DOS-Adoption Notice: Updated Substantial Compliance System
From here:
“The Department has approved an update to the Substantial Compliance System which includes revised weightings for a number of standards as well as simplified and clarified rating indicators. The updated SCS will take full effect on June 1, 2020, as described below, allowing accredited agencies and approved persons (ASPs) ample time to demonstrate compliance with the revised weightings.
The accreditation and approval of ASPs is carried out by a Department-designated accrediting entity (AE). Pursuant to regulations, the AE must use an approved method for determining whether an ASP has achieved and maintains substantial compliance with the regulations at 22 CFR Part 96, Subpart F. The method, known as the Substantial Compliance System (SCS), must include an assigned value (weighting) for each standard, a manner of rating ASP compliance with each standard (rating indicator), and a method of evaluating each ASP’s overall compliance with all applicable standards. The SCS includes three weightings: foundational (lowest weight), critical, and mandatory (highest weight) and assigns a weighting to each accreditation standard. The current SCS has been in place without updates since the accreditation regulations were published in 2006.
The Department had previously received recommendations from Council on Accreditation (COA), then an AE, on modifications to the SCS. In particular, COA recommended modifying the weightings of thirty-nine standards. As part of the intended alignment of COA’s procedures with those of newly-designated AE, Intercountry Adoption Accreditation and Maintenance Entity, Inc. (IAAME), the Department discussed COA’s proposal with both AEs in the fall of 2017.
The Department has now approved SCS updates which include revised weightings for a number of standards as well as simplified and clarified rating indicators (see below with changed weightings in bold). The revised weightings involve 46 changes, including 38 changes recommended by COA. As before, the weighting system assigns three categories of weight: foundational, critical, and mandatory.
The updated SCS weightings and rating indicators will apply as follows:
- To all initial accreditation and approval applications filed after the date of this notice;
- To all renewal accreditation and approval applications filed for agencies and persons whose accreditation or approval expires on or after June 1, 2020;
- On June 1, 2020 for all accredited or approved ASPs for the purposes of the AE’s monitoring and oversight responsibilities in accordance with 22 CFR Part 96, Subpart F.
IAAME will shortly publish a version of their Policy and Procedure Manual containing the updated SCS.
Frequently Asked Questions
Q1: When did the current Substantial Compliance System come into effect?
The current SCS weightings and rating indicators have been in place since the accreditation regulations were published in 2006.
Q2: Why is the Substantial Compliance System being changed?
22 CFR 96.27(d) establishes the requirement for a method to determine compliance with the accreditation standards. In addition to defining the parameters of this method, the regulation requires the Secretary of State to “ensure that the value assigned to each standard reflects the relative important of that standard to compliance with the Convention, the IAA [Intercountry Adoption Act of 2000], and the UAA [Intercountry Adoption Universal Accreditation Act of 2012].”
More than ten years after the Hague Adoption Convention entered into force for the United States, and almost five years since the effective date of the UAA, ASPs’ understanding of the accreditation standards is more robust and well documented than it was when the current SCS was published. It is also evident that many years after the United States began accreditation, the current “foundational” weighting of some standards do not adequately reflect “the relative importance of that standard to compliance with the Convention, the IAA, and the UAA.”
Q3: How many weightings of standards are changing?
The SCS identifies 144 separate accreditation standards. The updated SCS will change the weighting of 46 of those standards as shown.
| CURRENT WEIGHTING | REVISED WEIGHTING | # OF STANDARDS IMPACTED |
| Foundational | Mandatory | 1 |
| Foundational | Critical | 37 |
| Critical | Mandatory | 8 |
Ten foundational, 76 critical, and 12 mandatory standards remain unchanged.
Q4: How do the changes compare with what COA recommended?
For all but nine standards, the new weightings are identical to those proposed by COA in 2016. COA proposed lowering the weighting of one standard from mandatory to critical, but the standard remains unchanged. There are eight foundational standards to which COA did not recommend changes that are being changed to a weighting of critical. These eight standards generally require provision of information to and protections for adoptive parents.
Q5: Is anything else changing in the SCS?
Yes. The definitions for the rating indicators of “full compliance,” “substantial compliance,” “partial compliance,” and “non-compliance” have been simplified to assist the AE in applying the indicators. The most significant change removes the lengthy definition of “non-compliance” to state simply that failure to achieve the required rating for any particular standard will result in a finding of non-compliance. See below regarding changes to determining substantial compliance with all standards.
Q6: The current SCS has a “formula” for determining substantial compliance overall (with all applicable standards). Is the formula changing?
Yes. The method for evaluating substantial compliance with the accreditation regulations overall has been changed in light of the reduction in the number of foundational standards. Substantial compliance with the accreditation regulations overall will result when compliance with each standard’s applicable weighting is achieved.
Q7: How will accredited agencies and approved persons demonstrate compliance with the new SCS weightings?
The rating indicators and weightings, read together, describe the level of compliance and the method of review the AE will use to determine compliance with each standard. As required by the regulations, the AE will generally review actual performance in considering compliance with applicable standards. The process for review of compliance will remain the same as that conducted under the current SCS and include review of initial and renewal applications for accreditation and approval, as well as routine monitoring and oversight and investigation of complaints.
Q8: When will the updates to the SCS take effect?
In order to allow ample time for ASPs to achieve and document compliance in accordance with the revised weightings and rating indicators, the updated SCS will become fully effective no later than June 1, 2020 as follows:
- For all initial accreditation and approval applications filed after the date of this notice;
- For all renewal accreditation and approval applications filed for agencies and persons whose accreditation or approval expires on or after June 1, 2020;
- On June 1, 2020 for all accredited or approved ASPs for the purposes of the AE’s monitoring and oversight responsibilities in accordance with 22 CFR Part 96, Subpart F.
IAAME will shortly publish a version of their Policy and Procedure Manual containing the updated SCS.
Substantial Compliance System
- What are the Rating Indicators and how do the evaluators assign ratings?
The Substantial Compliance System (SCS) uses a four point rating system to guide the evaluators in determining the adoption service provider’s degree of compliance with each standard. With prior approval from an accrediting entity (AE) or as indicated by a particular standard, an adoption service provider can be assigned a rating of “not applicable” for some standards.
Hague Accreditation/Approval Rating Indicators
Ratings
1 Full Compliance
2 Substantial Compliance
3 Partial Compliance
4 Non-Compliance
NA Not Applicable
Rating Indicators (Rating Guidance)
1 Full Compliance
Description: The relevant policies, procedures, and performance fully meet the standard as written and conform to the principles of the Hague Adoption Convention (the Convention). All elements or requirements are evident in performance with extremely rare or no exceptions. Exceptions in compliance do not affect, in any way, consistency with the aims of the Convention, the IAA, the UAA, the regulations, organizational performance, or quality of service.
2 Substantial Compliance
Description: Performance exhibits a high level of compliance with accreditation standards. The majority of the standard’s requirements are met, but one or more factors need clarification or augmentation. Policies and procedures have sufficient detail, are consistently applied, and personnel are adequately informed of policies and procedures. Evaluators are able to verify performance is in compliance with the standard and/or the organization can describe how it meets the standard. Any minor inconsistencies and underdeveloped policies or performance noted do not jeopardize persons served, overall performance, or consistency with the aims of the Convention, the IAA, the UAA, or the regulations in any way.
3 Partial Compliance
Description: A significant aspect of the organization’s operations or service delivery deviates from the standard’s requirements or from written material, or capacity is at a basic level. Policies or procedures lack sufficient detail and/or are not consistently applied; personnel are inadequately informed of policies and procedures. Evaluators are unable to verify consistent performance in compliance with the standard and/or the organization can only anecdotally describe how it meets the standard. Performance, as is, may compromise care of persons served, imperil organizational functioning, or be inconsistent with the aims of the Convention, the IAA, the UAA, or the regulations.
4 Non-compliance
Description: Any standard for which an ASP does not receive the required rating described above (1, 2 or 3) will be rated as non-compliant.
2. Which value (weight) is assigned to each standard?
All of the intercountry adoption standards are important to the operation of a well-functioning adoption program and adoption service providers must strive to comply with them. However, some standards have a higher weight assigned to them, than others, and failure to comply with certain standards reflects a fundamental weakness in operations or inconsistency with the principles of the Convention. All sub-sections have been designated as Mandatory, Critical, or Foundational Standards.
Mandatory Standards:
Mandatory standards represent practices that are essential to fulfillment of the aims of the Convention, the IAA, the UAA, and the regulations, and have the greatest impact in preventing risks to children and families. ‘Mandatory’ is the highest weight assigned to regulation standards. An ASP must have a performance rating of full compliance on all Mandatory standards to receive accreditation/approval or renewal of accreditation/ approval.
Critical Standards:
Critical Standards represent practices that have a significant impact on fulfillment of the aims of the Convention, the IAA, the UAA, and the regulations. ‘Critical” is a high weight assigned to regulation standards. A majority of the accreditation standards have a weight of Critical. An ASP must have a performance rating of Full or Substantial Compliance on all Critical Standards to receive accreditation/approval or renewal of accreditation/ approval.
Foundational Standards:
Foundational Standards are important to the operation of a well-functioning adoption program. They derive from and support compliance with the Convention, the IAA, the UAA, and the regulations. ‘Foundational’ is a weight below that of Mandatory and Critical. An ASP must have a performance rating of partial compliance or higher on all Foundational Standards to receive accreditation/approval or renewal of accreditation/approval
Each of the standards has been assigned a weighting which has been approved by the Department of State as follows:
Mandatory Standards: Standards that are in the mandatory category are: 96.30 (a), 96.30 (b), 96.30 (c), 96.30 (d), 96.31 (a), 96.31 (b), 96.33 (b), 96.33 (c), 96.34 (a), 96.34 (b), 96.34 (c), 96.35 (a), 96.35 (b), 96.35 (c), 96.35 (d), 96.36 (a), 96.36 (b), 96.39 (e), 96.42 (e), 96.49 (j) and 96.53 (c)
Critical Standards: Standards that are in the critical category are: 96.32 (a), 96.32 (b), 96.32 (c), 96.32 (d), 96.32 (e), 96.33 (a), 96.33 (d), 96.33 (e), 96.33 (f), 96.33 (g), 96.33 (h), 96.33 (i), 96.34 (d), 96.34 (e), 96.34 (f), 96.35 (e), 96.37 (a), 96.37 (b), 96.37 (c), 96.37 (d), 96.37 (e), 96.37 (f), 96.37 (g), 96.38 (a), 96.38 (b), 96.38 (c), 96.39 (a), 96.39 (c), 96.39 (d), 96.39 (f), 96.40 (a), 96.40 (b), 96.40 (c), 96.40 (d), 96.40 (e), 96.40 (f), 96.40 (g), 96.40 (h), 96.41 (a), 96.41 (b), 96.41 (c), 96.41 (d), 96.41 (e), 96.41 (f), 96.41 (g), 96.41 (h), 96.42 (a), 96.42 (b), 96.42 (c), 96.42 (d), 96.43 (a), 96.44 (a), 96.44 (b), 96.45 (a), 96.45 (b), 96.46 (a), 96.46 (b), 96.46 (c), 96.47 (a), 96.47 (b), 96.47 (c), 96.47 (d), 96.48(a), 96.48 (b), 96.48 (c), 96.48 (e), 96.48 (f), 96.48 (g), 96.48 (h), 96.49 (a), 96.49 (b), 96.49 (c), 96.49 (d), 96.49 (e), 96.49 (f), 96.49 (g), 96.49 (h), 96.49 (i), 96.49 (k), 96.50 (a), 96.50 (b), 96.50 (c), 96.50 (d), 96.50 (e), 96.50 (f), 96.50 (g), 96.50 (h), 96.51 (a), 96.51 (b), 96.51 (c), 96.51 (d), 96.52 (a), 96.52 (b), 96.52 (c), 96.52 (e), 96.53 (a), 96.53 (b), 96.53 (d), 96.53 (e), 96.54 (a), 96.54 (b), 96.54 (c), 96.54 (d), 96.54 (f), 96.54 (g), 96.54 (h), 96.54 (j), 96.54 (k), 96.55 (a), 96.55 (b), 96.55 (d), 96.55 (e) and 96.55 (f)
Foundational Standards: Standards that are in the foundational category are: 96.38 (d), 96.39 (b), 96.43 (b), 96.43 (c), 96.43 (d), 96.48 (d), 96.52 (d), 96.54 (e), 96.54 (i), and 96.55 (c)
3. What ratings do we need to be accredited or approved? What does Substantial Compliance mean?
Substantial Compliance with the Accreditation Standards as a Whole: The accreditation regulations require agencies and persons to demonstrate they are in substantial compliance with the standards in 22 CFR Part 96, subpart F. In the accreditation and renewal processes, substantial compliance is the term we apply when an ASP achieves at least the minimum rating assigned to each regulation standard. It represents the level of compliance with regulation standards as a whole needed to satisfy the requirements for accreditation/approval or renewal of accreditation/approval.
In order to be accredited or approved, or to have accreditation or approval renewed, the adoption service provider must:
- receive ratings of Full Compliance on 100 percent of all applicable Mandatory Standards;
- receive ratings of Full or Substantial Compliance on 100 percent of all applicable Critical Standards; and
- receive ratings of Partial Compliance or higher on 100 percent of all applicable Foundational Standards.”
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