1.6 Administrative and Clinical Performance Reviews

Revised October 2019


All DHS MCH grants will be evaluated at least annually by the state Maternal and Child Health staff and their designees to review the program's progress according to stated goals, measurable objectives, and administrative operations.


The Department or it's designee will monitor the delivery of DHS MCH Program activities through:

  1. Quarterly communication in which quarterly performance data and trends will be highlighted and technical assistance will be provided to recommend areas of improvement and discuss barriers to program service delivery as needed.
  2. Annual programmatic clinical reviews shall address the following points:
    1. Comparison of the objectives enunciated in the project plan with the actual achievements of the project.
    2. Indicators of project productivity; e.g., clients served, encounters, referrals, tests performed, personnel trained, etc.
    3. Scope and success of program outreach efforts
    4. Unresolved problems; e.g., with fiscal resources, external relationships, etc. and issues which need to be addressed in the future.
    5. Annual on-site reviews which will include:
      1. Technical Assistance based on chart reviews performed by the MCH Nurse Consultant prior to the visit.
      2. Clinical Review based on the Review Tool that applies to the quarterly performance reviewed.
      3. An observation of service delivery when appropriate.
      4. A review of data reports from the Departments Cornerstone system.
      5. Verification of documentation necessary per the Clinical Review Tool.


The Department will review the performance criteria of each program at least once annually following the steps outlined below.

  1. The department will send a formal Annual review Introduction Letter to schedule the site visit to Agency Administrator and Program Coordinators at least 15 business days prior to the review date.
  2. The MCH Nurse consultant will complete Chart Reviews for each program being reviewed from Cornerstone and evaluate the most recent quarterly performance report available for the agency using the Chart Review Tool for the corresponding quarter that is being reviewed (i.e. if FY19 Q4 data is being reviewed, the review tool used will be the FY19 review tool even if the date of the on-site review is scheduled after July 1, 2019).
    1. Chart Review Tools
  3. The MCH Nurse Consultant will review randomly selected charts for each program using Department's current chart sample selection criteria for Case Management programs.
  4. On the date(s) of the review, the MCH Nurse Consultant will complete the review and conduct any Technical Assistance (TA) that came up as being needed during the performance reviews.
  5. The MCH Nurse Consultant will then complete the Clinical Review Tool and Review Findings (if any are found) and will return the outcomes of the review within 15 business days of completing the on-site review to the Agency Administrator and Program Coordinators.
    1. Clinical Review Tools
  6. The Agency will receive a summary letter from the Department which will include the Clinical Review Tools for the programs reviewed and the Review Findings within 15 business days of receipt of the completed clinical review.
  7. The Agency will respond to the MCH Nurse Consultant completing the review within 15 business days of the receipt of the summary letter with a Corrective Action Plan (CAP) for any of the findings revealed in the review.
  8. The MCH Nurse Consultant will review and accept the CAP within 15 business days of receipt.
  9. Follow-up will be provided by the MCH Nurse Consultant by phone or email to determine that the CAP has been completed in the timeframe outlined within three months of the CAP approval.


  1. If during an annual review, the MCH Nurse Consultant determines that the agency has substantially failed to comply with the terms of the grant agreement and program standards, they may recommend that an agency program be placed on provisional status.
  2. Each MCH program that the agency offers is reviewed annually. Each Performance Review Tool will identify the total Review Findings for the program in question.
  3. Any MCH program with five (5) or more Corrective Actions in a program reviewed may be recommended for provisional status for that program and the following actions will be taken.
    1. The Bureau Chief will meet with the MCH Nurse Consultant and any Department personnel deemed necessary to review Provisional Determination to discuss the recommendation and what steps the Department will require the Agency to take to remove the provisional status from their record.
    2. Once a final decision has been determined, the Agency will receive a letter of Provisional Status within 25 business days of the completion of the annual review which will outline why the Provisional Status was determined and what actions will need to be taken to remove the Provisional Status from the agency.
    3. The Agency will be asked to return a Corrective Action Plan (CAP) to the MCH Nurse Consultant within 15 business days of receipt of the Provisional Letter.
    4. Once the CAP is approved, the MCH Nurse Consultant will notify the agency in writing within 15 business days of receipt of the CAP from the Agency.
    5. The MCH Nurse Consultant will be available in subsequent months primarily by phone / email to provide ongoing Technical Assistance (TA) and assistance to try to meet the CAPs required in the program.
    6. A subsequent review of the program(s) put on provisional status will then be completed within 6 months of the formal notification of the program's provisional status and the Provision Letter being sent to the agency. If a satisfactory review is completed, then the agency will again be certified.
  4. If an agency has substantially failed to comply with the grant award as documented at site reviews for two consecutive years and is placed on provisional status in 2 consecutive reviews, funding may be reduced or terminated. Substantial failure means failure to meet requirements other than a variance from the strict and literal performance which result in unimportant omissions or defects given the particular circumstances involved.