2014-2015 SA Guidelines for Tools and Documents

2014-2015 Self-Assessment Tools &
Documents
Guidelines for the Delegate
Agency/Early Childhood Education
Providers
Table of Contents
Table of Contents ............................................................................................................................ 2
Introduction ..................................................................................................................................... 3
Agency Self-Assessment Compliance Workbook Guidelines .......................................................... 5
Environmental Rating Scale (ERS) Summary of Findings Form Guidelines ............................... 11
Approval Signature Form Guidelines ........................................................................................... 13
Self-Assessment Final Report Template Guidelines ..................................................................... 14
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Introduction
What is a Self-Assessment and why do we do it?
Continuous quality improvement is a fundamental tenet of the Los Angeles County Office of
Education Head Start-State Preschool (LACOE HS-SP) program with the goal of providing
program excellence in services delivered to the most vulnerable of children and their families in
Los Angeles County. The Self-Assessment (SA) is an integral part of LACOE HS-SP’s program
planning as it is the opportunity to assess the effectiveness of key management systems, program
operations, and service delivery areas. Further, federal regulations1 require that programs
complete an annual Self-Assessment (SA) for the purposes of assessing the effectiveness and
progress in (1) meeting goals and objectives, and (2) implementing federal regulations identified
in the Head Start Performance Standards and the Head Start Act. In effect, SA supports
continuous improvements that strengthen the quality of services and support the positive
outcomes of Head Start eligible children and families. The SA involves the participation of Boards,
parents, the Policy Council and Policy Committees, LACOE HS-SP management and staff, and
Delegate Agency/Early Childhood Education Providers (Agencies) management and staff.
What does the Self-Assessment process involve?
The SA process involves the collection of information from a variety of sources to determine if
management systems and services have been implemented and are working effectively. During
the SA process, agencies must develop a SA Plan that is approved by LACOE HS-SP. In addition,
agencies review, analyze, and incorporate information from multiple sources including (but not
limited to): 1) Grantee monitoring reports, 2) the Program Information Report (PIR), and 3) child
outcome and classroom assessment data. (Refer to Self-Assessment GIM 1304.51(i)1)_(33)v.2 for
comprehensive description of requirements.)
What LACOE HS-SP tools and documents are required to complete the Self-Assessment?
LACOE HS-SP does not prescribe the specific methods or strategies agencies use to collect,
review, and analyze the information necessary to conduct the SA. LACOE HS-SP provides tools
and documents that all agencies are required to complete and provides this guideline to follow in
order to ensure a structured self-assessment approach. This approach also facilitates the
systematic inclusion of agency results into LACOE HS-SP’s SA. This guideline provides
instruction for using and completing each of the following tools and documents required by
LACOE HS-SP:
1.
2.
3.
4.
Agency Self-Assessment Compliance Workbook 2014-2015
Environmental Rating Scales (ERS) Summary of Findings Form
Approval Signatures Form
Self-Assessment Final Report Template
1 1304.50(d)(1)(viii), 1304.51(i)(1), Head Start Act 641(A)(g)(1), 641(A)(g)(2)(A), 641(A)(g)(2)(B)
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What happens once my agency completes all required Self-Assessment tools and
documents?
Per the Self-Assessment GIM, all required SA tools and documents are electronically submitted to
LACOE HS-SP by the required deadline. LACOE HS-SP Delegate Liaison Team Leaders and
monitoring staff review all SA tools and documents (For more details, see Self-Assessment GIM
1304.51(i)1)_(33)v.2 as well as the LACOE HS-SP Contract Exhibit E for deadlines).
The Grantee aggregates and organizes the all SA data and analyzes trends and patterns across
management systems and service delivery areas. The Grantee develops an integrated SelfAssessment Final Report and Executive Summary, which emphasizes areas of strength, potential
areas to further strengthen to enhance effectiveness, and areas for program improvement.
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Agency Self-Assessment Compliance Workbook Guidelines
The Agency Self-Assessment Compliance Workbook 2014-2015 is an Excel tool used by agencies to
document and record compliance with federal standards, regulations, as well as LACOE HS-SP
Instructional Memos (GIMs) and contractual mandates during the 2014-2015 program year. This
workbook is based on:
 FY2011, FY2012, FY2013, and FY 2015 OHS Monitoring Protocols
 Federal Performance Standards and Head Start Act regulations
 LACOE HS-SP GIMs and LACOE HS-SP Contractual agreements
 Evaluation results from the 2013-2014 Self-Assessment
Worksheet Tabs
The workbook contains a total of 18 worksheet tabs. The first 16 worksheet tabs address eight
management systems and eight service delivery areas. These tabs are highlighted in green (see
example).
The last two worksheet tabs contain the auto-populated Summary Sheet (blue tab) and the
Agency SA Survey (purple tab).
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Management System/Service Area Worksheets
The 16 management system/service area worksheets all follow the same format. Each contains:
a. Grouping of Performance Standards/Regulations: Some Performance
Standards/Regulations have been grouped based on OHS Monitoring Protocols.
b. Performance Standards/Regulations: Listing of the relevant Head Start performance
standards, Head Start Act requirements, LACOE GIM and contractual agreements relevant
to each system/service area.
c. In Compliance?: Where compliance for each standard/regulation is recorded using a
drop-down menu.
d. Results: Corresponding auto-populated result to the recorded determination of
compliance (e.g. “Write a PIP”).
Example of the Health Services worksheet tab:
Once compliance for each standard/regulation has been determined through the self-assessment
process, a compliance response must be recorded in the appropriate space using (see figure above,
column C).
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Below is a description of each compliance determination option:
 Yes= In Compliance: Select this option when the review indicates compliance with this
standard/regulation was met 100% of the time.
 No= Not in Compliance: Select this option when the review indicates compliance with
this standard/regulation was not met 100% of the time.
 N/A= Not Applicable: Select this option when the regulation is not applicable to your
agency (e.g., your agency does not provide transportation service).
Once a response has been recorded, a corresponding result will auto-populate. The example
below shows all possible results. A worksheet is complete when a compliance score is recorded
for every standard/regulation identified.
A cell in the
auto-populated
Results column
will turn pink to
indicate noncompliance and
serve as a visual
reminder that a
PIP is required.
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Summary Sheet Worksheet
The Summary Sheet (blue tab) is a locked auto-populated worksheet. All of the information
contained on this sheet is a numeric tabulation of your agency’s responses on all of the 16
management system/service area worksheets. It also provides a summary of your agency’s
responses and serves as a checklist to indicate systems and areas that require the development of
a PIP.
Example
The Summary Sheet below shows the following:
 The Health Services worksheet shows “In Compliance” on all 36 standards with no
required PIPs (see red circle).
 The Nutrition Services worksheet shows “Not in Compliance” for three standards and the
Number of Required PIPs (last column) indicate that three PIPs are required (see blue
circle).
 The Mental Health Services worksheet indicates that this worksheet has not been
completed fully, as indicated by the notification in red “Check this worksheet for blanks”
(see red arrow) in the Worksheet Completion column. This requires returning to the
Mental Health Services worksheet to ensure that all the responses have been recorded.
Once completed, the Summary Sheet automatically updates the status to “Worksheet is
complete.”
 The Disabilities Services worksheet also shows that three standards were designated as
“N/A” (see green circle) and no PIPs are required.
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Agency SA Survey
The Agency SA Survey (purple tab) is a survey to evaluate the process used to complete the SA.
Survey responses are used to continually strengthen and improve agency Self-Assessment tools,
resources, and the SA process.
Excerpt of the survey:
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Notable Features of the Workbook:
 Printer-friendly Worksheets: All 18 worksheet tabs are printable. The printer settings
have been pre-set for each worksheet to print on 8.5”x11” size paper in landscape layout.
However, due to printer differences, make sure your printer is set for landscape printing
and print one worksheet as a test page.
Note: Any changes you make to the row height, column width, or font size in the
worksheets will likely change the pre-set printer settings.

Additional Pop-up Instructions: Comment boxes containing additional instructions or
guidance appear on various worksheets.
Example:
The yellow comment box above explains that the header in the dark gray box applies only to the
shaded standards below it.
Note: These comment boxes do not print with the worksheet and therefore do not need to be
removed prior to printing.
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Environmental Rating Scale (ERS) Summary of Findings Form
Guidelines
The Environmental Rating Scale (ERS) Summary of Findings Form ensures a systematic approach
to the annual recording and submission of the ERS ratings and improvement plans as part of the
Self-Assessment process. The ERS is inclusive of three assessments:
 ECERS – Early Childhood Environment Rating Scale
 FCCERS – Family Child Care Environment Rating Scale
 ITERS – Infant/Toddler Environment Rating Scale
The ERS Summary of Findings Form is completed for the ECERS, FCCERS, and ITERS, as
applicable. Instructions for completion are located on the last page of the form. Below is a list of
general guidelines and an excerpt of the form.

Conduct ERS observations for:
o 50% of preschool classrooms (ECERS)
o 100% of family child care homes (FCCERS)
o 100% of Early Head Start classrooms (ITERS)
Excerpt of the ERS Summary of Findings Form:
2014-2015
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




Submit one form per Rating Scale per agency (see red arrow in example above).
Calculate average scores for each subscale (see section a).
Describe key findings for each subscale for which the average score falls below a “5.0” (see
section b).
Provide improvement plans for each subscale for which the average score falls below a
“5.0” (see section c).
Note expected completion date and persons responsible (see section d). The last column
may be left for agency and Grantee follow-up of progress.
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Approval Signature Form Guidelines
As described in the Self-Assessment GIM, Self-Assessment results, including PIPs, must be
approved by the Policy Committee and Board.
The Approval Signatures Form was developed as a standardized tool to record PC approval and
signatures.
Page 1 of the form is specifically designed for the PC. Page 2 of the form is specifically designed
for Board approval signatures.
Note: These signed documents must be scanned and provided electronically to LACOE HS-SP
(See Self-Assessment GIM for detailed information).
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Self-Assessment Final Report Template Guidelines
The purpose of the Self-Assessment Final Report Template is to provide a comprehensive summary
of your agency’s compliance with the federal standards and regulations, LACOE HS-SP GIMs, and
LACOE HS-SP contractual agreements.
At a minimum, the Self-Assessment Final Report Template must include the following sections:
1.
Introduction that includes timeframe used to conduct the SA as well a description of why
the SA is completed annually.
2. Process and Methodology which describes the process the agency implemented to
complete the SA as well as participants involved in the process.
3. Results which describes:
a. Current Program Improvement Plans (PY 2014-2015) details a description of
program improvement plans (PIPs) developed to address non-compliant findings
identified through the SA as well as any outstanding non-compliances (e.g.,
identified by LACOE HS-SP monitoring staff, health and safety screener noncompliances, governance screener non-compliances, etc.) at time of the SA.
b. Previous Performance Improvement Plans (PY 2013-2014) identifies the PIPs
developed to address non-compliances identified in the previous year’s SA and the
status of those PIPs. This information is also included to assist the agency in
identifying any trends that may need further analysis and/or action.
c. Potential Future Areas of Non-Compliance details a description of areas that relate
to policies, processes, and/or practices that may need to be further strengthened to
enhance effectiveness and ensure future compliance.
d. Areas of Strength details notable examples of new or innovative
practices/programmatic elements that helped overcome challenges, improved
service quality, or surpassed established regulations and/or standards.
Note: The Self-Assessment Final Report is submitted electronically as a Word document,
not a pdf file. Also, the template provides instructions in yellow highlight that can deleted
to finalize the document.
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