LSC REFERENCE GUIDE: AREAS ASSESSED DURING COMPLIANCE REVIEWS

REFERENCE GUIDE

OVERVIEW OF AREASASSESSEDDURING COMPLIANCE REVIEWS

Major Objectives for Compliance Reviews

Assess the recipient’s compliance with the following:

  1. Case tracking system/case management system - CSR Handbook (2008 Ed., as amended 2011), Chapter III;
  2. Case management policy and Intake;
  3. 45 CFR Part 1611 (Financial Eligibility);
  4. 45 CFR Part 1626 (Restrictions on Legal Assistance to Aliens);
  5. 45 CFR § 1611.9 (Retainer Agreements);
  6. 45 CFR Part 1636 (Client Identity and Statement of Facts);
  7. 45 CFR § 1620.4 and § 1620.6(c) (Priorities in Use of Resources);
  8. CSR Handbook (2008 Ed., as amended 2011), § 5.6 (Legal Assistance Documentation Requirements);
  9. CSR Handbook (2008 Ed., as amended 2011), Chapters VIII and IX (Case Definition and Closure Categories and Legal Problem Categories and Codes);
  10. CSR Handbook (2008 Ed., as amended 2011), § 3.3 (Timely Closing of Cases);
  11. CSR Handbook (2008 Ed., as amended 2011), § 3.2 (Single Reporting of Cases);
  12. 45 CFR Part 1604 (Outside Practice of Law);
  13. 45 CFR Part 1608 (Prohibited Political Activities);
  14. 45 CFR Part 1609 (Fee-Generating Cases);
  15. 45 CFR Part 1610 (Use of non-LSC funds, transfer of LSC funds, program integrity);
  16. 45 CFR Part 1614 (Private Attorney Involvement);
  17. 45 CFR Part 1627 (Subgrants and Membership Fees or Dues);
  18. 45 CFR Part 1635 (Timekeeping Requirement);
  19. 45 CFR Part 1630 (Cost Standards and Procedures);
  20. 45 CFR Part 1612 (Restrictions on Lobbying and Certain Other Activities);
  21. 45 CFR Parts 1613 and 1615 (Restrictions on Legal Assistance with Respect to Criminal Proceedings and Restrictions on Actions Collaterally Attacking Criminal Convictions);
  22. 45 CFR Part 1617 (Class Actions);
  23. 45 CFR Part 1632 (Redistricting);
  24. 45 CFR Part 1633 (Restriction on Representation in Certain Eviction Proceedings);
  25. 45 CFR Part 1637 (Representation of Prisoners);
  26. 45 CFR Part 1638 (Restriction on Solicitation);
  27. 45 CFR Part 1643 (Restriction on Assisted Suicide, Euthanasia, and Mercy Killing);
  28. 42 USC 2996f § 1007 (b) (8) (Abortion);
  29. 42 USC 2996f § 1007 (b) (9) (School Desegregation Litigation);
  30. 42 USC 2996f § 1007 (b) (10) (Military Selective Service Act or of Desertion from the Armed Forces);
  31. LSC Accounting Guide for LSC Recipients; and
  32. Fiscal Internal Controls.

To assess the program’s compliance with LSC regulatory and statutory requirements, particularly basic client eligibility, intake and case management;

To ensure that the program has correctly implemented the CSR Handbook (2008 Ed., as amended 2011); and

To determine the cost of any significant non-compliance with any legal authorities.

Reporting Case Review Findings

See Reference Guide: Guidelines for Citing Cases for complete instructions on citing cases in both individual and team reports.

Scope of Review

The compliance review will focus on conducting interviews and a review of policies and procedures, and reviewinga sample of closed and opencases for a specified timeframe. In so doing, the team will assess the program’s case intake, case acceptance, case management and case closure practices and policies in all of its substantive units and offices, and conduct a review of case files and fiscal internal controls. The aim of the review is to both assess compliance with the applicable regulations and assess the accuracy of the CSR data to be provided by the program and its fiscal internal controls.

This will necessitate an on-site visitto the program’s main office, in addition to a majority of the program’s branch and satellite offices, if applicable. In so doing, the team will interview members of the program’s upper and middle management and staff and assess case intake, case acceptance, case management, and case closure practices and policies in all of its substantive units. Additionally, on-site visits will be conducted at the programs clinics and subgrantees.

As noted above, the team will review open and closed cases and interview representatives of upper management, middle management, fiscal and advocate staff, and support workers in an effort to assess compliance. Case file reviews will rely upon both randomly selected files as well as files identified for which specific questions may exist; the latter are referred to as “target” cases. Randomly selected cases will be chosen using a randomizing system. Target cases will be selected to test for, among other things, duplication, timely closing, and proper application of closing categories.[1]

Areas of Review[2]
  1. Case Tracking System/Case Management Systems

Review:CSR Handbook (2008 Ed., as amended 2011), Chapter III.

Conduct a test of the computer intake processes to determine the scope of information obtained and to ensure that such systems lead to compliance with all necessary basic requirements,i.e., that the program’s management has timely access to accurate information on cases and the capacity to meet funding sources’ reporting requirements, that cases involving the same and related legal problems are not reported to LSC more than once, that the timely closing of cases are tracked by the generatingcase management reports, and that its overall systems approach is sufficient to support compliance requirements.

Conduct a test of the program’s manual or paper processes to determine the scope of the information obtained and that such systems lead to compliance with all necessary basic requirements.

Assess the case tracking system utilized by the program. Assess its effectiveness for case tracking. Determine whether LSC can rely upon the computer case printouts (if provided by the program) and, if not, discuss any shortcomings. Obtain the program’s management input into any deficiencies noted.

  1. Case Management Policy and Intake

Assess all of the program’s policies which involve intake, case acceptance, and case management and determine whether such policies comply with the LSC Act, regulations, and other appropriate guidelines.

Assess the computerized intake system.

Determine whether the program’spractices regarding the above policies are consistent with the policy.

Assess all of the program’s policies that involve CSRs and determine whether such policies comply with the appropriate guidelines.

Assess the program’s policy changes that were effected as a result of the issuance of the 2008 CSR Handbook (as amended 2011) and Program Letter 99-3 (July 14, 1999).

Determine whether the program’spractices regarding CSR policies are consistent with the policy.

Assess what policies have been developed in response to LSC Program Letter 01-5 (July 25, 2001).

Assess what program policies were developed in response to the self-inspections of the prior three years CSR data and their effectiveness.Assess what program policies have been developed in response to therespective LSC Program Letters.

Assess what program policies have been developed in response to LSC Program Letter 02-6 (June 6, 2002).

Bring significant variations to the attention of the team leader. Discuss all variations in your report.

Determine how intake is organized; i.e., by unit, by office, centralized hotline, or a combined method.

Determine who is responsible for case acceptance.

Interview intake/case acceptance personnel and complete the intake form.

NOTE: A designated team member will be assigned the responsibility of conducting intake analysis. This team member must complete an intake form for each officevisited and collect any intake forms, or other forms, in use for comparison and analysis. A brief narrative of the interviews and the findings reachedwill be included in the team members’ individual report.

NOTE:A designated team member will be assigned the responsibility for checking the program’s use of its computerized case management system (if applicable). This analysis will be more focused on the end of the data collection process;i.e., how the data is used once in the system. Part of this will be to assess whether LSC can rely on the CSR data produced through the program’s system.

  1. Compliance under 45 CFR Part 1611 - Financial Eligibility

Review: CSR Handbook (2008 Ed., as amended 2011), §§ 2.1, 2.4, and 5.2; 45 CFR Part 1611; LSC Program Letters 99-3 (July 14, 1999) and 01-5 (July 25, 2001).

Review the sample of cases to determine whether all clients in the review sample are eligible under 45 CFR Part 1611. Determine whether the program is appropriately screening for financial eligibility (income and assets) and contemporaneously recording the data.

Interview program staff to determine whether they are familiar with the applicable regulations, policies, and procedures and to ensure that they are appropriately applying them. In addition, review any anomalies discovered during the random review of cases.

Reportswill identify cases reviewed that do not comply with 45 CFR § 1611.4, Program Letters 99-3 or Program Letter 01-5, or that lack income/asset information or are otherwise at variance with 45 CFR Part 1611 and/or the CSR Handbook (2008 Ed., as amended 2011) in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, a strong representative sampling will be selected and the report will discuss the variances in detail. Significant violations of 45 CFR Part 1611 will be brought to the attention of the team leader on-site.

The team leader will select one (1) group case and ascertain the type of proof offered to determine the group’sPart 1611 eligibility, if appropriate.

  1. Compliance under 45 CFR Part 1626 – Restrictions on Legal Assistance to Aliens

Review: CSR Handbook (2008 Ed., as amended 2011), §§ 2.4, 5.1, and 5.2; 45 CFR Part 1626; LSC Program Letters 99-3 (July 14, 1999), 14-2 (May 19, 2014), 14-3 (October 29, 2014), and 16-2 (May 19, 2016), and Office of Legal Affairs Advisory Opinion 2016-03.

Review the sample of cases to determine whether the program is screening for citizenship or eligible alien status (if any non-compliance is noted, such as acceptance of an ineligible client, it will be discussed withthe team leader and an explanation from the program will be obtained regarding the non-compliance).

Interview program staff to determine whether they are familiar with applicable regulations, policies, and procedures and to ensure that they are appropriately applying them.[3] In addition, review any anomalies discovered during the random review of cases.

Reportswill identifyall cases reviewed in which the documentation required by Part 1626 and/or Program Letter 99-3 is either lacking or deficient, in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail. Counsel and advice and brief service telephone cases will be excluded from discussions. Significant violations mustbe brought to the attention of the team leader on-site.

The team leader will select one (1) group case and ascertain the type of proof offered to determine the group’s Part 1626 eligibility, if appropriate.

  1. Compliance under 45 CFR § 1611.9 - Retainer Agreements[4]

Review: 45 CFR § 1611.9.

Review the sample of cases to determine whether the program is executing retainer agreements when necessary.[5] Ensure that retainers are being signed before the commencement of work on the case or as soon thereafter as is practicable. If any significant non-compliance is noted, such as an absence of information, the untimely execution of the retainer, or a retainer where the services provided do not match the services requested, it will be discussed with the team leader and then an explanation obtained from the program regarding the issues.

Interview program staff to determine whether they are familiar with the applicable regulations, policies, and procedures and to ensure that they are appropriately applying them. In addition, review any anomalies discovered during the random review of cases.

Reportswill identify files required retainers but were lacking them and/or files that contained a deficient retainer agreement, in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail. Counsel and advice, limited service, and PAI cases will be excluded from discussion.

  1. Compliance under 45 CFR Part 1636 – Client Identity and Statement of Facts

Review:45 CFR Part 1636 and OPO’S Memo to All LSC Program Directors (December 8, 1997).

Review the sample of cases to determine compliance with 45 CFR § 1636.2.

Reports will contain a detailed discussion of any and all anomalies.

  1. Compliance under 45 CFR § 1620.4 and § 1620.6(c) – Priorities in Use of Resources

Review:CSR Handbook (2008 Ed., as amended 2011), § 2.1; 45 CFR §§1620.4 and 1620.6(c); the program’s priorities; and the program’s emergency case acceptance procedures.

Review the sample of cases to determine whether each case is within the program’s priorities or is an emergency case accepted under the program’s emergency case acceptance procedures. If any significant non-compliance is noted, it will be discussedwith the team leader and then an explanation obtained from the program regarding the issues.

Interview program staff to determine whether they are familiar with the applicable regulations, policies, and procedures and to ensure that they are appropriately applying them. In addition, review any anomalies discovered during the random review of cases.

Reportswill identify cases reviewed in which legal assistance was provided in a non-emergency case, involving an issue outside the program’spriorities, in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail. Significant violations will be brought to the attention of the team leader on-site.

  1. CSR Handbook (2008 Ed., as amended 2011), § 5.6 - Description of Legal Assistance Provided

Review:CSR Handbook (2008 Ed., as amended 2011), §§ 2.3, 2.4, 2.5, 4.1 - 4.5, 5.6, and Chapter VIII and 45 CFR §§ 1620.2(a) and 1635.2(a).

Review the sample of cases to determine whether legal advice or assistance has been provided by an attorney or paralegal.

Interview program staff to determine whether they are familiar with the applicable regulations, policies, and procedure and to ensure that they are appropriately applying them. In addition, review any anomalies discovered during the random review of cases.

Reportswill identify cases reviewed in which legal assistance was not provided, where legal assistance was not provided at the level reported by the program, or that lacks support for the level of assistance reported to LSC by the program in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail.

  1. Case Service Reports “CSR” Closing Codes

Review:CSR Handbook (2008 Ed., as amended 2011), Chapters VIII and IX.

Review the sample of closed cases to determine whether the program properly coded the cases consistent with CSR Handbook instructions.

As necessary, interview staff to determine whether they are familiar with the applicable policies and procedures and to ensure that they are appropriately applying them. In addition, review any anomalies discovered during the random review of cases.

Interview program staff in each office/unit to determine how LSC CSR case closure categories are utilized. Obtain copies of any written intake and case handling policies that are unique to each office.

Reportswill identifycases reviewed in which the CSR case closure category is inconsistent with Chapters VIII and IX of the CSR Handbook (2008 Ed., as amended 2011), in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail.

  1. Timely Closing

Review: CSR Handbook (2008 Ed., as amended 2011), § 3.3.

Review the sample of closed cases to ensure that the program is timely closing cases so that case service reports submitted to LSC contain current and accurate information about both open and closed cases for the grant year.

Reportswill identify untimely closed cases reviewed, in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will a strong representative sampling and discuss in detail. Reportswill also contain a supporting explanation demonstrating why the case should have been closed sooner.

  1. Duplicate Reporting

Review: CSR Handbook (2008 Ed., as amended 2011), Chapter VI.

Review sample of cases to determine whether the program has reported more than one (1) type of assistance to an eligible client during the reporting period in an attempt to resolve essentially the same legal problem, as demonstrated by the factual circumstances giving rise to the problem.

Review the sample of closed cases to determine whether the program has reported assistance provided more than once within the same reporting period to an eligible client who has returned to the program with essentially the same legal problem, as demonstrated by the factual circumstances giving rise to the problem.

Review the sample of closed cases to determine whether the program has reported as a single case effort to resolve related legal problems handled simultaneously through a single legal process.

Interview program staff in each office/unit to determine familiarity with CSR Handbook (2008 Ed., as amended 2011), Chapter VI, and methods used by the program to identify duplicates.

Reportswill identify duplicate cases, in accordance with the Reference Guide: Guidelines for Citing Cases. If there are a significant number of such cases, team members will select a strong representative sampling and discuss in detail. Reportswill also contain a brief, supporting explanation demonstrating at least three (3) duplicate sets, if the total number of duplicates is greater.

  1. Compliance under 45 CFR Part 1604 – Outside Practice of Law

Review:45 CFR Part 1604.

Review the program’s policies to determine whether they are consistent with the LSC Act, regulations, and other applicable authorities.

Review the list of attorneys, if existing and applicable, who have engaged in the outside practice of law and assess and, through discussions with attorney(s) in question and their supervisor(s), determine whether their outside practice was/is consistent with Part 1604.

Bring significant variations to the attention of the team leader on-site. All variations will be discussed in the report.

  1. Compliance under45 CFR Part 1608 – Prohibited Political Activities

Review:45 CFR Part 1608.

Review the program’s policies, if any, to determine whether they are consistent with the LSC Act, regulations, and other applicable authorities. Bring significant variations to the attention of the team leader on-site. All variations will be discussed in the report.