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Chapter 5
Determination of Substantial Conformity

After the completion of the onsite review phase of the Child and Family Services Reviews (CFSRs), the Children's Bureau Regional Office, in conjunction with the National Review Team (NRT) Team Leader makes a determination regarding substantial conformity for each of the seven outcomes and seven systemic factors under review. The requirements for determining substantial conformity are set forth at 45 Code of Federal Regulations (CFR) §1355.34. States may be determined to be in substantial conformity with one or more outcomes and systemic factors and not in substantial conformity with the others. These findings, along with information on the State child welfare agency's strengths and areas needing improvement in serving children and families, are submitted to the State in a Final Report prepared by the Children's Bureau Regional Office after the onsite review. (See chapter 6 for information on the Final Report.)

Program Improvement Plans (PIPs) are prepared, and financial penalties are assessed, if necessary, only for outcomes or systemic factors determined not to be in substantial conformity. (See chapter 7 for information on the preparation of the PIP.) Different methods are used to determine substantial conformity with the outcomes and the systemic factors. Appendix H, Pathway to Substantial Conformity, displays the data indicators and criteria for determining substantial conformity with the outcomes and the systemic factors.

This chapter describes the process for determining substantial conformity with the outcomes and systemic factors, including rating items and comparing data indicators with the national standards. It also provides information on resolving discrepancies between the findings of the Statewide Assessment and the onsite review, either through the provision of additional information or the review of additional cases.

A. Determination of Substantial Conformity With the Outcomes

During the Statewide Assessment and onsite review, the review team assesses seven outcomes in three domains (safety, permanency, and child and family well-being) by examining 23 items. (See Appendix B, Index of Outcomes and Systemic Factors, and Associated Items and Data Indicators.)

For two of the seven outcomes, Safety Outcome 1 and Permanency Outcome 1, decisions about substantial conformity are based on both the data indicators and the onsite case review findings. For these outcomes, the following performance indicators are used to determine substantial conformity:

• The State's performance on the related data indicators (national standards have been established for four data indicators for Permanency Outcome 1, and two data indicators for Safety Outcome 1)
  
  
• The percentage of cases reviewed on site in which the outcome was determined to be substantially achieved (95 percent)

For the remaining five outcomes, Safety Outcome 2, Permanency Outcome 2, and the three Child and Family Well-Being Outcomes, the percentage of cases reviewed on site in which the outcome was determined to be substantially achieved is used to determine substantial conformity (95 percent).

Following the onsite review, the Children's Bureau Regional Office, in collaboration with the NRT Team Leader for the review, uses the data gathered through the Statewide Assessment and onsite review to make determinations regarding substantial conformity with the outcomes for the State as a whole. The diagram below illustrates the process of determining substantial conformity with the outcomes.

Below is an overview of how case records and statewide data are examined to determine conformity.

A.1. Determination of Conformity With the Outcomes: Case Record Reviews

Pairs of reviewers, comprising one Federal Review Team member and one State Review Team member, conduct case record reviews. (See chapter 2, section C, for more information on the Onsite Review Team, and chapter 4 for more information on the onsite review.) Each pair of reviewers gathers information on a case by reviewing the case record and conducting case-related interviews. Reviewers use the automated Child and Family Services Reviews Onsite Review Instrument in conducting the case record reviews. The Instrument lists the items that reviewers examine in assessing achievement of each outcome. For each case, once the reviewers have examined the items and entered the relevant information, the automated Instrument provides a rating for each item of strength, area needing improvement, or not applicable. The system then records whether, for each case, each of the seven outcomes was substantially achieved, partially achieved, not achieved, or not applicable.

The outcomes are rated using the following guidelines (see the Onsite Review Instrument and Instructions, which is available on the Children's Bureau Web site at www.acf.hhs.gov/programs/cb):

• Substantially achieved: The required number of applicable items are rated as strengths.
  
  
• Partially achieved: Some applicable items are rated as strengths, but the number does not meet the level required for the outcome to be rated as substantially achieved.
  
  
• Not achieved: None of the applicable items is rated as a strength.
  
  
• Not applicable: None of the items is applicable.

To rate an outcome as substantially achieved, the following criteria must be met:

• Safety Outcome 1, "Children are, first and foremost, protected from abuse and neglect": All applicable items are rated as strengths (disregard items rated as not applicable).
  
  
• Safety Outcome 2, "Children are safely maintained in their homes whenever possible and appropriate": All applicable items are rated as strengths (disregard items rated as not applicable).
  
  
• Permanency Outcome 1, "Children have permanency and stability in their living situations": Item 7 and the relevant item (8, 9, or 10) rated for this case must be rated as strengths, and no more than one of either items 5 and 6 (if applicable) may be rated as an area needing improvement (disregard items rated as not applicable). If the State is using concurrent planning for the case being reviewed and, therefore, the reviewer rated two of the relevant items (8 and 9, 8 and 10, or 9 and 10), then both must be rated as strengths.
  
  
• Permanency Outcome 2, "The continuity of family relationships and connections is preserved for children": No more than one of the applicable items for this outcome is rated as an area needing improvement (disregard items rated as not applicable).
  
  
• Child and Family Well-Being Outcome 1, "Families have enhanced capacity to provide for their children's needs": Item 17 must be rated as a strength, plus no more than one of the remaining applicable items may be rated as an area needing improvement (disregard items rated as not applicable).
  
  
• Child and Family Well-Being Outcome 2, "Children receive appropriate services to meet their educational needs": Item 21 is rated as a strength.
  
  
• Child and Family Well-Being Outcome 3, "Children receive adequate services to meet their physical and mental health needs": All applicable items are rated as strengths (disregard items rated as not applicable).

A.2. Determination of Substantial Conformity With the Outcomes: Data Indicators

The regulation at 45 CFR §1355.34, which sets forth the requirements for determining substantial conformity through the CFSRs, includes the establishment of national standards for certain data indicators. These standards are used in conjunction with case record reviews to determine substantial conformity under titles IV-B and IV-E of the Social Security Act. The national standards are based on information that States report to the Adoption and Foster Care Analysis and Reporting System (AFCARS) and the National Child Abuse and Neglect Data System (NCANDS).

A.2.1. National Standards Used During the Second Round of Reviews

For the second round of reviews, the Children's Bureau will use six data indicators to determine substantial conformity with two outcomes. The data indicators include two individual data indicators for Safety Outcome 1 and four data indicators in the form of composites for Permanency Outcome 1. Each of the four composites incorporates one or more components. Components are the general factors that contribute to the composite score. Each component comprises two or more measures.

Two individual data indicators rather than composites are used as part of the assessment of substantial conformity with Safety Outcome 1. These data indicators are:

• Absence of maltreatment recurrence. Of all children who were victims of substantiated or indicated abuse or neglect during the first 6 months of the reporting year, what percent did not experience another incident of substantiated or indicated abuse or neglect within a 6-month period?
  
  
• Absence of child abuse and/or neglect in foster care. Of all children in foster care during the reporting period, what percent were not victims of a substantiated or indicated maltreatment by foster parents or facility staff members?

For each composite related to Permanency Outcome 1, the Children's Bureau used the distribution of county scores across States to establish six separate national standards, one for each composite. Because the primary purpose of a data composite is to capture overall performance in a particular domain, the Children's Bureau did not establish national standards for the individual measures incorporated in the permanency composites. Therefore, States are not expected to meet a standard for any individual permanency measures, but to achieve an overall performance level in the composites related to Permanency Outcome 1. However, the Children's Bureau will provide States with information regarding each individual measure within the composites, including the mean, median, and range of scores across States, to enable States to identify the individual measures within a composite where improvements are needed.

The four data indicators that will be used as part of the assessment of substantial conformity with Permanency Outcome 1 are:

• Permanency Composite 1: Timeliness and Permanency of Reunifications. The following components and measures are included in this composite:
  • Component 1: Timeliness of reunification. The following measures are included in this component:
    • Of all children discharged from foster care to reunification in FY 2004 who had been in foster care for 8 days or longer, what percent were reunified in less than 12 months from the date of the latest removal from home?
      
      
    • Of all children exiting foster care to reunification in 2004 who had been in foster care for 8 days or longer, what was the median length of stay in months from the date of the most recent entry into foster care until the date of reunification?
      
      
    • Of all children entering foster care for the first time in the second 6 months of FY 2003 who remained in foster care for 8 days or longer, what percent were reunified in less than 12 months of the date of entry into foster care?
  • Component 2: Permanency of reunification
    • Of all children exiting foster care to reunification in FY 2003, what percent re-entered foster care in less than 12 months?
• Permanency Composite 2: Timeliness of Adoptions. The following components are included in this composite:
  • Component 1: Timeliness of adoptions of children exiting foster care.
    • Of all children who were discharged from foster care to a finalized adoption in FY 2004, what percent was discharged in less than 24 months from the date of the latest removal from the home?
      
      
    • Of all children who were discharged from foster care to a finalized adoption in FY 2004, what was the median length of stay in foster care (in months) from the date of removal from the home to the date of discharge?
  • Component 2: Progress toward adoption of children who have been in foster care for 17 months or longer.
    • Of all children in foster care on the first day of FY 2004 who were in foster care for 17 continuous months or longer, what percent was discharged from foster care to a finalized adoption before the end of the fiscal year?
      
      
    • Of all children in foster care on the first day of FY 2004 who were in foster care for 17 continuous months or longer, what percent became legally free for adoption in less than 6 months from the beginning of the fiscal year?
  • Component 3: Timeliness of adoptions of children who are legally free for adoption.
    • Of all children who became legally free for adoption during FY 2003, what percent were discharged from foster care to a finalized adoption in less than 12 months of becoming legally free?
• Permanency Composite 3: Achieving permanency for children in foster care. The following components are included in the composite:
  • Component 1: Achieving permanency for children in foster care for long periods of time.
    • Of all children who were discharged from foster care in FY 2004 who were legally free for adoption (i.e., there was a termination of parental rights (TPR) for each living parent), what percent were discharged to a permanent home prior to their 18th birthday, with a permanent home defined as having a discharge reason of adoption, reunification (including living with relative), or guardianship?
      
      
    • Of all children who were in foster care for 24 months or longer on the first day of FY 2004, what percent were discharged from foster care to a permanent home prior to their 18th birthday and by the end of the fiscal year?
  • Component 2: Children growing up in foster care.
    • Of all children who were emancipated from foster care or reached their 18th birthday while in foster care, what percent had been in foster care for 3 years or longer?
• Permanency Composite 4: Placement stability. The following components are included in this composite:
  • Component 1: The principal components analysis for this composite yielded one component that incorporates the following three measures:
    • Of all children in foster care in FY 2004 who were in foster care for 8 days or longer and less than 12 months, what percent had two or fewer placement settings?
      
      
    • Of all children in foster care in FY 2004 who were in foster care for at least 12 months but less than 24 months, what percent had two or fewer placement settings?
      
      
    • Of all children in foster care in FY 2004 who were in foster care for 24 months or longer, what percent had two or fewer placement settings?

A.2.2. Failure To Meet the National Standards

If the State's data fail to meet the national standards, the State is required to implement a PIP designed to improve the State's performance on each outcome for which the data indicators do not meet the standards. (The criteria for determining the amount of improvement that must be achieved through a PIP are discussed in chapter 7.)

The goal of the CFSRs is continuous quality improvement. A State, therefore, whose data remain below a national standard in subsequent reviews is required to establish new benchmarks for improvement, with the goal of eventual attainment of the standard. As long as the State reaches the level of improvement agreed to in the PIP for a data indicator, failure to reach the national standard on an indicator is not a basis for withholding Federal funds.

Below are two examples of determining substantial conformity using the case record ratings and data indicators.

Example 1

The following example illustrates how cases reviewed on site are tallied by outcome, as part of determining whether the State is in substantial conformity. In this example, assume that this was the State's second review and that the data indicators met the national standards for Safety Outcome 1 and Permanency Outcome 1. The CFSR Data Management System tallies the ratings for the cases reviewed onsite, as shown in the following table.

 

Outcome	Number of Cases Substantially Achieved	Number of Cases Partially Achieved	Number of Cases Not Achieved	Percentage of Cases Substantially Achieved 1N=65 2N=40
Safety Outcome 1: Children are, first and foremost, protected from abuse and neglect.	54	11	0	83%1
Safety Outcome 2: Children are safely maintained in their homes whenever possible and appropriate.	62	0	3	95%1
Permanency Outcome 1: Children have permanency and stability in their living situations.	21	8	11	52%2
Permanency Outcome 2: The continuity of family relationships and connections is preserved for children.	40	0	0	100%2
Child and Family Well-Being Outcome 1: Families have enhanced capacity to provide for their children's needs.	43	12	10	66%1
Child and Family Well-Being Outcome 2: Children receive appropriate services to meet their educational needs.	65	0	0	100%1
Child and Family Well-Being Outcome 3: Children receive adequate services to meet their physical and mental health needs.	62	3	0	95%1

 

According to the case record review ratings, and the State's performance on the national standards, the State would not be in substantial conformity with: Safety Outcome 1, Permanency Outcome 1, and Child and Family Well-Being Outcome 1.

Example 2

The example below illustrates the process of determining substantial conformity for Permanency Outcome 1, "Children have permanency and stability in their living situations."

The following six items (reviewed on site) and four data indicators are used to determine substantial conformity for Permanency Outcome 1:

• Items:
  • Foster care re-entries
    
    
  • Stability of foster care placements
    
    
  • Permanency goal for child
    
    
  • Reunification, guardianship, or permanent placement with relatives
    
    
  • Adoption
    
    
  • Other planned permanent living arrangement
• Data Indicators:
  • Permanency Composite 1: Timeliness and permanency of reunifications
    
    
  • Permanency Composite 2: Timeliness of adoptions
    
    
  • Permanency Composite 3: Achieving permanency for children in foster care
    
    
  • Permanency Composite 4: Placement stability

As discussed in sections A.1. and A.2., the items are rated on the basis of the case record reviews, using the Onsite Review Instrument, and the data indicators are obtained from the data profiles included in the Statewide Assessment.

The following must occur for the State to be determined to be in substantial conformity with Permanency Outcome 1:

• The Onsite Review Team must determine that Permanency Outcome 1 was substantially achieved in 95 percent of the cases reviewed.
  
  
• The four data indicators for Permanency Outcome 1 must meet the national standards
.

In this example, assume that we determine from the case record reviews that 95 percent of the cases reviewed achieved ratings of "substantially achieved" for Permanency Outcome 1. In addition, the Statewide Assessment shows that the State meets the national standards for three of the relevant data indicators (timeliness and permanency of reunifications, achieving permanency for children in foster care, and placement stability), but not for one indicator (timeliness of adoptions).

Because the State did not meet the national standards for all four data indicators, it is not in substantial conformity with this outcome. The State therefore must prepare a PIP to improve its performance on the data indicator that did not meet the standard, "timeliness of adoptions."

B. Determination of Substantial Conformity With the Systemic Factors

The Child and Family Services Plan (CFSP) and other program requirements provide the basis for determining substantial conformity with each of the systemic factors. (Review team leaders examine 22 items under the systemic factors; these items are listed in Appendix B, Index of Outcomes and Systemic Factors, and Associated Items and Data Indicators.) During the Statewide Assessment, the Statewide Assessment Team compiles and evaluates information on the systemic factors. During the onsite review, the Team Leaders and Local Site Leaders conduct State and local stakeholder interviews to collect the information necessary to evaluate the systemic factors. Using this information, the Children's Bureau Regional Office, in collaboration with the NRT Team Leader for the review, makes the following determinations regarding each systemic factor:

• Whether the CFSP requirements and other program requirements attached to the systemic factor are actually in place in the State
  
  
• Whether the CFSP requirements and other program requirements attached to the systemic factor are functioning as described in the applicable regulation or statute

Because the systemic factors are statewide issues, the NRT Team Leader collects information from the three local review sites by downloading the information collected using the automated Stakeholder Interview Guide. The Children's Bureau Regional Office, in conjunction with the NRT Team Leader, then makes the final determination of substantial conformity regarding the systemic factors following the onsite review. This information is included in the Final Report, which the Children's Bureau Regional Office releases to the State after the onsite review.

Six of the seven systemic factors are rated on the basis of multiple CFSP and other program requirements. One systemic factor, "statewide information system," is rated on the basis of only one CFSP requirement. For a State to be found in substantial conformity with a systemic factor, the information obtained from the Statewide Assessment and stakeholder interviews must indicate that the required number of CFSP and other program requirements for that factor are in place and functioning as required.

The following table describes how the CFSP and other program requirements are used to determine substantial conformity with the systemic factors, using the ratings shown. For a specific systemic factor to be determined to be in substantial conformity, the Children's Bureau Regional Office, in collaboration with the NRT Team Leader for the review, must assign it a rating of "3" or "4."

Rating the Systemic Factors

Not in Substantial Conformity		Substantial Conformity
1	2	3	4
None of the CFSP or program requirements is in place.	Some or all of the CFSP or program requirements are in place, but more than one of the requirements fail to function as described in each requirement.	All of the CFSP or program requirements are in place, and no more than one of the requirements fails to function as described in each requirement.	All of the CFSP or program requirements are in place and functioning as described in each requirement.

 

Two of the seven systemic factors are rated for substantial conformity slightly differently, as follows:

• The systemic factor, "statewide information system," has only one CFSP requirement subject to review. If it is determined that this requirement is in place but not functioning as required, this factor is given a rating of "2" rather than "3."
  
  
• Two performance indicators are associated with the systemic factor, "quality assurance system." For this systemic factor to be in substantial conformity, it must be rated a "3" or "4." To be rated a "4," both items must be in place in the State and functioning at the required level. To be rated a "3," both items must be in place and item 31 must be functioning at the required level; item 30 does not need to be functioning at the required level for a finding of substantial conformity on this systemic factor.

If item 31 is not in place or is not functioning at the required level, however, the systemic factor is rated either a "1" or "2" depending on the State's performance on item 30. If item 30 is in place, but not functioning, the factor is rated a "2." If item 30 is neither in place nor functioning, the factor is rated a "1."

B.1. Example of Determining Substantial Conformity With the Systemic Factors

Below is an example of how the method described in section B is used to determine substantial conformity for the systemic factor "case review system."

The systemic factor, "case review system," has five CFSP and other program requirements subject to review. For purposes of this example, the Statewide Assessment indicates that policies and procedures are in place statewide that address all five requirements:

• Each child has a written case plan with the required content developed jointly with the child's parent(s) (item 25 in the Summary of Findings. Form)
  
  
• The status of each child in foster care is reviewed no less frequently than once every 6 months (item 26).
  
  
• Permanency hearings are held as required (item 27).
  
  
• TPR petitions are filed under the required circumstances (item 28).
  
  
• Foster parents, pre-adoptive parents, and relative caregivers of children in foster care are notified of, and given an opportunity to be heard in, reviews or hearings held with respect to the child (item 29).

While all five requirements are in place, we cannot determine from the Statewide Assessment whether they are functioning properly; the Team Leaders and Local Site Leaders make that determination on the basis of the stakeholder interviews that they conduct during the onsite review.

In this example, assume that those interviews indicated the following:

• The case plan requirement is functioning consistently statewide and in the three local review sites. Item 25, therefore, is rated as a strength.
  
  
• The periodic reviews do not occur on a timely basis in two of the three local review sites. Item 26, therefore, is rated as an area needing improvement.
  
  
• The permanency hearings are not held according to the requirements of Federal and State law in any of the three local review sites. Item 27, therefore, is rated as an area needing improvement.
  
  
• The procedures for TPR are functioning statewide and in all three local review sites. Item 28, therefore, is rated as a strength.
  
  
• The required parties are notified of hearings statewide and in all three local review sites. Item 29, therefore, is rated as a strength.

The information from the Statewide Assessment and the onsite review indicates that three of the five CFSP and other program requirements for this systemic factor are both in place statewide and functioning as required, while two are in place but fail to function as required. This systemic factor, therefore, would be rated a 2 and would not be in substantial conformity, according to the table above "Rating the Systemic Factors."

C. Resolution of Discrepancies Between the Statewide Assessment and the Onsite Review

In some instances, there may be discrepancies between the data indicators, information in the Statewide Assessment, and information on the corresponding items that is obtained during the onsite review.

For example, the State might acknowledge that the onsite review findings accurately reflect State practice, although they differ from the information in the Statewide Assessment or the data indicators. In these situations, the Children's Bureau can make a determination about substantial conformity or how to rate the performance indicator in which the discrepancy exists. In other circumstances in which there is no clear explanation of the discrepancies, however, they must be resolved before a determination about substantial conformity or how to rate the performance indicator in question can be made.

If the Children's Bureau Central Office determines that there is a discrepancy in the findings, the Children's Bureau Regional Office informs the State, in writing, of the discrepancy within 30 days of the onsite review, describes the options available to resolve the discrepancy, and informs the State about the timeframe for responding.

The regulation at 45 CFR §1355.33(d) provides a State with two options for resolving discrepancies:

• The State may submit additional information for the item(s) in which a discrepancy(s) occurred.
  
  
• The Children's Bureau and the State may review additional cases for the item(s) in which a discrepancy(s) occurred.

C.1. Resolution of Discrepancies Through Submission of Additional Information

The standards applied to the review process in determining substantial conformity are the same whether or not a discrepancy exists: applicable data indicators must meet the national standards, and the required percentage of cases reviewed on site must be substantially achieved. States therefore need to determine the most effective option for resolving the discrepancy on the basis of the nature of the discrepancy.

Submitting additional information, for example, is not a reasonable option for resolving a discrepancy when the data indicators meet the national standards, but the case record reviews indicate that in less than 95 percent of the cases, the outcome was determined to be substantially achieved. In this situation, only a review of additional cases would help to determine whether the State meets the criteria for substantial conformity. On the other hand, submitting additional information is a reasonable option when, through the case record review, it is determined that in 95 percent or more of the cases, the outcome was determined to be substantially achieved, but the data indicators associated with that outcome fail to meet the national standards. In this case, submitting additional information could resolve the discrepancy by establishing that the State has met the national standards.

Typically, the additional information that the State submits is data related to the national standards:

• In the event that a discrepancy occurred because the State submitted inaccurate data through AFCARS or NCANDS, the State may make corrections to the original AFCARS and NCANDS data and resubmit these data to the Children's Bureau Central and Regional Offices.
  
  
• The State may attempt to submit more recent AFCARS or NCANDS data because the onsite review addresses a more recent period than do the AFCARS and NCANDS data submissions used in preparing for the review. By doing so, the State might resolve the discrepancy by showing that the data indicators met the national standards subsequent to the initial submission of the data.

If the State chooses to submit data from a source other than NCANDS, the Children's Bureau must approve the use of the additional data (such as data from a special study or an alternate source). In assessing the alternate data, the Children's Bureau uses the following criteria:

• The Children's Bureau must determine that the results of the special study, or of a State's quality assurance activities, meet rigorous standards of sampling and evaluation, that the special study or quality assurance activities cover the period under review, and that the parameters of the special study or quality assurance activities are consistent with the parameters used to develop the national standard.
  
  
• The Children's Bureau must determine that the data conform to the logic used in developing the applicable national standard, that there is ample justification for using data other than NCANDS, and that NCANDS data cannot be corrected to reflect the alternate source of data.

C.2. Resolution of Discrepancies Through Review of Additional Case

Reviewing additional cases is the best option for resolving a discrepancy in cases in which the following occur:

1. The percentage of cases reviewed on site that are determined to be substantially achieved falls short of the percentage required to establish substantial conformity for the outcome, and
   
   
2. The data indicators for the outcome conform to the national standards.

If the State chooses this option, the additional cases are selected from the original samples of in-home services and foster care cases that were drawn for the review. If additional cases are needed to comprise a statistically significant sample, the Children's Bureau Central Office works with the Children's Bureau Regional Office and the State to determine the methods for identifying and selecting the additional cases to be reviewed. (See chapter 4, section C, for more information on case selection and review.)

For the State to be determined to be in substantial conformity through the review of additional cases, on an outcome for which there is a discrepancy, the following conditions must occur:

• The total number of cases, when the additional cases are added to the original sample of cases, comprises a statistically significant sample, with a tolerable sampling error of 5 percent and a confidence coefficient of 95 percent.
  
  
• The outcome is determined to have been achieved in 95 percent (90 percent in the initial review) of the cases reviewed
.

Typically, about 150 cases are needed to comprise a statistically significant sample at this level. Children's Bureau statisticians are available to assist the Children's Bureau Regional Office staff in determining the exact number of additional cases to be drawn. A joint Federal and State team reviews the additional cases only for the item or outcome in question, and the cases must fall into the original review's period under review. The results of the additional case record review, combined with the results of the original case record review, are the basis for determining substantial conformity.

The Children's Bureau Regional Office determines the timing, process, and review team associated with the additional case record review, on the basis of the number and complexity of the discrepancies to be resolved. When an additional case record review is needed, it follows the onsite review as soon as possible so that a prompt and accurate determination regarding substantial conformity can be made.

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