their consultants for assistance, but the required written plans for consultants maintained by the providers were not reviewed. Also, the inspection form used by licensing specialists for centers/group day care homes does not include anything regarding consultants nor is any consultant information captured by the provider data base maintained by DPH (described below.) There is an initiative underway between DPH and other agencies, however, to begin collecting centralized consultant information, although the initiative is in its beginning stages.

Other Technical Assistance Services

Technical assistance services from outside the Division of Community Based Regulation for child care providers occur. Other units within DPH provide technical assistance services, along with other agencies, namely DSS.

DPH offers services to providers in areas like water quality, lead/paint issues, and immunizations. In the area of water quality, for example, DPH is responsible for overseeing public water supplies serving 25 people or more, including child care facilities. Through the department's Water Supplies Section, specialists provide technical assistance services to child care providers, including training and discussions about proper water maintenance, state drinking water requirements, and on-site sampling used for testing. The services are providers for all prospective child care licensees meeting the public water system threshold. For FY 00, the water section estimates it spent between 600-700 hours providing assistance to child care providers.

Outside of the public health department, DSS funds and/or coordinates technical assistance services for child care providers. For example, DSS funds counselors within Infoline (a nonprofit resource and referral service) to assist child care providers and families with questions. Connecticut Charts a Course, which offers training and continuing education services to child care providers throughout the state, is funded by DSS. The newsletter "All Children Considered" sent quarterly to all licensed child care providers is also funded by DSS. The newsletter provides information to providers, including information about child care regulations and licensing.

Provider Data Base

As mentioned above, the community base regulation division maintains data bases for licensing, enforcement, and complaints. The licensing data base for technical assistance information was examined as a way to gauge whether providers are receiving technical assistance and its effect on regulatory compliance.

In short, the data base is very limited in the technical assistance information it tracks. For example, there are specific fields dedicated to capturing technical assistance data for center-based facilities and family day care homes. There is currently no technical assistance information tracked for centers, and, as referenced earlier in this chapter, the family provider technical assistance information is strictly for the recently-established technical assistance visit program for new providers.

The committee was told the technical assistance fields in the licensing data base for centers and family day care homes were only added to the data base within the past year. As a result, the division is in the beginning stages of capturing technical assistance information in the data base. Despite this, the committee believes such information is critical for management analysis purposes and determining the department's compliance with C.G.S. Sec. 19a-82. As part of its overall performance monitoring of technical assistance, the division should be collecting, automating, and analyzing technical assistance data to determine such factors as if technical assistance is being provided, how many and what providers are receiving technical assistance, and whether technical assistance is meeting the needs of providers to comply with child care regulations.

Summary of Findings

· Although state law requires DPH to provide "consultative services" to specific licensed providers, the department uses the term "technical assistance" to describe its outreach efforts. The department believes "technical assistance" more aptly describes its current services to child care providers.

· State law specifically requires "consultative services" be provided to child care centers and group day care homes, but is silent regarding family day care providers.

· DPH has not adopted a formal working definition of "technical assistance" as it relates to child care regulation. Although the term has a general meaning as used in statute, it may or may not be obvious to licensing specialists or the child care providers they regulate. There is nothing in writing used by DPH child care licensing personnel or distributed to the more than 5,000 licensed providers throughout the state to adequately describe the purpose of technical assistance and what it means.

· Technical assistance services to help child care providers attain and maintain state regulations are provided by the public health department through a variety of methods, yet the services lack a centralized focus. The current process also lacks a cohesive master implementation plan for proper service coordination. The full range of services needs to be more fully communicated internally and externally, and better management analysis regarding overall performance needs to occur.

· There is no formal process in place to assess child care providers' needs for technical assistance or determine if department's technical assistance services are adequate to meet those needs.

· Although attempts are being made to provide resource material, a survey of providers shows they are not fully aware of the services offered by DPH. Moreover, the types of resource information distributed by licensing specialists are not consistent among licensing specialists.

· Other units within DPH, along with the state's social services department and nonprofit organizations, offer technical assistance services to child care providers.

· Automated technical assistance information contained in the provider data base maintained by the community based regulation division is limited and insufficient for proper management analysis purposes.

Recommendations

1. C.G.S. Sec. 19a-82 should be amended to change "consultative services" to "technical assistance," as it relates to the services offered by the public health department to help child care providers and applicants attain and maintain compliance with state licensing regulations.

2. C.G.S. Sec. 19a-82 should include family day care homes in the types of providers required to receive technical assistance.

3. The Division of Community Based Regulation shall develop a formal definition of technical assistance based on C.G.S. Sec. 19a-82. The division shall also ensure all child care regulatory staff and child care providers know and understand the definition.

4. The Division of Community Based Regulation shall take the following actions.

a. Develop clear and concise management objectives relating to technical assistance to child care providers. At minimum the objectives should specify the division's definition of technical assistance, the purpose of technical assistance, and the division's technical assistance policy.

b. Integrate the various technical assistance methods/services for child care providers currently used by the division into a formal implementation plan. At minimum, the plan should detail the technical assistance services available to providers, how providers can obtain the services, and when/where the services are available. The division should develop the implementation plan in consultation with provider groups, statewide child care associations, and the day care council. The division's plan shall be communicated with individual providers and the broader child care community.

c. Develop a systematic approach to hold licensing specialists, supervisors, and managers accountable for carrying out the division's technical assistance objectives and providing the technical assistance services outlined in the implementation plan. This includes regular analysis of the technical assistance services provided for performance measurement purposes.

d. Communicate the management objectives, implementation plan, and performance measurement method(s) with each division manager, supervisor, and licensing specialist involved with child care technical assistance services.

e. Fully communicate the outcome of the plan development and implementation with the child care community, as identified by the division. A plain-language summary of the division's technical assistance objectives and services shall be distributed to each licensed child care provider on a regular basis determined by the division or upon substantive changes to services/objectives.

5. The Division of Community Based Regulation shall develop a system to formally identify and assess the types of technical assistance desired or required by licensed child care providers. A system to collect feedback from licensed child care providers on the types of technical assistance they desire and regarding the performance of current technical assistance services shall also be established. Such feedback shall be collected on a routine basis and the information collected shall be used to develop, eliminate, or enhance the division's technical assistance services. The information shall be used by the division for developing its management objectives and services as part of implementing C.G.S. Sec. 19a-82.

6. Regular and thorough management analysis and performance measurement of the technical assistance services offered to child care providers through the Division of Community Based Regulation shall be conducted. Proper and adequate data regarding technical assistance services shall be collected, automated, and used for management analysis purposes.

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