Part V. Service Planning, Delivery, Transition, and Discharge
12VAC35-225-120. Individualized family service plan (IFSP) development.
A. A written IFSP shall be developed and implemented, with parental consent, for each eligible child.
B. The IFSP shall include:
1. The child's name, date of birth, gender, and city or county of residence; IFSP date and the dates the six-month IFSP review is due and dates reviews are completed; child's and family's primary language or mode of communication; parents' and, if requested by the family, other family members' contact information; and the service coordinator's name and contact information;
2. Information about the child's and family's daily routines and activities;
3. The child's present levels of physical, including vision, hearing, motor, and health status, cognitive, communication, social or emotional, and adaptive development based on the information from eligibility determination and assessment for service planning;
4. With the concurrence of the family, a statement of the family's resources, priorities, and concerns related to enhancing the development of the child;
5. The measurable outcomes to be achieved for the child, including preliteracy and language skills, as developmentally appropriate for the child, and the criteria, procedures, and timelines for determining the degree to which progress toward meeting the outcomes is being made and whether revisions to the outcomes or early intervention services identified in the IFSP are necessary;
6. The specific early intervention services, based on peer-reviewed research (to the extent practicable), that are needed to meet the unique needs of the child and family and to achieve the identified outcomes including:
a. Assistive technology devices and assistive technology services;
b. Audiology services;
c. Developmental services;
d. Counseling services;
e. Family training services;
f. Health services;
g. Medical services;
h. Nursing services;
i. Nutrition services;
j. Occupational therapy;
k. Physical therapy;
l. Psychological services;
m. Service coordination services;
n. Sign language and cued language services;
o. Social work services;
p. Speech-language pathology services;
q. Transportation services and related costs;
r. Vision services; or
s. Other services, as identified by the IFSP team;
7. The length, duration, frequency, intensity, method, and location of service for each service;
8. A statement of the natural environment in which each early intervention service will be provided or a justification made by the IFSP team, including the parent, as to why, based on the child's outcomes, the service cannot be provided in the natural environment;
9. Payment arrangements, if any;
10. To the extent appropriate, the medical and other services that the child or family needs or is receiving through other sources, but that are neither required nor funded under Part C and the steps the service coordinator or family may take to assist the child and family in securing those other services if those services are not currently being provided;
11. The projected date for the initiation of each early intervention service identified in the IFSP, which shall be as soon as possible but no more than 30 days from the date the parent signs the IFSP unless the IFSP team agrees on a later start date in order to meet the needs of the child or family;
12. The name of the service coordinator who will be responsible for implementing the early intervention services identified in the IFSP; and
13. The steps and services to be taken to support the smooth transition of the child from early intervention services to preschool services under Part B or other appropriate services, if any. The transition steps in the IFSP shall include, but are not limited to, the following:
a. Discussions with, and training of, parents, as appropriate, regarding future placements and other matters related to the child's transition;
b. Procedures to prepare the child for changes in service delivery, including steps to help the child adjust to, and function in, a new setting;
c. Confirmation that the required notification, unless the parent disagrees, and with parental consent additional information, such as copies of evaluations and assessments and the most recent IFSP, needed by the local school division to ensure continuity of services have been sent to the local school division; and
d. Identification of transition services and other activities that the IFSP team determines are necessary to support the transition of the child.
C. A meeting to develop the initial IFSP shall be held within 45 days from the date the referral is received.
D. Meetings of the multidisciplinary IFSP team, which must include two or more certified early intervention practitioners from separate disciplines or professions, shall include the following participants:
1. The parent or parents of the child;
2. Other family members, as requested by the parent, if feasible to do so;
3. An advocate or person outside of the family if the parent requests that the person participate;
4. The service coordinator who will be responsible for implementing the IFSP;
5. A person or persons directly involved in conducting eligibility determination, assessment for service planning, or both; and
6. As appropriate, persons who will be providing early intervention services to the child or family.
E. Each meeting to develop an IFSP shall:
1. Take place in a setting and at a time that is convenient to the family; and
2. Be conducted in the native language of the family or other mode of communication used by the family, unless it is clearly not feasible to do so.
F. If an IFSP team member is unable to attend an IFSP meeting, the service coordinator shall make arrangements for the person's involvement through other means, which may include participating by telephone, having a knowledgeable authorized representative attend the meeting, or submitting a written report.
G. The service coordinator shall provide prior written notice of the date, time, and location of the IFSP meeting to the family and other participants early enough before the IFSP meeting date to ensure that they will be able to attend.
H. The service coordinator shall assist the parent in preparing for the IFSP meeting and shall ensure that the parent has the information needed in order to fully participate in the meeting.
I. With parental consent, an interim IFSP shall be developed and implemented when an eligible child or the child's family has an immediate need for early intervention services prior to completion of eligibility determination and assessment for service planning.
1. The interim IFSP shall include the name of the service coordinator who will be responsible for implementing the interim IFSP and coordinating with other agencies and persons; the early intervention services that have been determined to be needed immediately, including the frequency, intensity, length, location, and methods of delivery; and the parent's signature indicating consent to implement the interim IFSP.
2. The development of an interim IFSP shall not negate the requirement to complete the eligibility determination and assessment for service planning and develop an initial IFSP within 45 calendar days of referral.
J. The service coordinator shall document in a contact note any circumstances that result in eligibility determination, assessment for service planning, or initial IFSP development occurring more than 45 calendar days after referral.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-130. IFSP approval and selection of service providers.
A. The service coordinator shall explain the contents of the IFSP to the parent, and informed written consent shall be obtained as indicated by the parent's signature and date of signature on the IFSP prior to the provision of early intervention services.
B. The service coordinator shall assist the family in selecting a service provider for each early intervention service listed on the IFSP from among those provider agencies, including independent providers, that are qualified to provide the services identified on the IFSP, that are in the parent's payor network, and that practice in the area where the child and family live. The parent's choice of service providers shall be documented on the IFSP addendum page, which shall be signed and dated by the parent prior to service delivery.
1. If no early intervention service provider that can support and assist the family in accomplishing the IFSP outcomes is available within the family's Medicaid or private insurance network, then the parent shall be able to choose an early intervention service provider from outside the parent's third party payor network.
2. If there is only one provider agency for the service needed by the child and family, then the parent shall be offered a choice of early intervention service providers from within that one provider agency for services other than service coordination. If the parent elects not to receive services from the one provider agency, then the local lead agency shall work to identify an alternative early intervention service provider.
3. The parent shall be offered the opportunity to select a provider agency any time a new service is added or when a change in provider agency is needed.
4. If the selected provider agency is unable to provide the service due to full provider caseloads or the requested early intervention service provider within that provider agency is unavailable, then the service coordinator shall explain to the parent the option to begin services right away with an available provider or to wait for his chosen provider to become available. If the parent chooses to wait, the service coordinator shall document the parent's decision in a contact note, the parent's consent to the IFSP service shall begin once the parent's specific provider is available, and services shall be provided in a timely manner following parental consent.
5. The service coordinator shall inform the parent that he may request to change his service provider at any time by contacting the service coordinator.
C. The service coordinator shall retain a signed copy of the IFSP and, as soon as possible following development of the IFSP, shall provide a copy to the parent at no cost to the family and to all service providers that participated in assessment or development of the IFSP or will be implementing the IFSP.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-140. IFSP periodic review and updates.
A. A periodic IFSP review shall be conducted every six months or any time the parent, service coordinator, or another member of the IFSP team identifies the potential need for revisions to the IFSP outcomes or services.
B. Each periodic IFSP review shall provide for the participation of the IFSP team members listed in 12VAC35-225-120 D 1 through D 4. If conditions warrant, provisions must be made for the participation of other representatives identified in 12VAC35-225-120 D.
C. Each periodic IFSP review shall include a determination of the degree to which progress has been made toward achieving the outcomes identified in the IFSP and the need for revisions of the outcomes or early intervention services identified in the IFSP.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-150. Annual IFSP review.
A. An annual IFSP review shall be conducted to evaluate and revise, as appropriate, the IFSP for each child and the child's family.
B. The annual IFSP review shall include a determination of the child's continuing eligibility to receive early intervention services.
1. If the child's records document a diagnosed physical or mental condition with a high probability of resulting in developmental delay, then a service coordinator or certified early intervention professional shall complete and sign the eligibility determination form to document review of the record.
2. If the child's records document a developmental delay based on ongoing assessment, then a certified early intervention professional shall review the record to determine whether it establishes eligibility and shall complete and sign the eligibility determination form if it does.
3. In all other circumstances, a multidisciplinary team shall review existing health and developmental information gathered through records, parent input, observation, and an evaluation tool, if needed, to determine the child's continuing eligibility. The child's continuing eligibility determination date, methods, participants, and results shall be documented on the eligibility determination form.
4. The service coordinator shall provide the family, at no cost, with a copy and explanation of the eligibility determination form as soon as possible following the eligibility determination.
C. Each annual IFSP review shall be conducted by the child's multidisciplinary team that includes the team members listed in 12VAC35-225-120 D.
D. During the annual IFSP review, the results of any current evaluations and assessments of the child and family shall be used in determining the early intervention services that are needed and will be provided.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-160. Physician certification.
A. Physician certification shall be required regarding the medical necessity for services if the child (i) is covered by public health insurance (Medicaid, FAMIS, or TRICARE) or by private health insurance that requires such certification and (ii) will receive services that can be reimbursed under that insurance plan. Certification shall be obtained at the initial and annual IFSP and any time a service is added or the frequency of a service is changed through a periodic IFSP review.
B. The service coordinator shall obtain a written certification of medical necessity from a physician (or physician assistant or nurse practitioner). A written certification requires:
1. A signature on the IFSP;
2. A signed letter referencing the IFSP; or
3. A completed and signed IFSP summary letter.
C. The service coordinator shall ensure that the certification required by this section certifies the IFSP as a whole. Early intervention service providers shall not be permitted to seek physician certification for individual services.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-170. Service delivery.
A. Each early intervention service listed on a child's IFSP shall begin as soon as possible but no more than 30 days from the date the parent signs the IFSP unless the IFSP team decides on and documents the reasons for a later start date to meet the individual needs of the child and family. The 30-day timeline does not apply to delivery of an assistive technology device, which must be secured as soon as possible after the parent signs the IFSP.
B. Early intervention supports and services shall be provided only by certified early intervention service practitioners.
C. The service coordinator shall be responsible for the following:
1. Assisting parents of children with disabilities in obtaining access to needed early intervention services and other services identified in the IFSP, including making referrals to providers for needed services and scheduling appointments for children and their families;
2. Coordinating the provision of early intervention services and other services, such as educational, social, and medical services that are not provided for diagnostic or evaluative purposes, that the child needs or are being provided;
3. Conducting referral and other activities to assist families in identifying available early intervention service providers;
4. Coordinating, facilitating, and monitoring delivery of early intervention services required to ensure the services are provided in a timely manner;
5. Conducting follow-up activities to determine that appropriate early intervention services are being provided;
6. If the child has Medicaid or FAMIS:
a. Documenting in a contact note the family's preferred method of contact (i.e., face-to-face, phone, email, or text) for the family contacts that are required every three months and any change in the family's preferred method of contact;
b. Making at least one direct contact with the family every three calendar months, beginning no later than the month after the initial IFSP is signed, with the method of contact determined by the family; and
c. Requesting completion of a health status report by the child's physician every six months.
D. Early intervention service providers shall deliver services in accordance with the IFSP and make a good faith effort to assist each eligible child in achieving the outcomes in the child's IFSP.
E. Early intervention sessions canceled by the provider or missed due to a holiday shall be made up as quickly as possible unless the parent declines a make-up session.
F. Parents may request to change their early intervention service provider at any time by notifying their service coordinator.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-180. Service documentation.
A. Early intervention service providers shall document all contacts made and all activities completed with or on behalf of families in a contact note within five business days of the contact. All contact notes shall include:
1. The child's first and last names;
2. Type of early intervention service provided;
3. Method of contact;
4. Date of the note and date of the contact if the note is not written on the same date; and
5. The early intervention provider's signature, with a minimum of first initial and last name, discipline and credentials of the provider, and the date the note is signed by the provider.
B. Contact notes that document a service session also shall include:
1. A narrative description of what occurred during the session including what was done; what the family or other caregiver did during the session, including how they actively participated during the session; how the child responded during the session, including what the child was able to do in relation to outcomes and goals; and suggestions for follow-up;
2. Who was present;
3. Length of session (in minutes);
4. Location or setting in which service was provided;
5. Information from the family about what has happened since the last session; and
6. Plan for the next contact.
C. Contact notes that document a service coordination contact or activity also shall include the length of the contact or activity (in minutes), the service coordination short-term goal that the contact activity is addressing, and progress toward achieving the service coordination goal.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-190. Transition.
A. A child shall be considered potentially eligible for preschool services under Part B unless there is a clear expectation that the child will no longer require services by the time he reaches age three years. The determination of whether a particular child receiving early intervention services is potentially eligible for Part B shall be made by that child's IFSP team as part of the transition process.
B. The department shall ensure the parent of a child with disabilities is informed of the availability of services under § 619 of the Individuals with Disabilities Education Act not fewer than 90 days prior to the toddler's third birthday.
C. For each child who is potentially eligible for preschool services under Part B, and unless the parent objects, the service coordinator shall ensure notification to the local school division and the Virginia Department of Education not fewer than 90 days before the child's third birthday or the anticipated date of transition if the child is age two years by September 30 of a given school year.
1. The notification shall include the child's name, date of birth, and parental contact information including the parents' names, addresses, and telephone numbers.
2. The parent shall be informed in writing, on the IFSP, of the information that will be included in the notification, the earliest date on which the notification will be sent to the local school division and the Virginia Department of Education, and his right to opt out of the notification by initialing the opt out statement on the IFSP.
3. If the parent opts out of the notification, the notification shall not be sent.
D. If a child is potentially eligible for preschool services under Part B, the service coordinator shall, with the approval of the child's family, convene a transition conference among the local early intervention system, the family, and the local school division at least 90 days and (at the discretion of all parties) up to nine months before the child's third birthday, or anticipated date of transition if the child is age two years by September 30 of a given school year, to discuss any services the child may receive under Part B.
E. If a child is not potentially eligible for preschool services under Part B, the service coordinator shall, with the approval of the family, make a reasonable effort to convene a transition conference among the local early intervention system, the family, and providers of other appropriate services, as available, to discuss appropriate services that the child may receive.
F. The service coordinator shall ensure development of a transition plan in the IFSP at least 90 days and (at the discretion of all parties) up to nine months before the child's third birthday, or anticipated date of transition if the child is age two years by September 30 of a given school year, for all children exiting early intervention.
1. The family shall be included in the development of the transition plan.
2. The transition plan shall include steps for the child to exit the early intervention system and any transition services that the IFSP team identifies as needed by that child and family.
3. The service coordinator shall review with the parent the program options for a child with a disability for the period from his third birthday through the remainder of the school year.
G. The meeting to develop the transition plan and the transition conference may be combined.
H. The meeting to develop the transition plan and the transition conference, whether combined or held separately, shall meet the requirements of an IFSP meeting in 12VAC35-225-120.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.
12VAC35-225-200. Referral and discharge.
A. The service coordinator shall transmit, with parental permission, child-specific information (e.g., current IFSP), recent assessment findings, and other pertinent records to the appropriate school division in which the child resides as soon as possible after the notification to the local school division to ensure continuity of services.
B. If the child is found eligible for early intervention services more than 45 days but less than 90 days before (i) the child's third birthday or (ii) April 1 when the child will reach the age of eligibility for special education at the beginning of the upcoming school year, then as soon as possible after eligibility is determined, the service coordinator shall provide the notification required in 12VAC35-225-190 C unless the parent objects to such disclosure.
C. If a child is referred to the local early intervention system less than 45 days before the child's third birthday and that child may be eligible for preschool services under Part B, the service coordinator shall, with parental consent, refer the child to the local school division and Virginia Department of Education, but the local early intervention system shall not be required to conduct an eligibility determination, assessment for service planning, or hold an initial IFSP meeting under these circumstances.
D. The service coordinator shall ensure exit ratings on the child outcome indicators required by the U.S. Department of Education, Office of Special Education Programs are completed prior to discharge from Virginia's early intervention system for all children who had an entry rating and who have been in the early intervention system for six months or longer since their initial IFSP.
1. The exit rating shall be done no more than six months prior to the child's exit from Virginia's early intervention system.
2. Any circumstances that prevent completion of exit ratings shall be documented in a contact note.
E. The service coordinator shall ensure that no early intervention services are provided on or after the child's third birthday.
Statutory Authority
§ 2.2-5304 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 32, Issue 10, eff. February 27, 2016.