4100 Inspecting Child Care Homes and Operations

August 2012

 

Licensing staff inspect child care operations to assess the risk to children in those operations, in accordance with licensing law, administrative rules, and minimum standard rules.

To determine an operation’s compliance, Licensing staff:

  1. observe the operation’s performance;
  2. review the records and files maintained by the operation;
  3. cite the operation’s deficiencies, based on the minimum standards;
  4. document observations to capture scope and severity;
  5. consider the risks posed by violations of the minimum standards;
  6. use critical thinking to assess the operation’s overall compliance history;
  7. help the permit holder identify problems that contribute to deficiencies and provide technical assistance to help the permit holder understand how to comply; and
  8. consider all of the relevant information together for a broad perspective.

The operation is responsible for developing and implementing plans to correct problems and prevent risk to children.

Licensing staff are not responsible for managing the operation.

40 TAC §745.8403; 745.8401

 

Procedure

Licensing staff evaluate the risk associated with deficiencies and help the permit holder understand that he or she must comply with licensing law, administrative rules, and minimum standard rules.

 

Determining Compliance with Licensing Law and Rules

For specific procedures on determining compliance with licensing law, administrative rules, and minimum standard rules, see the section above.

 

Documenting Findings

Once compliance is determined, Licensing staff document the results of:

  • their observations, to capture the scope and severity of issues that potentially pose a risk to children in care; and
  • their inspections, within the specified time frame.

All monitoring activities, inspections, technical assistance, and administrative reviews must be documented in the Child Care Licensing Automation System (CLASS). Form 2936 Child-Care Facility Inspection is generated from CLASSMate.

See 4160 Documenting the Results of an Inspection.

 

4110 The Authority to Monitor Child Care in Texas

November 2011

 

Licensing staff may visit an operation during operating hours to investigate, inspect, and evaluate.

Texas Human Resources Code §42.044(a)

40 TAC §§745.8401, 745.8403, 745.8407(1)

Licensing staff have the authority to:

  1. determine whether an operation is subject to regulation;
  2. verify the operation’s compliance with licensing law, administrative rules and minimum standard rules; and
  3. investigate reports related to all operations.

 

4120 Types of Inspections

December 2015

 

Licensing staff select the most appropriate inspection type to record an inspection in CLASS. Except for inspections of child-placing agencies, all inspections at all operations must include a walk-through for obvious minimum standard deficiencies (deficiencies that are in plain view).

See:

4121 Application Inspections

4122 Attempted Inspections

4123 Follow-Up Inspections

4124 Initial Inspections

4125 Investigation Inspections

4126 Monitoring Inspections

4127 Monitoring and Investigation Inspections

4128 Other Types of Inspections

4150 Conducting Inspections

 

4121 Application Inspections

December 2011

 

Procedure

Application inspections are conducted during the application phase and generally include an evaluation of all applicable subchapters. See 3313 Inspecting the Operation (Except Listed Homes).

 

4122 Attempted Inspections

August 2012

 

Procedure

Attempted inspections include inspections conducted without making contact with the operation. See 4156 When an Inspection Is Attempted.

 

4123 Follow-Up Inspections

September 2019

 

Procedure

Follow-up inspections include evaluating individual minimum standards, conditions, or restrictions, rather than evaluating an entire subchapter of minimum standards or all conditions or restrictions associated with the operation. See 4300 Conducting a Follow-Up With an Operation.

Examples of reasons follow-up inspections are made include, but are not limited to:

  1. ensuring that recent deficiencies or a pattern of repeated deficiencies are addressed;
  2. meeting with the designated director at a licensed day care center (see 4131.3 Child Day Care – Annual Meeting with the Designated Director);
  3. amending a permit or certificate (see 3810 Circumstances That May Require Amending the Permit);
  4. evaluating an operation’s compliance with the conditions established to address the issues identified during a risk evaluation (see 4152 Reviewing Restrictions and Conditions and 10000 Background Checks);
  5. following up on suspension, revocation, or denial (see 7636 Follow-Up to Suspension, Revocation, or Denial);
  6. monitoring during the appeal process (see 7731 Regulation During Appeal Process);
  7. following up on a waiver-variance condition (see 4152 Reviewing Restrictions and Conditions and 5120 Setting and Monitoring Conditions for the Waiver or Variance); or
  8. monitoring the temporary relocation of an operation (see 7320 Temporary Relocation).

 

4124 Initial Inspections

December 2015

 

Procedure

Initial inspections are inspections that are conducted during the initial period for a licensing permit.

See 3511 Conducting Inspections During the Initial License Period.

 

4125 Investigation Inspections

September 28, 2018

 

Procedure

Investigation inspections include the investigation of reports alleging:

  • violations of Licensing statutes;
  • violations of administrative rules;
  • violations of minimum standards; or
  • a combination of these.

If an investigation interview is conducted at an operation other than the one named in the report, the inspection is classified as Other in CLASS. See 6000 Investigations.

 

4126 Monitoring Inspections

December 2015

 

Procedure

Monitoring inspections must include evaluation of at least one entire subchapter of the applicable minimum standards and may include evaluation of additional individual laws, administrative rules, or minimum standards, or any conditions or restrictions. See 4140 Preparing for Inspections.

 

4127 Monitoring and Investigation Inspections

December 2015

 

Monitoring and investigation inspections include the investigation of a report during a monitoring inspection.

See 4125 Investigation Inspections and 4126 Monitoring Inspections.  

 

4128 Other Types of Inspections

March 2017

 

Other types of inspections are conducted for purposes other than determining compliance with pre-identified minimum standards, such as:

  1. consulting with an operation’s administrator or director;
  2. hand-delivering a corrective or adverse action notice; or
  3. conducting an investigation interview.

 

4130 Minimum Requirements for Monitoring Inspections

December 2016

 

The operation’s permit type determines:

  • the minimum frequency with which monitoring inspections are conducted; and
  • the time frame by which compliance with all minimum standards have to be evaluated.

An operation’s deficiencies and the associated weight of the deficiencies may indicate a need for more frequent inspections. The recommended monitoring frequency can be found on the Enforcement Recommendations page in CLASS.

See:

4131 Minimum Requirements for Licensed Operations

4132 Minimum Requirements for Registered Child Care Homes

4133 Operations That Are Not Regularly Inspected

4500 Evaluating Risk to Children

7425 Inspecting an Operation During a Corrective Action

 

4131 Minimum Requirements for Licensed Operations

October 2019

 

First 12 Months After Issuance of a Full License

During the first 12 months following the issuance of a full license, the inspector:

  • conducts at least one unannounced monitoring inspection every six months; and
  • evaluates for compliance with all minimum standards within 12 months.

The inspector has until the last day of the last month during each six-month period to complete the inspection that is due during the relevant six-month period. For example, a full license is issued in January 2019, so:

  • the first six-month inspection is due by June 30, 2019;
  • the second six-month inspection is due by January 31, 2020; and
  • the inspector would cumulatively have to evaluate the operation for compliance with all minimum standards during the entire 12-month period.

 

Subsequent Years After Issuance of a Full License

After the first 12 months following the issuance of a full license, the inspector:

  • conducts an unannounced monitoring inspection at least annually (not more than 366 days), based upon an assessment of risk to children; and
  • evaluates for compliance with the following minimum standards, depending on the operation type:
Type of Operation What Standards and in What Time Frame
Licensed Child Care Centers, School-Age Programs, Before- or After-School Programs, and Licensed Child Care Homes
  • All minimum standards every two years.
  • Core health and safety minimum standards annually.
See 4131.4 Health and Safety Audits for Licensed Child Day Care Operations
Licensed residential operations All minimum standards every two years.

Texas Human Resources Code §42.044(b)

45 Code of Federal Regulations §98.41

 

Required Inspections During Night or Weekend Hours for Residential Operations (Other Than a Child-Placing Agency)

At least once every two years, Licensing staff must inspect a residential operation (other than a child-placing agency) after 7 p.m. on a weekday or anytime on the weekend. Licensing staff are not required to read records when conducting an inspection at a residential operation during night hours.

Required Inspections for Day Care Operations When Nightime Care is Provided

At least once every two years, Licensing staff must inspect a day care operation that provides nighttime care during the hours that the operation provides nighttime care. Licensing staff must conduct at least some portion of the inspection between 9 p.m. and 6 a.m. during hours of operation.

Procedure

If an inspection cannot be made during night or weekend care, Licensing staff:

  1. obtain supervisory approval to conduct the inspection during regular visiting hours;
  2. document the justification for conducting the inspection during regular visiting hours in CLASS as a Chronology with a category of Monitoring; and
  3. document a plan for how nighttime and weekend care will be evaluated for compliance with minimum standards.

 

Two-Year Period Measurement

Procedure

The inspector measures a two-year period by beginning with the first day of the month in which Licensing issued the full license and counting in two-year increments. For example, if the license was issued on September 10, the two-year period would begin on September 1 and end on August 31 two years later.

 

4131.1 Residential Child Care Monitoring Inspections for CPA Branch Offices

September 28, 2018

 

When a child-placing agency (CPA) with a full license opens a branch office, the inspector conducts a monitoring inspection at the branch office.

 

Branch Office Opens During the First 12 Months After the CPA is Issued a Full License

Procedure

When a CPA opens a branch office during the first 12 months following the issuance of the CPA’s full license, the inspector:

  • conducts a monitoring inspection at the branch office evaluating compliance with all minimum standards within six months after the branch office opens; and
  • schedules and conducts additional inspections at the branch office according to the monitoring frequency of the CPA’s main office, until the CPA has had a full license for one year.

After the CPA has had a full license for more than 12 months, the inspector:

  • conducts additional monitoring inspections at the branch office at least annually, based upon an assessment of the risk to children (see 4130 Minimum Requirements for Monitoring Inspections); and
  • evaluates each CPA branch office for compliance with all minimum standards during each two-year period.

 

Branch Office Opens More than 12 Months After the CPA is Issued a Full License

Procedure

When a CPA opens a branch office after the first 12 months following the issuance of the CPA’s full license, the inspector conducts a monitoring inspection at the branch office and evaluates for compliance with all minimum standards within six months after the branch office opens.

Thereafter, the inspector:

  • schedules inspections in CLASS.
  • conducts additional monitoring inspections at least annually, based upon an assessment of the risk to children (see 4130 Minimum Requirements for Monitoring Inspections); and
  • evaluates each CPA branch office for compliance with all minimum standards during each two year period.

 

4131.2 Residential Child Care Team Inspections

December 2011

 

Licensing staff conduct an unannounced team inspection at each residential child care facility, including each child-placing agency (CPA) branch office, at least once annually. A team inspection is an inspection that is conducted by at least two residential child care inspectors.

Texas Human Resources Code §42.044(b-1)

 

Procedure

Licensing staff conduct team inspections at each residential child care facility, including CPA branch offices, at least once per year. Each team inspection must:

  • be unannounced; and
  • be conducted by at least two residential child care inspectors who work at different residential child care inspection units.

If the inspectors do not work at different inspection units, Licensing staff:

  • document the reason in the CLASS Chronology / Monitoring Category; and
  • obtain approval from a Licensing supervisor before conducting the team inspection.

 

4131.3 Child Day Care Annual Meeting with the Designated Director at a Licensed Child Care Center

November 2017

 

The inspector meets with the designated director at least once annually during an unannounced inspection at a licensed child care center, to determine whether the designated director:

If the director is not present during at least one of the unannounced inspections within a 12-month period, the inspector schedules a meeting with the director to review the director’s qualifications. This meeting must be held at the operation.

Texas Human Resources Code §42.044(b-2)

 

Procedure

Annual Review of the Designated Director’s Qualifications

The inspector meets with the designated director of a licensed child care center during at least one monitoring inspection within a 12-month period. During this meeting, the inspector evaluates the director’s qualifications by reviewing:

  1. The original Child Care Center Director’s Certificate or approved waiver or variance for director qualifications; and
  2. Most recent background check to ensure it is current.

The inspector documents the review of the director’s qualifications by selecting the Dir Qual Eval box on the Inspection Detail page in CLASS.

The inspector cites the appropriate minimum standard and unchecks the Valid Director Certificate checkbox on the Governing Body Designation page in CLASS, if:

  • the director does not meet the qualifications or have a current waiver or variance for director qualifications; or
  • the director’s certificate has expired.

If the designated director has an approved waiver or variance for director qualifications, the inspector documents whether the director has made progress toward compliance in the Narrative text box on the Inspection Detail page in CLASS. The inspector also evaluates whether the director qualifies for a non-expiring director’s certificate if the director has an expiring one.

If there are any changes in how the director qualifies since the last inspection, the inspector documents how the director meets the qualifications by selecting the appropriate option in the How DC Director Qualified field on the Governing Body Designation page in CLASS and issues a new director certificate that indicates how the director now meets the qualifications.

 

When the Director is Not Present for an Annual Review of Qualifications

If the designated director is not present during at least one unannounced monitoring inspection, within a 12-month period, the inspector meets with the director at the center as outlined in the following chart:

Deficiency Cited at the Last Monitoring Inspection? Complete the Annual Review of Director Qualifications During…
Yes an unannounced follow-up inspection conducted no later than 15 days after the latest compliance date for any deficiency noted in CLASS Form 2936 Child-Care Facility Inspection at the last monitoring inspection
No an announced or unannounced follow-up inspection conducted no later than 15 days after the last monitoring inspection.

If the director is not present during an unannounced follow-up inspection, the inspector schedules a meeting with the director. The meeting must be held at the operation.

If the director does not respond to a request to meet, the inspector cites the facility for a violation of minimum standards and follows up as appropriate.

 

When the Annual Review of Qualifications is Late

If the director’s qualifications cannot be reviewed within the required 12-month period, the inspector:

  • obtains the supervisor’s approval to conduct the inspection at a later date; and
  • documents the supervisor’s approval in CLASS, in the Chronology/Monitoring Category.

 

Tracking How Frequently a Director is Present During Inspections

The inspector evaluates how frequently or infrequently the director is not present by reviewing how often the Director Present check box in CLASS has been checked in the past year. If the director is frequently not present, the inspector determines a plan of action, which may include contacting the permit holder to acquire the director’s work schedule.

 

4131.4 Health and Safety Audits for Licensed Child Day Care Operations

August 2019

 

Licensing must annually conduct at least one health and safety audit during an unannounced monitoring inspection for licensed child care centers, before- or after-school programs, school-age programs, and licensed child care homes.

45 Code of Federal Regulations §98.42

 

Procedure

A health and safety audit is a review of core measures related to health and safety, conducted during a monitoring inspection. The inspector completes a health and safety audit by completing the appropriate Health and Safety Audit Checklist or conducting a standard-by-standard monitoring inspection.

Selecting Subchapters on the Inspection Form

The Licensing inspector selects a minimum standard subchapter on CLASS Form 2936 Child-Care Facility Inspection when:

  • the inspector plans to evaluate the entire subchapter, not just a core measure within the subchapter; or
  • the operation is deficient with two or more core measures within a content area that requires a review of an entire subchapter.

See:

4161.1 Creating a Draft CLASS Form 2936

 

4132 Minimum Requirements for Registered Child Care Homes

August 2019

 

First 12 Months After Issuance of a Registration

During the first 12 months following the issuance of the registration, the inspector conducts an unannounced monitoring inspection to evaluate compliance with all minimum standards.

Additional monitoring inspections are based on an assessment of risk to children and are scheduled CLASS.

40 TAC §745.8407(2)

45 Code of Federal Regulations §98.42

 

Subsequent Years After Issuance of a Registration

The inspector conducts unannounced inspections for compliance with all minimum standards at least every two years, unless the home has an agreement to receive a subsidy from the Texas Workforce Commission (TWC).

The inspector measures a two-year period by beginning with the first day of the month in which Licensing issued the registration and counting in two-year increments. For example, if a registration was issued on September 10, the two-year period would begin on September 1 and end on August 31 two years later.

 

Registered Child Care Homes with a TWC Subsidy Agreement

For a registered child care home that has entered into a subsidy agreement with TWC, the inspector conducts an unannounced standard-by-standard monitoring inspection annually.

The inspector conducts the inspection within 12 months from the date the operation’s subsidy status changed in CLASS, or two years from the date of the last monitoring inspection, whichever comes sooner.

 

4133 Operations that are Not Regularly Inspected

August 2012

 

Listed Family Homes

Licensing staff inspect listed family homes only as part of an investigation.

See 6221.3 Reports Received for Listed Homes.

Texas Human Resources Code §§42.044(b), 42.044(c-1)(1)

40 TAC §745.8407(1)

Small Employer-Based Child Care and Temporary Shelter Programs

Licensing staff do not conduct regular monitoring inspections on small employer-based child care. However, Licensing staff may need to conduct any of the other types of inspections listed below:

  1. Application Inspections
  2. Follow-up Inspections
  3. Investigation Inspections
  4. Other

See:

4121 Application Inspections

4123 Follow-Up Inspections

4125 Investigation Inspections

4128 Other Types of Inspections

Texas Human Resources Code §§42.153, 42.162, 42.203, 42.209

40 TAC §§745.8407(5), 745.8407(6)

 

4140 Preparing for Inspections

 

 

4141 Preparing for Application, Initial, and Monitoring Inspections

December 2015

 

Licensing staff prepare for each application, initial, or monitoring inspection by reviewing the:

  • operation’s record;
  • last enforcement action recommended for the operation;
  • frequency of inspections of the operation;
  • operation’s compliance history, as documented in CLASS;
  • operation’s fee payment history;
  • operation’s background check records, as documented in CLASS;
  • operation’s controlling person list, as documented in CLASS;
  • recommendations from enforcement team conferences (for inspections of residential operations except independent foster homes); and
  • results of random-sampling inspections of CPA foster homes (for inspections of CPAs only).

Licensing staff use the information obtained during the review to determine which minimum standards to evaluate during the planned inspection.

If deficiencies with standards that pose a risk to the health and safety of children were cited during a previous inspection, Licensing staff must reevaluate the same and related standards at the inspection.

Draft Form 2936 Child-Care Facility Inspection

Staff must create and save the initial draft of Form 2936 Child-Care Facility Inspection in CLASS before conducting the inspection. See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

For information on preparing for investigation inspections, see 4142 Preparing for Investigation Inspections.

Procedure

Reviewing Background Materials

To prepare for an inspection, Licensing staff review all of the following:

  1. The most recent information in CLASS on enforcement recommendations for the operation, including the recommendation, the enforcement actions taken by other Licensing staff, and the operation’s recommended monitoring frequency;
  2. The capacity of the operation, the ages of the children served, the hours of operation (including days and months), and the services provided;
  3. The operation’s address, including the Location Address Validation Status and Mailing Address Validation Status, to determine whether either status is set to Not Validated;
  4. The directions to the operation;
  5. The name of the designated director, operator, or licensed administrator;
  6. The qualifications of the designated director or operator;
  7. The last renewal date of the license of a designated director or licensed administrator, if applicable;
  8. A history of the operation, including all of the following:
    • Prior investigations, including investigation and inspection findings and technical assistance provided;
    • Prior inspections, including findings and technical assistance provided;
    • Minimum standard rules that may need to be reevaluated for compliance;
    • Conditions and expiration dates of any waivers, variances, and risk evaluations;
    • Results of random-sampling inspections for CPA foster homes (for inspections of child-placing agencies only; see 4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency);
  9. The operation’s fee payment history to determine whether the operation is current on all applicable fees, unless the operation is exempt from paying all fees (see 5260 Verification of Fee Payment);
  10. The operation’s background check records in CLASS to verify that the operation has complied with all background check requirements (see 10000 Background Checks);
  11. The operation’s controlling person list in CLASS to determine whether any person on the list has a status of Review (see 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS for procedures to follow when a person has a status of Review);
  12. Recommendations from enforcement team conferences (for inspections of CPAs and RTCs; see 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations);
  13. Optional checklists, forms, reading guides, and applicable technical assistance materials;
  14. Create a Draft Inspection Form in CLASS; and
  15. After reviewing the background materials related to an operation but before conducting the inspection, Licensing staff:
    • complete a draft inspection Form 2936 Child-Care Facility Inspection, located in CLASS; and
    • upload the draft Form 2936 to CLASSMate.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

 

4141.1 Monitoring Inspections During an Investigation

December 2015

 

If an operation is under investigation, inspectors consult with the Licensing supervisor while preparing for the inspection to determine whether an inspection will interfere with the investigation. Licensing staff do not conduct an inspection if it would interfere with an ongoing investigation.

 

4142 Preparing for Investigation Inspections

August 2012

 

Licensing staff prepare for an investigation inspection by reviewing:

  1. intake report;
  2. operation’s record;
  3. last enforcement action recommended for the operation;
  4. frequency of inspections made of the operation;
  5. operation’s compliance history, as documented in CLASS; and
  6. operation’s background check records, as documented in CLASS.

Draft Form 2936 Child-Care Facility Inspection

After reviewing the information listed above, but before conducting the inspection, Licensing staff create and save the initial draft of Form 2936 Child-Care Facility Inspection in CLASS. See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

For information on preparing for other types of inspections, see 4141 Preparing for Application, Initial, and Monitoring Inspections.

Reviewing Background Materials

To prepare for an inspection, Licensing staff review all of the following:

  1. The most recent information in CLASS on enforcement recommendations for the operation, including the recommendation, and the enforcement actions taken by other Licensing staff;
  2. The capacity of the operation, the ages of the children served, the hours of operation (including days and months), and the services provided;
  3. The operation’s address and the directions to the operation;
  4. The name of the designated director, operator, or the name of the licensed administrator;
  5. A history of the operation, including all of the following:
    • Prior investigations;
    • Previous deficiencies;
    • Conditions and expiration dates of any waivers or variances and risk evaluations, if included as part of the allegations; and
  6. The operation’s background check records in CLASS to verify that the operation has complied with all background check requirements (see 10000 Background Checks); and
  7. Optional checklists, forms, reading guides, and applicable technical assistance materials.

Create a Draft Inspection Form in CLASS

After reviewing the background materials related to an operation but before conducting the inspection, Licensing staff:

  • complete a draft inspection Form 2936 Child-Care Facility Inspection, in CLASS; and
  • download the draft Form 2936 to CLASSMate.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

 

4150 Conducting Inspections

September 28, 2018

 

When conducting any type of inspection, Licensing staff must:

  1. identify themselves as HHSC Licensing staff and state the specific purpose of the inspection upon arrival at the site;
  2. assess the risk to children;
  3. terminate the inspection if the safety of Licensing staff is threatened;
  4. document the inspection results in CLASS (see 4160 Documenting the Results of an Inspection);
  5. conduct an exit interview at the end of the inspection; and
  6. offer technical assistance to help the permit holder identify problems that contribute to deficiencies with the minimum standard rules and understand how to comply with the rules.

40 TAC §745.8401

General Procedures

Procedure

Licensing staff must observe the following requirements when conducting any type of inspection on an operation:

  1. Carry a valid HHSC identification card and present it to the person in charge.
  2. Explain to the person in charge, upon arrival:
    1. the purpose of the inspection;
    2. the law, administrative rules, or minimum standards by which compliance will be evaluated;
    3. that compliance with additional minimum standards may be evaluated as the situation demands; and
    4. that photographs and video may be taken during the inspection.
  3. Obtain written consent before interviewing biological or adopted children, even when the owner’s or operator’s children are in care at the operation. Children in care may be interviewed, provided the child’s parent has not previously refused to allow Licensing to interview his or her children. See 6000 Investigations.
  4. Terminate the inspection at any time when Licensing staff feel unsafe. Staff must not be placed at risk. Report termination of an inspection to the supervisor. If the danger arises from the caregiver’s resistance to the inspection, follow the procedures in 4159 Handling Resistance or Refusal to Allow Inspection.
  5. Follow the procedures in 7200 Handling Immediate Danger to Children, if children are at risk.
  6. Follow the procedures in 4155 Determining When An Inspection is Attempted, if there is no one at the operation or no children are in care.
  7. Follow the procedures in 6210 Receipt of Intake Reports From Statewide Intake, if abuse or neglect is reported or is observed during the inspection.

 

4150.1 Additional Requirements for All Inspections on Licensed Child Care Centers

November 2017

 

At least once per year, inspectors must meet with the designated director of a licensed child care center during an unannounced monitoring inspection, as outlined in 4131.3 Child Day Care: Annual Meeting with the Designated Director at a Licensed Child Care Center.

 

4150.2 Additional Requirements for All Inspections on Registered Child Care Homes

August 2012

 

Procedure

If Licensing staff find the following conditions when inspecting a registered child care home that participates in the Child and Adult Care Food Program (CACFP) of the Texas Department of Agriculture, staff send a letter to the contract manager for the CACFP, using Form 2874 Report of Provider Contact:

  1. The operator is not caring for children.
  2. No children are in care when meals are served.
  3. The operator has a full-time job outside of the home.
  4. Meals are served, but child care is not provided.
  5. Only the operator’s own children are in care.
  6. The home has exceeded its capacity (serves more children than it is approved to serve).
  7. The children in care are older or younger than the home is approved to serve.

 

4150.3 Additional Requirements for Monitoring Inspections on Residential Child Care Facilities

August 2012

 

Procedure

Licensing staff inspecting residential child care operations also perform the following tasks during each inspection:

  • Read a sampling of serious incident reports.
  • Conduct a subsequent inspection the following business day, if one is necessary to complete the monitoring inspection.

See:

4420 Monitoring Child-Placing Agencies

4430 Random-Sample Monitoring of CPA Foster Homes

 

4150.4 Additional Requirements for Investigation Inspections

June 2015

 

The investigator conducts an unannounced investigation inspection at an operation that is the subject of the investigation according to the time frames in 6000 Investigations.

The first investigation inspection to the operation may be announced if the investigator has:

  1. attempted one or more unannounced inspections;
  2. obtained supervisory approval to conduct an announced inspection; and
  3. documented the following in the Observations Made During Inspection narrative box on the Investigation Conclusion page in CLASS:
    • The reason for an unannounced inspection could not be conducted.
    • The dates supervisory approval was requested and obtained.

Subsequent investigation inspections may be announced or unannounced.

Inspection Not Required

An investigation inspection is not required when the investigation was assigned:

  • a priority of 5 (P5); or
  • a priority of 3 (P3) to process a sex offender proximity report.

See 6000 Investigations.

40 TAC §745.8407

 

4150.5 Additional Requirements for Initial and Monitoring Inspections

August 2019

 

The inspector evaluates the operation’s compliance in validating its Employee List at every initial and monitoring inspection.

See 10740 Validating the Employee List

 

4151 Operation Walk-Throughs

June 2015

 

Any time Licensing staff visit an operation other than a child placing agency, staff perform an operation walk-through and cite any deficiencies observed during the walk-through.

Licensing staff walk through all of the following areas in the operation:

  1. Indoor and outdoor activity areas;
  2. Areas where meals are prepared and served;
  3. Restrooms accessible to children; and
  4. Sleeping areas.

Procedure

During all inspections, Licensing staff walk through the operation and assesses the risk to children related to obvious violations of the Licensing statutes, administrative rules, or minimum standards related to:

  1. supervision of children;
  2. child/caregiver ratio;
  3. swimming pools and transportation safety, if applicable;
  4. fire, safety, and sanitation requirements; and
  5. responsibilities of the director, administrator, staff, or caregivers.

 

4151.1 Exceptions for an Investigation Inspection

June 2015

 

If Licensing staff has conducted previous investigations at the operation and a supervisor determines that Licensing staff is sufficiently familiar with the operation’s compliance and investigation history, the supervisor may grant an exception that allows Licensing staff to conduct a condensed operation walk-through.

However, at minimum, Licensing staff must walk through:

  1. the sleeping area of the alleged victim, if applicable;
  2. the restrooms accessible to the alleged victim, if applicable; and
  3. the specific area where the incident being investigated is alleged to have occurred.

When granting approval, the supervisor explains to Licensing staff which areas of the operation that Licensing staff is required to conduct a walk-through.

Licensing staff documents the exception approved by the supervisor in CLASS.

Procedure

For investigation inspections, Licensing staff is responsible for:

  1. obtaining approval from the supervisor before conducting a condensed operation walk-through;
  2. checking for and citing any obvious plain-view violations observed during the operation walk-through; and
  3. inspecting the specific area where the incident being investigated is alleged to have occurred and citing any necessary deficiencies.

For an investigation inspection, Licensing staff documents the exception to conducting a full walk-through in the Observations Made During the Inspection section of the Investigation Conclusion page in CLASS. Documentation must include:

  • the areas included in the walk-through; and
  • the date the supervisor approved the exception.

 

4151.2 Exceptions for a Follow-Up Inspection

June 2015

 

If a follow-up inspection is conducted within the time frame referenced in 4311 Following Up With an Inspection, Licensing staff may conduct a condensed walk-through limited to the area of the operation relevant to the follow-up inspection.

If a follow-up inspection is not conducted within the time frames referenced in 4311. Licensing staff must conduct a full walk-through.

 

4152 Reviewing Restrictions, Conditions, Waivers, and Variances

June 2016

 

At each initial or monitoring inspection, Licensing staff review any:

  • restrictions on a permit;
  • conditions on a permit;
  • conditions related to a waiver or variance still in effect;
  • conditions related to a risk evaluation still in effect;
  • conditions related to a corrective action still in effect; and
  • waivers or variances that have expired since the last monitoring inspection.

During an investigation or follow-up inspection, Licensing staff review and evaluate the operation’s compliance with any restrictions or conditions if they are relevant to the investigation or follow-up being conducted.

 

4152.1 Documenting Deficiencies Related to Restrictions and Conditions

June 2016

 

After reviewing the restrictions and conditions, Licensing staff document an operation’s deficiencies in CLASS.

Procedure

For each inspection in which restrictions or conditions are reviewed, Licensing staff document any violations of restrictions or conditions on CLASS Form 2936 Child Care Facility Inspection by:

  • citing the Licensing statute, administrative rule, or minimum standard that has been violated;
  • describing the restriction or condition that was violated. If multiple restrictions or conditions were originally referenced using numbers or letters, it is permissible to use numbers or letters to reference each restriction or condition when it is being evaluated;
  • describing the deficiency observed;
  • describing how the deficiency was identified, such as whether staff reviewed paperwork, interviewed the operation’s staff or the children, or took photographs; and
  • documenting the following, depending on whether the deficiency was corrected during the inspection:
    • If the deficiency was corrected during the inspection, Licensing staff explain how it was corrected.
    • If the deficiency was not corrected during the inspection, Licensing staff:
      • explain what correction is needed to either meet the conditions or to comply with the Licensing statute, rule, or minimum standard; and
      • provide a correction deadline date.

See:

4161 Completing CLASS Form 2936 Child Care Facility Inspection

7425 Inspecting an Operation During a Corrective Action

 

4152.2 When an Operation Repeatedly Fails to Meet Restrictions or Conditions

March 2017

 

If the operation repeatedly fails to meet the restrictions or conditions, Licensing staff consult with the supervisor on what action to take.

See:

3800 Handling Changes in an Operation, Type of Permit, Location, and Ownership

5140 Rescinding or Amending a Waiver or Variance

10000 Background Checks

7000 Voluntary Actions and Enforcement Actions

 

4152.3 Discussing Waivers and Variances

June 2016

 

Licensing staff discuss any waivers or variances that have expired since the last monitoring inspection with the operation to assess the outcome of the waiver or variance and document the outcome in CLASS. Licensing staff also discuss any waivers or variances that are still in effect to determine if any are no longer needed.

See 5121 Documenting Outcomes for Waivers and Variances.

 

4153 Reviewing Records at an Operation

March 2019

 

Licensing staff review the records of licensed, registered, and certified operations to evaluate compliance with Licensing statutes, administrative rules, and minimum standards.

Licensing staff must review a minimum number of records based on the operation’s type and its capacity unless the inspection is being conducted during night hours at a residential operation.

The records are reviewed at the operation or at a central administrative location. Licensing staff may make copies of documents, as needed, but they do not remove original records from the operation.

40 TAC §§745.8415; 745.8417

After evaluating records, Licensing staff document the type and number of records evaluated on CLASS Form 2936 Child-Care Facility Inspection.

See 4161 Completing CLASS Form 2936 Child-Care Facility Inspection.

 

4153.1 Selecting a Sample of Records for a Monitoring Inspection or Two-Year Period

November 2017

 

Procedure

Types of Records to Read

Types of records that Licensing staff must read include those that relate to:

  1. enrolled in or admitted to the operation;
  2. employees;
  3. verified foster homes;
  4. approved adoptive homes, for child-placing agencies (CPAs);
  5. birth parents who have applied for services (for CPAs that do private adoptions); and
  6. serious incident reports (for residential operations).

Licensing staff do not sample background check records. For policies on reviewing background check records, see 4153.2 Reviewing Background Check Records During Inspections.

Determining the Number of Records to Read at a Residential Child Care Operation for Each Monitoring Inspection

At each monitoring inspection, Licensing staff read the minimum number of each type of record based on:

  • the operation’s capacity, if the operation is a general residential operation or independent foster family or group home; or
  • the total number of verified foster homes and/or approved adoptive homes, if the operation is a child-placing agency.

At each monitoring inspection, Licensing staff read the minimum number of records for each type of record according to the operation’s capacity or number of homes in the following chart:

Capacity/Number of Homes Minimum Number of Each Type of Record to Review During Each Inspection
44 or less 2
45-74 3
75-94 4
95 or more 5

Note: Exception to the chart: If the operation is on evaluation or probation, Licensing staff are only required to read two of each type of record at each monitoring inspection during the corrective action period.

Licensing staff may read more than the minimum number of records, if necessary, based on the risk identified at the operation or patterns of deficiencies observed.

Determining the Number of Records to Read at a Child Day Care Operation in Each Two-Year Period

During at least one monitoring inspection during the operation’s two-year compliance period, as indicated on the Minimum Standards Evaluated Details page in CLASS, Licensing staff read the minimum number of each type of record, according to the following chart:

Capacity Minimum Number of Each Type of Record in Each Two-Year Period
44 or less 4
45-74 6
75-94 8
95 or more 10

Licensing staff may read more than the minimum number of records, if necessary, based on the risk identified at the operation or patterns of deficiencies observed.

Records that are Not Eligible for Sample

When selecting records to read, Licensing staff must not select records of children who are no longer clients of the operation or staff who are no longer employed by the operation, unless Licensing is evaluating standards related to discharge requirements or the availability of records.

 

4153.11 Sampling Additional Records During a Follow-Up Inspection

November 2017

 

During a follow-up inspection conducted to confirm that the operation is now in compliance, Licensing staff may sample additional records to ensure compliance. See 4300 Conducting a Follow-Up with an Operation.

 

4153.2 Reviewing Background Check Records During Inspections

June 2015

 

During each application, initial, and monitoring inspection, Licensing staff review background check records on all persons required to have a background check to determine whether the operation is in compliance with all background check requirements.

During each investigation inspection, Licensing staff ensures the operation has complied with background check requirements concerning the persons involved in the investigations, including principals and any collaterals interviewed. For follow-up inspections, Licensing staff review any background check records relevant to the follow-up being conducted.

See 4140 Preparing for Inspections, and 10700 Determining Compliance with Background Check Requirements.

 

4153.3 Reviewing Information on Controlling Persons

June 2015

Procedure

During inspections with a category of Application, Initial, or Monitoring, the inspector reviews the list of controlling persons with the person in charge to determine if:

  1. the list accurately reflects the status of all controlling persons for the operation;
  2. the information entered on each controlling person on the Controlling Person Detail page in CLASS is accurate; and
  3. the operation has complied with all requirements on controlling person in statute, administrative rules, and minimum standards.

Controlling Person with a Status of Review

If any controlling person on the list has a status of Review, the inspector follows the procedures in 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS.

List of Controlling Persons in CLASS is Inaccurate

If the list of controlling persons in CLASS is inaccurate, the inspector:

  1. documents the changes in a Chronology (category, Controlling Persons);
  2. directs the operation to submit updated information according to the procedures in 5420 When and How Applicants and Operations Submit Information on Controlling Persons; and
  3. cites a deficiency of the appropriate minimum standard, if the operation did not notify Licensing within two days of when a person became or ceased to be a controlling person.

 

4153.4 Reviewing Records at a Central Administrative Location

June 2015

 

When reviewing records at a central administrative location that does not have an operation number, Licensing staff:

  • document deficiencies as an assessment in CLASS for the applicable operation; and
  • follow-up on deficiencies with the operation that was cited or with the person who maintains records at the central administrative location.

 

4154 Technical Assistance

 

 

4154.1 Providing Technical Assistance

September 28, 2018

 

Licensing staff provide technical assistance as needed to help applicants, permit holders, and operation employees understand and comply with Licensing statutes, administrative rules, and minimum standards.

Technical assistance supplements Licensing's regulatory requirements by providing additional information or clarification. Technical assistance does not repeat the language as written in the minimum standard, rule, or statute.

All technical assistance provided by Licensing staff must be documented in CLASS. See 4154.2 Documenting Technical Assistance.

Procedure

Licensing staff provide technical assistance by giving applicants, permit holders, and operation employees additional guidance and information to help them understand and comply with requirements in a specific minimum standard, administrative rule, or statute.

Technical assistance can be provided during inspections or through communications such as telephone and email.

Distributing Documents as Part of Providing Technical Assistance

Any documents Licensing staff distribute as part of providing technical assistance must:

  • come from the Technical Assistance Library (TA Library); or
  • be an approved HHSC form.

Licensing staff may print or email documents from the TA Library to applicants, permit holders, or operation employees.

 

4154.2 Documenting Technical Assistance

August 2012

 

Licensing staff document all technical assistance provided to an applicant, permit holder, or operation employee in CLASS, including the:

  • name of any technical assistance resource or document given; and
  • details of discussions regarding how to achieve or maintain compliance.

Documenting Technical Assistance Provided During an Inspection

Procedure

To document technical assistance provided during the course of an inspection, Licensing staff enter the following information on the Standards Detail page of the inspection in CLASSMate or CLASS:

  1. Select an individual Licensing statute, administrative rule, or minimum standard and choose the appropriate finding.
  2. Mark the Technical Assistance check box.
  3. Document in the CLASS or CLASSMate Technical Assistance Documentation narrative box:
    • a summary of the information provided to the operation, and
    • the documents that were shared with the operation. See 4154.1 Providing Technical Assistance.

Documenting Technical Assistance Provided Outside of an Inspection

Procedure

If Licensing staff provide technical assistance (TA) outside the course of an inspection, staff document the TA in the operation's record in CLASS as follows:

  1. Create a new chronology, selecting Operation General for the type of chronology.
  2. List which minimum standard, administrative rule, or statute the assistance was related to.
  3. Summarize the information provided.
  4. List which documents were shared with the operation. See 4154.1 Providing Technical Assistance.

 

4155 Determining When a Deficiency Can Be Corrected at Inspection

March 2019

 

Licensing staff evaluate certain criteria to determine whether a deficiency may be corrected at inspection or whether Licensing staff must follow up on a deficiency with or without an inspection. Licensing staff consider the following criteria:

  • risk to children;
  • scope and severity of the deficiency;
  • time and expense needed to correct the deficiency;
  • provider’s previous compliance history, including previous enforcement actions;
  • provider’s willingness and ability to comply; and
  • action taken by the operation to comply.

See 4310 How to Conduct a Follow-Up with an Operation

Procedure

Licensing staff may indicate that the operation corrected the deficiency at the inspection if Licensing staff determines that:

  • the operation has the ability to correct the deficiency at the time of the inspection; and
  • no follow-up action is needed to further evaluate compliance with the minimum standard.

Before concluding the inspection, Licensing staff documents that the operation corrected the deficiency at inspection. On the CLASS Form 2936 Child-Care Facility Inspection, Licensing staff:

  • selects the Corrected at Inspection check box associated with the deficiency that was corrected; and
  • documents how the operation corrected the deficiency at inspection in the Narrative section associated with the deficiency.

 

4156 When an Inspection is Attempted

August 2012

 

For all inspections, except follow-up inspections on operations with a suspended, revoked, or denied permit, when there is no contact person at the operation when Licensing staff arrives to conduct the inspection, Licensing staff:

  • document in CLASSMate and in CLASS that the inspection was not carried out for lack of a contact at the operation; and
  • establish contact with the operation to determine whether the operation is providing child care services, unless contacting the operation would impede an ongoing investigation. Licensing staff document all contacts or attempted contacts in CLASS as a Chronology with a category of Monitoring or Investigation, as appropriate.

For instructions on attempted inspections related to a follow-up inspection on an operation with a suspended, revoked, or denied permit, see 7636 Follow-Up to Suspension, Revocation, or Denial.

Procedure

Licensed, Certified, Registered, or Listed Operations

Licensing staff document an attempt to inspect a licensed, certified, registered, or listed operation as follows:

  1. Complete CLASS Form 2936 Child-Care Facility Inspection, documenting the attempted inspection and cite any observed deficiencies of Licensing statutes, administrative rules, or minimum standards, if appropriate.
  2. If mailing the form would not impede an ongoing investigation, Licensing staff include in the form:
  • a request that the operation contact Licensing staff within 10 days of receiving the form or letter, and
  • a warning that failure to respond may be interpreted by Licensing as an indication that the operation has voluntarily closed.
  1. Mail a copy of the form to the operator, applicant, or designee by regular mail.
  2. If mailing the form would impede an ongoing investigation, Licensing staff consult with the supervisor on when to mail the form to the operator, applicant, or designee.

If Licensing staff mail Form 2936 after the attempted inspection, Licensing staff follow the procedures in the chart below, based upon the operation’s response to receiving Form 2936:

If … then …
the operation does not respond on or before the first workday after 13 calendar days from the date Form 2936 was mailed (10 days after the date that the operation is presumed to receive the notification by regular mail) … re-inspect to ensure the operation has closed.
If there is no staff at the operation during the second attempt to inspect:
  • enter the inspection in CLASS as Attempted (see 7340 Voluntary Closure); and
  • close the operation in CLASS.
the operation notifies Licensing that it is still in business but has no children in care … notify the operation that it must be open to inspection and maintain compliance with licensing statute, administrative rules, or minimum standards, unless the person in charge chooses to close temporarily. See 7330 Voluntary Suspension.
the operation responds and notifies Licensing that it is still in business and children are in care … conduct an inspection, and continue to conduct inspections, thereafter, as appropriate. See 4140 Preparing for Inspections.

CPA Foster Homes – Attempted Investigation Inspections

To document an attempt to conduct an investigation inspection of a foster home verified by a child-placing agency (CPA), Licensing staff do as follows:

  1. Complete CLASS Form 2936 Child-Care Facility Inspection, documenting the attempted inspection and cite any observed deficiencies of Licensing statutes, administrative rules, or minimum standards, if appropriate.
  2. If mailing the form would not impede an ongoing investigation, Licensing staff include in the form:
  • a request that the CPA contact Licensing staff within 10 days of receiving the form or letter, and
  • a warning that failure to respond may be interpreted by Licensing as an indication that the foster home is no longer verified by the CPA.
  1. Mail a copy of the form to the CPA by regular mail.
  2. If mailing the form would impede an ongoing investigation, Licensing staff consult with the supervisor on when to mail the form to the CPA.

After completing Form 2936, Licensing staff:

  • consult with the supervisor on how to proceed with the investigation; and
  • document the supervisor’s guidance in CLASS as a Chronology with the type of Investigation.

CPA Foster Homes – Attempted Random-Sampling Inspections

If the inspector attempts a random-sampling inspection of a foster home that is verified by a child-placing agency (CPA), the inspector follows procedures in 4435.3 Attempted Random-Sampling Inspections.

 

4157 Visiting an Operation to Conduct an Investigation Interview When the Operation is Not the Subject of the Investigation

August 2012

 

When Licensing staff visit an operation as part of an investigation to interview a child or a person of interest and the operation is not involved in the allegations, Licensing staff:

  1. Document the inspection on Form 2936 Child-Care Facility Inspection as Other. See 4161 Completing Form 2936 Child-Care Facility Inspection.
  2. Do not conduct a walk-through inspection, but do cite any obvious, plain-view deficiency seen or heard.
  3. Do not evaluate background check requirements.
  4. Do not evaluate the operation’s compliance with minimum standards.

 

4158 Avoiding Duplication of Child Day Care Inspections

July 2019

Licensing staff do not monitor a licensed child care center, school-age program, before or after-school program, licensed child care home, or registered child care home for compliance with minimum standards when another state agency or political subdivision has inspected it for compliance with equivalent standards. See Texas Human Resources Code §§42.0442; 42.0443.

 

4158.1 Avoiding Duplication of Child Day Care Inspections by State Agencies and Political Subdivisions

July 2019

 

To eliminate redundancy, Licensing reviews documentation from other state agencies and political subdivisions that inspect the same operations as Licensing. Licensing staff do not inspect an operation for compliance with a minimum standard if another agency or political subdivision:

  • inspected the operation for compliance with an equivalent requirement within the last 12 months before the Licensing inspection; and
  • found the operation to be in compliance, or the operation provides documentation showing that it has:
    • corrected deficiencies to the satisfaction of the other agency or political subdivision; and
    • complied with all restrictions or conditions placed by the other agency or political subdivision.

Licensing staff always investigate reports of alleged violations of minimum standards, regardless of whether another state agency or political subdivision has inspected the operation.

Procedure

The entities that inspect child day care operations for compliance with standards that are equivalent to Licensing’s minimum standards are:

  • Immunization Branch of the Texas Department of State Health Services (DSHS);
  • State Fire Marshal’s Office (SFMO);
  • Child and Adult Care Food Program (CACFP) of the Texas Department of Agriculture; and
  • Some political subdivisions (cities, counties, junior college districts or public health districts), depending on what inspection requirements exist in those areas.

Actions Required by Licensing

If a state agency or political subdivision finds that an operation is not in compliance with a requirement that is equivalent to a licensing law, administrative rules, or minimum standards and the operation does not correct the deficiency, Licensing staff:

  • evaluate the operation’s compliance with applicable minimum standards to ensure protection of the children; and
  • document any compliance or correction issues.

In All Cases

In all cases, during each inspection of an operation, Licensing staff:

  • evaluate the operation for obvious fire, sanitation, and safety hazards; and
  • cite the deficiencies observed.

If deficiencies related to fire safety or sanitation are cited at a licensed child care center, school-age program, or before or after-school program, report those deficiencies to the appropriate state agency or political subdivision, if applicable.

Texas Human Resources Code §42.0443

Civil Practices and Remedies Code §101.001(3)(B)

Fire, Immunization, Nutrition and Sanitation Standards for Child Day Care Facilities

Licensing staff do not evaluate for compliance with any part of the following minimum standards if the operation has documentation showing that another state agency or political subdivision evaluated equivalent requirements within the past year and there are no outstanding deficiencies:

Inspection Type Minimum Standard Rules
Fire

§§744.3561; 744.3563; 744.3565; 744.3603-3619

§§746.5207; 746.5209; 746.5211; 746.5303-5319

§§747.5007; 747.5011-5015; 747.5105-5117

Immunization

§§744.613-623

§§746.613-625

Nutrition

§§744.2403-2407; 744.2411-2417

§§746.3303-3307; 746.3315; 746.3316; 746.3319

§§747.3103-3107; 747.3113; 747.3115; 747.3116

Sanitation

§§744.2419; 744.2507; 744.2513; 744.2525-2531; 744.2701-2703; 744.3001-3011

§§746.3317; 746.3407; 746.3427; 746.3429; 746.3431; 746.3433; 746.3901; 746.3903; 746.4419; 746.4403; 746.4405; 746.4407; 746.4409; 746.4411; 746.4417

§§747.3117; 747.3203-3209; 747.3223-3229; 747.3701-3703; 747.4201-4207

 

4158.2 Child Day Care Operations Located at Public School Facilities

July 2019

 

Licensing does not evaluate for compliance with the following minimum standards if the operation is in a public school facility operated by the local independent school district.

Topic Minimum Standard Rules
Sanitation Inspection

§744.2501

§746.3401(a)

Fence

§744.2953

§746.4305(1)

Active Play Equipment

§744.3101

§746.4601(11)

Fire Inspection

§744.3501

§746.5101(a)

Fire–Extinguishing System

§744.3601

§746.5301

Smoke Detectors

§744.3611

§746.5311(b)

Gas

§744.3651

§746.5401

 

4159 Handling Resistance or Refusal to Allow Inspection

September 28, 2018

 

An operation’s employees must admit Licensing staff and not delay or obstruct Licensing staff from making inspections during hours of operation.

Texas Human Resources Code §§42.044(a) and 42.04412

40 TAC §§745.8413, 745.8415, 745.8419

Procedure

If the employees of an operation delay or obstruct Licensing from making an inspection during the operation’s business hours, Licensing staff follow the procedures outlined below.

If … then …

the operation’s employees:

  • refuse to admit Licensing staff to the operation;
  • attempt to delay or obstruct Licensing staff from inspecting the operation during business hours;
  • refuse to allow Licensing staff to inspect an area of the operation that affects or could affect the children’s health, safety, or well-being; or
  • delay or obstruct an attempt to inspect or investigate, so that Licensing staff cannot carry out their responsibilities …
Licensing staff:
  1. advise the person in charge of the operation that:
    • the inspection or investigation is authorized by Texas Human Resources Code §§42.044(a) and 42.04412, and
    • HHSC may take enforcement action against the operation’s permit if the resistance continues.
  2. obtain the name of the person in charge at the operation, if possible;
  3. cite obstruction of the inspection or investigation and violation of rules using Form 2936 Child-Care Facility Inspection in CLASS. Include documentation on the form that, if Licensing inspections are further denied, obstructed, or delayed, HHSC may take enforcement action against the operation’s permit under Texas Human Resources Code §§42.071 and 42.072;
  4. consult with the Licensing supervisor about the necessary follow-up actions;
  5. see 7200 Handling Immediate Danger to Children, if children are in immediate danger;
  6. take one or more of the following actions, depending on the circumstances:
    • Schedule an appointment with the permit holder or applicant.
    • Make an unannounced inspection of the operation.

See also 7600 Adverse Actions.

 

4160 Documenting the Results of an Inspection

August 2012

 

When documenting the results of an inspection, Licensing staff:

  1. documents deficiencies clearly and concisely;
  2. cites the specific Licensing statutes, administrative rules, or minimum standards for which compliance was evaluated and describes the deficiencies observed;
  3. documents the technical assistance given for each Licensing statute, administrative rule, or minimum standard, if applicable;
  4. states the dates by which corrections must be made. Compliance dates must be reasonable and based on the risk to children. See 4500 Evaluating Risk to Children; and
  5. provides the inspection results to the operation at the conclusion of the inspection, on the same day that the inspection took place.

Inspection results are documented on CLASS Form 2936 Child-Care Facility Inspection on the same day as the inspection. If inspection results are left pending or if corrections need to be made to the original Form 2936, Licensing staff create a supplemental Form 2936.

See:

4161 Completing CLASS Form 2936 Child-Care Facility Inspection

4162 Finalizing Form 2936 and Sychronizing CLASSMate with CLASS

4163 Final Determination of Findings Left Pending During an Inspection

4165 Completing a Supplemental Inspection Form

Citing Deficiencies Unrelated to an Inspection

If deficiencies unrelated to an inspection must be cited, Licensing staff use CLASS Form 2939 Child Care Facility Assessment. See 4200 Citing Deficiencies with an Assessment.

 

4161 Completing CLASS Form 2936 Child-Care Facility Inspection

August 2012

 

After reviewing the background materials related to the operation (see 4140 Preparing for Inspections), Licensing staff create a draft of CLASS Form 2936.

On the same day as the inspection, after the inspection is completed, Licensing staff complete CLASS Form 2936 Child-Care Facility Inspection to document inspection results.

Documenting a Possible Deficiency as Pending on Form 2936

If staff need to conduct further investigation or consult with the supervisor before determining compliance with a specific Licensing statute, administrative rule, or minimum standard, each item requiring further action is documented as Pending on CLASS Form 2936. Licensing staff use the Pending status only if staff cannot determine an operation’s compliance with a statute, rule, or standard before leaving the operation.

Licensing staff must determine whether issues related to an inspection that were documented as pending are deficient or compliant within 10 days after an inspection is completed. See 4163 Final Determination of Findings Left Pending During an Inspection.

Signing and Providing a Copy of Form 2936

Licensing staff provide a copy of Form 2936 to the person in charge after Licensing staff conduct the exit conference. See 4172 Signing and Providing a Copy of Form 2936 Child-Care Facility Inspection

 

4161.1 Creating a Draft CLASS Form 2936

August 2019

Licensing staff follow the procedures below to create a draft version of CLASS Form 2936 Child-Care Facility Inspection.

Enter the Details

To enter the inspection details in CLASS, on Form 2936 Child-Care Facility Inspection, Licensing staff take the following steps:

  1. On the Operation main page, select the Monitoring tab.
  2. On the Inspection/Assessment List page, select Add New Inspection.
  3. On the Inspection Details page in the General section, select the appropriate Inspection Type (see 4120 Types of Inspections).
  4. Choose the investigation numbers, if the inspection type is Investigation or Monitoring and Investigation.
  5. Choose the appropriate Follow Up to Inspections IDs (select up to three IDs), if the inspection type is Follow Up.
  6. Enter the Inspection Start Date (The inspection start date may be updated after the inspection, if necessary).
  7. Select the check box(es) corresponding to the subchapter(s) if evaluating compliance of all rules in the subchapter(s) as part of a Monitoring or Monitoring/Investigation inspection.
  8. Select the HASA check box if a health and safety audit or standard-by-standard evaluation is being conducted as part of an unannounced Monitoring or unannounced Monitoring/Investigation inspection of a licensed child care center, school-age program, before- or after-school program, licensed child care home or registered child care home.
  9. Complete other applicable fields and select Save.

Save and Download

  1. Save the draft form.
  2. Download the saved draft to CLASSMate before conducting the inspection.

See also 4311.1 Documenting Follow-Up Inspections

4161.2 Documenting Inspection Results on CLASS Form 2936

November 2017

 

Procedure

Licensing staff use CLASS Form 2936 Child Care Facility Inspection to document inspection.

All Inspections

Licensing staff documents:

  1. the finding (non-compliant, compliant, or pending) for each Licensing statute, administrative rule, or minimum standard that was evaluated during the inspection (see 4161.21 Documentation of the Findings Evaluated From the Inspection);
  2. technical assistance provided, if any (see 4154.2 Documenting Technical Assistance); and
  3. a list of any hazards that the operation must correct immediately.

If conducting an inspection at a licensed child care center, before- or after-school program, or school-age program, and the designated director is present during the inspection, Licensing staff selects the Director Present check box. See 4131 Minimum Requirements for Licensed Operations.

If conducting an inspection at a licensed child care center and the inspector evaluated the director’s qualifications during the inspection, Licensing staff selects the Dir Qual Eval check box. See 3331 Evaluating Director and Primary Caregiver Qualifications for Licensed Child Day Care Operations).

Initial and Monitoring Inspections

Licensing staff documents the review of restrictions and conditions by checking the …items regarding risk to children… check box (for initial and monitoring inspections only; see 4152 Reviewing Restrictions, Conditions, Waivers, and Variances);

Application, Initial, and Monitoring Inspections

Licensing staff documents whether Licensing staff assessed risk to children as required during the operation walk-through by checking the …items regarding risk to children…check box. Licensing staff check the …items regarding risk to children… check box for all application, initial, and monitoring inspections.

See:

4151 Operation Walk-Throughs

4157 Visiting an Operation to Conduct an Investigation Interview When the Operation is Not the Subject of the Investigation

Background Check Requirements During an Application, Initial, or Monitoring Inspection

If conducting an application, initial, or monitoring inspection, Licensing staff documents information to indicate whether Licensing staff has ensured the operation has complied with background check requirements by selecting the Background Checks have been Verified/Evaluated check box (see 10700 Determining Compliance with Background Check Requirements).

Background Check Requirements During an Investigation Inspection

If conducting an investigation inspection, Licensing staff documents information to indicate whether Licensing staff has ensured the operation has complied with background check requirements for principals and collaterals known at time of the inspection by selecting the Background Checks have been Verified/Evaluated check box (see 10700 Determining Compliance with Background Check Requirements).

Controlling Persons Verified During an Application, Initial, or Monitoring Inspection

If conducting an application, initial, or monitoring inspection, Licensing staff documents information to indicate that the inspector has discussed the list of controlling persons, as documented in CLASS, with the person in charge. If appropriate, the inspector checks the Controlling Persons Have Been Verified check box.

See:

4153.3 Reviewing Information on Controlling Persons

4171 Discussing the Results of an Inspection

5400 Controlling Person

Follow-Up Inspection

If conducting a follow-up inspection, Licensing staff document:

  • a list of all of the deficiencies or conditions being followed-up on and a finding of NC (deficient) or CO (compliant); and
  • a narrative explaining how the operation is compliant or the efforts the operation has made toward compliance.

 

4161.21 Documentation of the Findings Evaluated from the Inspection

June 2015

 

If documenting a deficiency, Licensing staff document the following in the Narrative field in CLASSMate or CLASS:

  • Explain how the operation is deficient. (Describe observations in detail. Do not merely repeat the requirement in the statute, rule, or minimum standard.)
  • Describe how the deficiency was corrected during the inspection, if applicable.

If further investigation or consultation with the supervisor is needed before determining whether the operation is in compliance with a statute, rule, or minimum standard, Licensing staff document the finding as Pending. If Form 2936 is completed in CLASS, rather than in CLASSMate, Licensing staff must type the following statement on the form for all pending deficiencies (the statement automatically prefills in CLASSMate). This possible standard violation is under further review. Final notification will be sent at a later time.

If documenting an inspection being conducted as part of an investigation, investigators also:

  • code any citations for plain-view violations observed during the walk-through as Monitoring (MN); and
  • add appropriate minimum standards with a code of Investigation (IV), if the investigator obtains information regarding a violation related to the allegation being investigated that was not previously identified.

 

4161.22 Limits to Documenting Names of Children

June 2015

 

When documenting inspection results, Licensing staff do not include the names of children when entering information that could be published on the public website. See 8230 Confidential Information Not to Be Released to the Public.

Licensing staff use only a child’s first name and last initial on hard copy forms (such as inspection guides) and in sections of CLASS that are not published on the public website, such as the Chronology and Contact fields.

 

4161.23 Limits to Documenting Names of Operation Employees

June 2015

 

When documenting inspection results, Licensing staff do not include the names of operation employees in documentation that is published on the public website. See 8230 Confidential Information Not to Be Released to the Public.

Licensing staff may use staff names on paper copies of forms, such as inspection guides, and in sections of CLASS that are not published on the public website, such as the Chronology and Contact fields.

 

4161.24 Technical Assistance for High Risk Violations

September 2015

 

When citing a high risk violation which may result in an administrative penalty, staff:

  • provides technical assistance on how to comply with the minimum standard or rule; and
  • advises the operation that another violation of the high risk minimum standard previously cited could result in an administrative penalty.

Staff documents, in the Technical Assistance narrative box in CLASS, as outlined in the Guidelines for Assessing Admin Penalties Related to BGC Deficiencies job aid, that:

  • the technical assistance on compliance was provided; and
  • the operation was advised of the risk of incurring an administrative penalty.

 

4161.3 Leaving an Operation Temporarily to Document Inspection Results

August 2012

 

Procedure

If Licensing staff leave the operation to record the results of the inspection on Form 2936 Child-Care Facility Inspection in CLASSMate, staff document in the Narrative field:

  • the time leaving the operation; and
  • the time returning to the operation to conduct the exit conference.

For example:

Left operation at (insert time) and returned at (insert time).

CLASSMate captures the time the inspection ended when Licensing staff click the Lock button on the form.

 

4161.4 Documenting an Inspection Continued on the Following Day

August 2012

 

Procedure

If an inspection must be continued on the following day, staff complete a new CLASS Form 2936 Child-Care Facility Inspection.

 

4162 Finalizing Form 2936 and Synchronizing CLASSMate with CLASS

August 2012

 

Finalizing Form 2936

Procedure

Before finalizing the form, Licensing staff:

  1. conduct the exit interview to discuss the results of the inspection with the person in charge at the operation;
  2. sign Form 2936;
  3. have the person in charge at the operation sign Form 2936.

See:

4170 Conducting the Exit Conference

4171 Discussing the Results of the Inspection

4172 Signing and Providing a Copy of Form 2936 Child Care Facility Inspection

After conducting the exit interview and signing the form, Licensing staff finalize Form 2936 Child-Care Facility Inspection in CLASSMate by clicking:

  • Save Final; and
  • Lock.

After finalizing the form, Licensing staff provide a copy of Form 2936 to the person in charge. See 4172.

Synchronizing CLASSMate with CLASS

On the same day Form 2936 is completed, when possible, Licensing staff synchronize with CLASS in order to upload the inspection into CLASS.

 

4163 Final Determination of Findings Left Pending During an Inspection

December 2015

 

Within 10 days after completing an inspection, Licensing staff must:

  • determine whether the operation is deficient or compliant regarding any pending inspection findings coded as Monitoring; and
  • document the final determinations on a supplemental Form 2936 Child-Care Facility Inspection and mail or email it to the operation. See 4165 Creating a Supplemental Inspection Form.

40 TAC §§745.8447(1); 745.8445

 

4164 Procedures When the Operation’s List of Controlling Persons Cannot Be Verified During the Inspection

March 2013

 

Procedure

If during an Initial or Monitoring inspection the inspector cannot verify whether the operation’s list of controlling persons in CLASS is accurate, the inspector does all of the following within 10 days of the inspection:

  1. Contacts the operation’s governing body to verify whether an operation’s list of controlling persons list in CLASS is accurate.
  2. Follows the procedures in 7773.4 Reviewing the Status of a Sustained Controlling Person in CLASS, if any controlling person on the list has a status of Review.
  3. Documents the contact with and information obtained from the governing body as a Chronology (category, Controlling Persons).
  4. Does as follows, if the controlling persons has changed:
    1. Documents the changes in a Chronology (category, Controlling Persons);
    2. Directs the operation to submit updated information according to the procedures in 5420 When and How Applicants and Operations Submit Information on Controlling Persons; and
    3. Cites a deficiency of the appropriate minimum standard by completing a supplemental CLASS Form 2936 Child Care Facility Inspection, if the operation did not notify Licensing within two days of when a person became or ceased to be a controlling person. See 4165 Completing a Supplemental Inspection Form.

 

4165 Completing a Supplemental Inspection Form

November 2017

 

Staff create a supplemental Form 2936 Child Care Facility Inspection in CLASS only to:

  • document the final determination about an operation’s compliance with Licensing statutes, administrative rules, or minimum standards that were left pending during an inspection; or
  • correct errors in spelling, grammar, or content on the original CLASS Form 2936 Child Care Facility Inspection.

If deficiencies unrelated to an inspection must be cited, Licensing staff use CLASS Form 2939 Child-Care Facility Assessment. See 4200 Citing Deficiencies With an Assessment.

Procedure

To complete a supplemental Form 2936 Child Care Facility Inspection, Licensing staff follow these steps:

  1. Select the appropriate inspection in CLASS.
  2. Update pending findings to NC (deficient) or CO (compliant).
  3. Enter the all of the following information in the Narrative field on the supplemental Form 2936:
    1. Description of the change that is being made.
    2. Statement that the supplemental Form 2936 replaces the original Form 2936 Child-Care Facility Inspection that was left at the operation on the date of the inspection.
    3. The date of the previous inspection.
    4. The posting requirements, if any apply. See 4173 Posting the Day Care Inspection Form or Assessment Form.
  4. Change the date of notification in CLASS to the date the supplemental Form 2936 is created.
  5. Save and finalize the second version of CLASS Form 2936 by selecting Save Final and Lock.

 

4165.1 Contacting the Permit Holder

September 2012

 

Before mailing the supplemental Form 2936, Licensing staff contact the permit holder to:

  1. discuss the determination made on findings left pending during the inspection, if any;
  2. discuss other changes to the inspection findings, if any; and
  3. inform the permit holder of his or her right to an administrative review. See 7710 Administrative Reviews.

 

4170 Conducting the Exit Conference

December 2015

 

After completing an inspection, Licensing staff conduct an exit conference with the person in charge at the operation. During the conference, staff:

  • discuss the results of the inspection, including the reason for any deficiency issued;
  • review, but do not provide copies of, all photographs that were taken during the inspection that relate to deficiencies;
  • provide any technical assistance that may assist the operation in addressing issues that have been identified and documented;
  • review the requirements and time frames to request an administrative review, if any deficiencies were issued; and
  • provide a copy of CLASS Form 2936 Child Care Facility Inspection to the person in charge.

See:

7711.3 Explaining the Right to an Administrative Review

8230 Confidential Information Not for Release to the Public

Texas Human Resources Code §42.0441

40 TAC §§745.8495; 745.8801 – 8811

When conducting the exit conference for an initial or monitoring inspection, Licensing staff also:

  • verify the operation’s contact information; and
  • review the operation’s compliance history, including concerns or patterns, with the person in charge.

 

4171 Discussing the Results of an Inspection

March 2017

 

Procedure

During each exit conference, Licensing staff do as follows:

  • Allow the person in charge an opportunity to discuss the findings.
  • Provide the person in charge with the following, if applicable:
    1. Any technical assistance needed to address issues that were identified and documented during the inspection, if applicable. (See 4154 Technical Assistance.).
    2. Information about how high-risk deficiencies or a pattern of deficiencies may affect the frequency of inspections.
    3. Information about how failure to comply within specified deadlines or repeated deficiencies may result in enforcement action without further opportunity to correct the deficiencies.
    4. Information about how to comment on the inspection by completing the CCL Inspection Feedback Survey. (The Web address for the survey is printed on CLASS Form 2936 Child-Care Inspection Form, which Licensing staff provide before leaving the operation.)
    5. Information about how the operation may request an administrative review in writing within 15 days of receiving the results of the inspection and information on what the request must include to be considered complete. (See 7713 Receiving a Request for an Administrative Review.)

Additional Requirements for Initial and Monitoring Inspections

During each exit conference for an inspection with a category of Initial or Monitoring, Licensing staff also:

  • review with the person in charge the operation’s compliance history since the previous monitoring inspection, including any concerns or patterns of deficiencies; and
  • verify the accuracy of the information entered on the Operation Main page in CLASS.

If either the Location Address Validation Status or Mailing Address Validation Status is set to Not Validated, Licensing staff must review the address with the person in charge. If the person in charge indicates that either the location or mailing address in CLASS is inaccurate, the inspector:

  • documents the correct information in a Chronology (category, Operation General); and
  • enters the corrected address in CLASS and attempts to validate the address according to the procedures in 1600 Validating an Address in CLASS following the inspection.

 

4171.1 Discussing Pending Results

September 2012

 

Except for inspection findings coded as Investigation, if a determination cannot be made on any aspect of an inspection, Licensing staff explain to the person in charge that Licensing:

  • will mail a final determination, in the form of a supplemental inspection form, within 10 days; and
  • may include additional information on the supplemental inspection form that was not included on the original CLASS Form 2936 Child Care Facility Inspection.

See:

4161 Completing CLASS Form 2936 Child Care Facility Inspection

4165 Completing a Supplemental Inspection Form

 

4171.2 Addressing an Operation’s Concerns About Inspection Findings

September 2012

 

Licensing staff work with the person in charge to address any concerns relating to:

  • minor changes to a deficiency narrative, if the change does not impact the meaning of the citation and does not minimize the scope or severity of the violation; and
  • compliance dates, if the person in charge has a valid reason for not being able to come into compliance sooner than the proposed date, as long as the change does not compromise the health or safety of children in care.

Immediately after changing any documentation on CLASS Form 2936 Child Care Facility Inspection as a result of feedback from the person in charge, Licensing staff enter a Chronology in CLASS that includes:

  1. the CLASS inspection number;
  2. a description of the changes requested by the person in charge; and
  3. a description of what changes were made.

 

4172 Signing and Providing a Copy of Form 2936 Child Care Facility Inspection

December 2015

 

Procedure

At the end of the exit conference, Licensing staff ask the person in charge to sign CLASS Form 2936 Child Care Facility Inspection, even if the findings are left pending. Licensing staff explain that signing Form 2936 does not indicate that the person signing agrees with the inspection results. It is only an acknowledgment that Licensing conducted an inspection at the operation and does not waive the operation’s right to an administrative review.

Both the Licensing staff and the person in charge at the operation sign Form 2936. If the person in charge refuses to sign Form 2936, Licensing staff note on the inspection form the person’s name and his or her decision not to sign.

After Form 2936 is signed by Licensing staff and the person in charge, Licensing staff provide the person in charge with a printed or emailed copy of the completed form before leaving the operation.

If the operation is required to post Form 2936 in a prominent place where it may be viewed by staff, parents, and others, Licensing staff must explain this to the person in charge before leaving the operation.

See:

4160 Documenting the Results of an Inspection

4161 Completing CLASS Form 2936 Child Care Facility Inspection

4173 Posting the Day Care Inspection Form or Assessment Form

 

4173 Posting the Day Care Inspection Form or Assessment Form

August 2012

 

A licensed child care center, a school-age program, a before or after-school program, a licensed child care home, and a registered child care home must display the most recent CLASS Form 2936 Child Care Facility Inspection or CLASS Form 2939 Child Care Facility Assessment in a prominent place where it may be viewed by staff, parents, and others; however, confidential information may not be posted.

26 TAC §§744.403; 746.403; 747.401

If the operation disagrees with a Licensing decision or action and requests an administrative review, the operation may delay posting Form 2936 or Form 2939 until the administrative review is complete.

40 TAC §745.8801

See:

4200 Citing Deficiencies with an Assessment

7710 Administrative Reviews

Procedure

Licensing staff explain to the person in charge of the operation that CLASS Form 2936 Child Care Facility Inspection or CLASS Form 2939 Child Care Facility Assessment, and any supplemental inspection forms, must be posted in a prominent place where it may be viewed by staff, parents, and other persons.

If Licensing staff document part of the inspection on Form 2936 and document the rest of the inspection on a supplemental inspection form, Licensing staff attach the original CLASS Form 2936 to the supplemental form so that both will be posted.

The person in charge of the operation may note the date a correction was made on the posted form.

The operation is not required to publicly post findings of abuse or neglect.

The names of children and staff:

  • must not appear on any forms or letters that require posting in a prominent place for viewing by staff, parents, and others (see 8230 Confidential Information Not to Be Released and 4160 Documenting the Results of an Inspection); and
  • must not be documented in the areas of CLASS that appear on the public website.

Children and staff names may be documented in the hard copy record or in the areas of CLASS that are not published on the public website.

See 6631 Notifying the Operation of the Results of an Investigation.

 

4200 Citing Deficiencies with an Assessment

January 2012

 

Licensing staff may learn about a deficiency at a child care operation from a variety of sources. In such cases, Licensing staff may assess the facts provided by the source and write a citation without making an inspection of the operation.

Only deficiencies may be cited based on an assessment. An assessment must not be used for an investigation. See 6430 Conducting Inspections.

Examples of situations in which deficiencies may be identified without making an inspection include the following:

  1. The permit holder informs Licensing that the operation continues to be deficient after the deadline for correction and Licensing staff decide to re-cite the deficiency.
  2. The information entered on a background check form indicates that the request for a background check was not submitted on time.
  3. The information entered into the People List in CLASS shows that the operation is not requesting background checks on staff every two years, as required.
  4. Licensing staff cite a child placing agency (CPA) for deficiencies after conducting a sampling inspection on one of the CPA’s foster homes.
  5. Licensing staff cite a CPA for deficiencies after an enforcement team conference. See 4421 Enforcement Team Conferences for Child-Placing Agencies.
  6. Licensing staff become aware of a deficiency at one operation while interviewing children at a different operation. (For example, if residential licensing staff become aware of deficiencies while interviewing children at a day care facility, the residential staff must report the deficiencies to the assigned day care inspector.)

Citing a deficiency without an inspection does not replace a required inspection.

Procedures

When Licensing staff become aware of a deficiency without making an inspection, staff:

  1. obtain approval from a supervisor, district director, or manager to issue a citation by assessment;
  2. document the approval in the Chronology field in CLASS;
  3. complete CLASS Form 2939 Child Care Facility Assessment within 10 days after becoming aware of the deficiency and document:
    • each deficiency cited;
    • the reason for each deficiency; and 
    • the date by which the operation needs to correct each deficiency.

Before mailing Form 2939, staff contact the permit holder or designee to:

  • discuss the deficiency; and
  • inform the permit holder or designee that he or she has a right to request an administrative review within 15 days from the date he or she receives Form 2939 (see 4170 Conducting the Exit Conference and 7710 Administrative Reviews).

An assessment may not be used for an investigation. See 6430 Conducting Inspections.

 

4300 Conducting a Follow-Up with an Operation

March 2019

 

Licensing staff conduct a follow-up with an operation to:

  1. ensure that the operation is in compliance with any standards or other laws that were cited during an inspection, investigation, or assessment;
  2. determine whether the operation is complying with the conditions of a waiver or variance;
  3. determine whether the operation is complying with the conditions of a risk evaluation;
  4. conduct the annual review of qualifications of the designated director of a licensed child care center;
  5. ensure that the operation is in compliance after a corrective action ended;
  6. ensure that the operation that is closed due to suspension, revocation, or denial of a permit is no longer operating;
  7. monitor the operation during the appeal process;
  8. monitor the operation during a temporary relocation; or
  9. determine whether the operation is operating after an annual fee notice is returned to HHSC.

See:

4131.3 Child Day Care – Annual Meeting with the Designated Director at a Licensed Child Care Center

4152 Reviewing Restrictions and Conditions

5120 Setting and Monitoring Conditions for the Waiver or Variance

5270 Fee Notice is Returned

10000 Background Checks

10412 When a Risk Evaluation May Be Requested

7320 Temporary Relocation

7636 Follow-Up to Suspension, Revocation, or Denial

7731 Regulation During Appeal Process

40 TAC §745.8449

Procedure

When determining the type of follow-up action to take, Licensing staff consider:

  1. the risk to children;
  2. scope and severity of the deficiency;
  3. time and expense needed to correct the deficiency; and
  4. the provider's previous compliance history.

 

4310 How and When to Conduct a Follow-Up with an Operation

October 2019

 

When following up with an operation regarding deficiencies that were not corrected at inspection (see 4155 Determining When a Deficiency Can Be Corrected at Inspection), Licensing staff verify that deficiencies were corrected, which may include:

  1. reviewing records that had deficiencies;
  2. inspecting areas of the physical plant that had deficiencies; and
  3. observing activities related to health and safety.

When Licensing Must Conduct a Follow-Up

Licensing staff must verify and document corrections of deficiencies within the time frames outlined in the following chart for violations cited in the same inspection, investigation or assessment.

Types of Violations Follow-Up Required By
High-weighted only Within 15 days of the latest compliance date.
Non-high-weighted only Within 30 days of the latest compliance date.
High- and non-high-weighted violations Within 15 days of the latest compliance date of the high-weighted violations.

4311 Following Up with an Inspection

October 2019

 

Procedure

If Licensing staff determine that any deficiency requires a follow-up inspection, Licensing staff conduct the follow-up inspection as soon as possible, but no later than the time frames outlined in 4310 How and When to Conduct a Follow-Up With an Operation. If Licensing staff determine that an operation is not in compliance, staff follow the procedures explained in 4313 When an Operation Continues to Be Deficient.

See also:

4152 Reviewing Restrictions, Conditions, Waivers, and Variances

4320 Exceptions to Time Frames for Completing a Follow-Up With an Operation

4322 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency

4510 The CLASS Risk Review and Enforcement Recommendations

5120 Setting and Monitoring Conditions for the Waiver or Variance

10400 Risk Evaluation of Criminal History or Findings of Abuse or Neglect

 

4311.1 Documenting Follow-Up Inspections

December 2015

 

For a follow-up inspection, Licensing staff:

  • creates a new CLASS Form 2936 Child-Care Facility Inspection to document the results of the inspection (see 4161 Completing CLASS Form 2936 Child-Care Facility Inspection); and
  • documents the outcomes as described below.

Procedure

If Licensing staff is conducting the follow-up inspection as a result of a deficiency cited during a previous inspection or assessment, Licensing staff documents the results of the follow-up in Form 2936 in CLASS as follows:

  1. Licensing staff links the current inspection to the appropriate previous inspection(s) or assessment(s).
  2. Licensing staff deletes any linked citations that automatically prefill on the Inspection Summary page if:
    • the citation is not being evaluated during the current follow-up inspection; or
    • the operation requested an extension during the current follow-up inspection and the extension was granted (staff will document the extension in the original inspection in CLASS; see 4322 Granting an Operation Additional Time to Comply With a Requirement Cited as a Deficiency).
  3. For the remaining linked citations, consult the table below:
    If… Then…
    the operation is in compliance… Licensing staff:

     

    • enters Compliance in the Finding field;
    • deletes the date in the Compliance Date field; and
    • deletes the text in the Narrative text box and replaces it with a statement outlining how the deficiency was corrected.
    the operation is still deficient… Licensing staff:

     

    • enters Deficiency in the Finding field;
    • enters the new compliance date in the Compliance Date field; and
    • deletes the text in the Narrative text box and replaces it with information about how the operation continues to be deficient.

 

4312 Following Up Without an Inspection

October 2019

 

Procedure

If Licensing staff determines a follow-up inspection is unnecessary, the operation may demonstrate compliance by submitting information, such as inspection reports, invoices, photos, or videos, to Licensing by mail, fax, email, phone, or other electronical means that demonstrate the deficiency is corrected. Licensing staff then reviews the information received from the operation to determine whether it has corrected the deficiency.

If Licensing staff determines that an operation is not in compliance, staff follows the procedures explained in 4313 When an Operation Continues to Be Deficient.

 

4312.1 Documenting Follow-Ups When an Inspection is Not Required

December 2015

 

Documenting Corrected Deficiencies on the Previous Inspection or Assessment Form in CLASS

If Licensing staff determines that the operation is in compliance, Licensing staff updates the inspection or assessment form for the previous inspection or assessment by documenting in the Follow-Up Information section of the Standard Details page in CLASS:

  • date that the follow-up information was received from the operation;
  • the follow-up method (for example, whether the information was sent by mail, fax, or email);
  • results (that the deficiency has been corrected); and
  • the following information in the Additional Documentation text box:
    • how the deficiency was corrected;
    • the type of documentation the operation submitted as proof (for example, a photograph, receipt, or work order); and
    • name of the person submitting the information for the operation.

If the Additional Documentation text box in the Follow-Up Information section includes documentation about a previous extension that was granted, the inspector adds the compliance information above the documentation for the extension. The inspector does not delete the extension documentation.

Documenting Deficiencies in CLASS that Continue to be Deficient Since the Previous Inspection or Assessment

If Licensing staff determines that the operation is still deficient, Licensing staff documents the results in the Follow-Up Assessment Form in CLASS as follows:

  1. When creating the Follow-Up Assessment Form, the inspector links the follow-up assessment to the appropriate previous inspection(s) or assessment(s).
  2. The inspector deletes any linked citations that automatically prefill on the Inspection Summary page if:
    1. the citation is not being evaluated during the current follow-up inspection;
    2. the operation requested an extension during the current follow-up inspection and the extension was granted (staff will document the extension in the original inspection or assessment form in CLASS; see 4322 Granting an Operation Additional Time to Comply With a Requirement Cited as a Deficiency); or
    3. the citation was found to be in compliance during the follow-up.
  3. For the remaining linked citations where the operation continues to be deficient, staff:
    1. enters Deficiency in the Finding field;
    2. enters the new compliance date in the Compliance Date field; and
    3. deletes the text in the Narrative text box and replaces it with information about how the operation continues to be deficient.

 

4313 When an Operation Continues to be Deficient

November 2017

 

Procedure

If an operation continues to be deficient after the deadline for correcting a deficiency, Licensing staff re-cite the deficiency during the follow-up inspection or by assessment (see 4200 Citing Deficiencies With an Assessment).

In addition to taking one of the above actions, Licensing staff may:

  1. issue a warning letter and conduct a follow-up with an inspection;
  2. expedite the next monitoring inspection; or
  3. recommend enforcement action such as a plan of action, corrective action, adverse action, or administrative penalties.

See:

4330 Sending a Warning Letter and Following Up with an Inspection

4510 The CLASS Risk Review and Enforcement Recommendations

7000 Voluntary Actions and Enforcement Actions

Appendix 7000-1: Factors to Consider for Enforcement Actions

 

4320 Exceptions to Time Frames for Completing a Follow-Up with an Operation

September 28, 2018

 

 

4321 Granting Staff Additional Time to Complete a Follow-Up with an Operation

November 2017

 

Licensing staff may extend the established time frames for completing a follow-up with an operation if:

  • the operation unexpectedly closes; or
  • a condition exists that is beyond Licensing's control (examples include weather-related office closures or natural disasters).

Licensing staff must obtain approval from a supervisor, program administrator, or district director to extend the follow-up time frame.

Procedure

If Licensing staff determines that an extension of the time frame for completing a follow-up is needed, staff consults with the supervisor, program administrator, or district director to request approval.

If the extension of the time frame is approved, Licensing staff documents the extension date, the date that Licensing approved the extension, and reason for the extension in the Additional Documentation field on the Standard Details page in CLASS.

 

4322 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency

November 2017

 

Licensing staff may extend the time an operation has to comply with a requirement cited as a deficiency if the operation:

  • provides the reasons that an extension is being requested; or
  • has requested an administrative review of the deficiency, and the deficiency does not pose an immediate danger to children in care (see definition of immediate danger in Definitions of Terms).

Procedure

If an Extension is Approved

Licensing staff notifies the operation about the approval (unless the extension is based on an administrative review of a citation) and then documents the extension in CLASS by completing the following steps:

  1. Open the inspection or assessment where the citation was originally issued;
  2. Change the date in the Compliance Date field to the new compliance date;
  3. Complete the following actions in the Follow Up Information section on the Standard Details page in CLASS:
    • Select the follow-up method in the Follow Up Method field;
    • Enter the date the extension was granted in the Follow Up Date field;
    • Select Extension granted in the Results field;
    • Enter the following information in the Additional Documentation text box:
      • the date of the follow-up;
      • the follow-up method;
      • a statement that the extension was granted;
      • the date that Licensing staff approved the extension;
      • the original compliance date and
      • the new compliance date (see Examples of An Extension Documented in CLASS); and
  4. Manually create a To-Do alert in CLASS to notify staff to follow up by the compliance date.

If an Extension is Denied

Licensing staff:

  • notifies the operation about the decision; and
  • enters on the Standard Details page in the Additional Documentation box the date that Licensing denied the extension.

If the compliance date has passed and Licensing staff determines that the operation is still not in compliance, staff follows the procedures explained in 4313 When an Operation Continues to be Deficient.

 

4330 Sending a Warning Letter and Following Up with an Inspection

March 2017

 

Licensing staff send a warning letter to caution the governing body of a child care operation about the risks identified during recent inspections.

The warning letter prompts the operation to:

  • resolve patterns of deficiencies in a timely manner; and
  • maintain compliance with the law, administrative rules, and minimum standard rules on an ongoing basis.

A subsequent follow-up with an inspection is required each time Licensing staff send a warning letter. The date for the inspection is set at the discretion of Licensing staff.

Licensing staff:

  • conduct the follow-up inspection; and
  • review the operation's compliance report (available in CLASSMate).

Procedure

When risks are identified during an inspection, Licensing staff take the following actions in CLASS:

  1. Alert the operation about the risks by sending a warning letter (Form 2939 Warning Letter).
  2. Compile a compliance history of the operation, using CLASS or CLASSMate.
  3. Set a date for a follow-up inspection on the Enforcement Recommendation page.
  4. Review the compliance history report with the director or person in charge of the operation, during the follow-up inspection.
  5. Follow up on deficiencies previously noted on the compliance history report.

If two warning letters are issued within 24 months, Licensing staff work with a Licensing supervisor to determine whether to take enforcement action or consider taking other actions if the operation's risk level does not improve.

 

4400 Additional Regulatory Activities for Certain Types of Operations

September 28, 2018

 

4410 Monitoring Certified (State-Operated) Child Care Operations

September 28, 2018

 

A certified child care operation must comply with all law, administrative rules, and minimum standard rules applicable to its facility type and the services it provides.

Situations that place children at risk must be immediately communicated to a Licensing supervisor, who ensures that the appropriate CCL director is informed about the situation and about any Licensing action taken.

Texas Human Resources Code §42.052(a) and (b)

Procedure

Licensing staff notify a Licensing supervisor about:

  • any resistance to regulation; and
  • any inspection or investigation of reports in which deficiencies involving the children's health or safety are cited.

The supervisor informs the appropriate CCL director about the concerns, who in turn notifies the assistant commissioner of Licensing.

If a state-operated facility violates the law, administrative rules, or minimum standard rules and the violation threatens serious harm to the children in care, the associate commissioner of Licensing notifies the executive commissioner.

At the commissioner's direction, the associate commissioner of Licensing notifies the governor, if the situation presents immediate danger to the children's health or safety.

Licensing staff send the associate commissioner of Licensing copies of:

  • any inspection or investigation reports that cite deficiencies involving the health or safety of children; and
  • all correspondence regarding corrective or adverse action.

 

4420 Monitoring Child-Placing Agencies

December 2011

 

A child-placing agency (CPA) verifies, approves, and monitors its foster family, foster group, and adoptive homes.

For the purposes of Licensing, branch offices, foster homes, and adoptive homes are considered part of the CPA. If the CPA, any branch office of the CPA, or any of the CPA's foster homes or adoptive homes fail to comply with administrative rules or minimum standards, Licensing may do one or both of the following:

  • Cite the CPA (including a branch office) for deficiencies.
  • Take adverse action, up to and including revocation, against the permit of the CPA.

Texas Human Resources Code (HRC) §42.053

26 TAC §749.301

Procedure

Inspectors:

  • monitor the CPA by conducting interviews and reviewing the CPA's records and the information gathered from random sampling of the CPA's foster homes; and
  • use the information to determine whether the CPA:
    • is complying with law, administrative rules, minimum standard rules; and
    • is following the policies it submitted to Licensing.

Texas Human Resources Code §42.044

See 4100 Inspecting Child Care Homes and Operations.

Branch Offices

Branch offices must comply with all statues, rules, and standards related to CPAs.

Inspectors maintain separate compliance information for each branch office, but notify the CPA permit holder about all deficiencies cited at the branch offices.

For purposes of data collection, CLASS assigns a branch number to each branch office and creates a separate file in CLASS for each branch office.

CLASS Documentation Requirements

Licensing staff document in CLASS:

  1. the location and effective date of each of the CPA's branch offices;
  2. CPA's records;
  3. CPA's foster homes; and
  4. names of the CPA's staff.

 

4421 Monitoring CPAs That Conduct International Adoptions

December 2011

 

A child-placing agency (CPA) that conducts international adoptions must comply with all law, administrative rules, or minimum standard rules that apply to the type of permit the CPA holds and the services it provides.

Texas Human Resources Code §§42.002(12); 42.072; 42.044(e)(4)

Procedure

Licensing staff monitor CPAs that provide international adoption services. A CPA's adoption activities that occur in Texas are evaluated for compliance with all applicable minimum standard rules.

Licensing staff do not evaluate child-placing activities that occur in other countries.

CPAs in Texas that handle international adoptions must comply with the U.S. Department of State's requirements for international adoptions. The requirements are based on The Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption (Hague Adoption Convention). Licensing staff do not enforce the requirements in the Hague Adoption Convention, but may provide technical assistance to help CPAs obtain information from the U.S. Department of State.

 

4422 Certifying the Licensing Status of a Child-Placing Agency for International Adoptions

September 28, 2018

 

A child-placing agency (CPA) licensed in Texas may request that HHSC certify, in writing, the status of its license.

Inspectors only process certification requests from child-placing agencies (CPAs) licensed in Texas.

Before preparing a response letter to the CPA, inspectors review the CPA's Licensing record to confirm that the CPA is in good standing.

Procedure

When Licensing receives a request to certify the status of a CPA's license, the inspector responsible for the CPA responds to the request.

The inspector provides certification status only:

  • to CPAs that are licensed in Texas; and
  • upon the CPA's request.

Upon receiving a request to certify the status of a CPA's license, the inspector takes the following actions:

  1. Review the Licensing record to ensure that the CPA is in good standing.
    • An operation with a valid permit is considered in good standing with Licensing, if no corrective or adverse action is pending against the operation.
    • If a CPA is on corrective or adverse action, or such action is pending, consult with the supervisor before replying to the request.
  2. Complete a reply letter (Form 2983 Certification of a CPA License Status Letter). The letter requires:
    • supervisor approval; and
    • a notarized signature.
  3. Send the letter to the CPA.
    Before responding to a CPA that is not in good standing (that is on corrective or adverse action, or that has such action pending), the inspector obtains approval from the director of residential licensing or a licensing attorney.
  4. Document the request in CLASS, in the Chronology field, and note the date the reply letter (Form 2983) is sent.
  5. File a copy of the reply letter in the CPA's hard copy record.

Other requests are handled as follows:

  • Requests from other entities, such as the U.S. Department of State, are handled as open records requests. See 8000 Responding to Requests for Licensing Information.
  • Requests for information not addressed in Form 2983 Certification of a CPA License Status Letter, require approval from the director of residential licensing or a licensing attorney.

 

4430 Random-Sample Monitoring of CPA Foster Homes

August 2012

 

The purpose of a random-sampling inspection is to ensure that a CPA:

  1. is complying with applicable law, administrative rules, and minimum standard rules;
  2. has correctly determined that a foster home meets the requirements for verification; and
  3. has made appropriate decisions regarding:
    • the foster home's ability to work with children of a certain age or gender,
    • foster home's ability to care for children who have special needs or supervision requirements,
    • services the foster home is able to provide, and
    • foster home's capacity.

Texas Human Resources Code §42.044(e)

26 TAC §749.2471(7)

Inspectors do not conduct a sampling inspection if the inspection would interfere with an ongoing investigation.

An investigation of a home does not replace a sampling inspection. A sampling inspection of a foster home does not replace a required monitoring inspection of the CPA that regulates the home.

 

4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency

August 2012

 

Inspectors must evaluate a child-placing agency's (CPA's) compliance history and sampling information on an ongoing basis to determine the CPA's compliance with law, administrative rules, and minimum standard rules.

Inspectors assigned to the CPA cite the CPA for a deficiency if the CPA fails to maintain substantial compliance with law or rule or if the random-sampling inspections show a pattern of non-compliances within the CPA.

Procedure

The inspector assigned to the CPA must evaluate the CPA's compliance with law, administrative rules, and minimum standard rules. This information is used to prepare for the CPA monitoring inspection, continuing appraisal of the CPA, and the CPA's annual enforcement team conference. To evaluate the CPA, the inspector reviews the following information:

  1. The sampling results received from the Licensing staff who conduct the random-sampling inspections of foster homes verified by the CPA;
  2. Any investigation results;
  3. Compliance history report for random-sampling in CLASS; and
  4. Other compliance information.

Inspectors must be alert to indicators such as:

  1. patterns or repetition found in the concerns noted during sampling inspections;
  2. falsification of CPA records;
  3. non-compliance with background check rules;
  4. immediate hazards observed during an inspection;
  5. conflict-of-care issues (disagreements between the family and the CPA about the method or quality of care expected); and
  6. the CPA's failure to correct concerns found during a random-sampling inspection.

See:

4140 Preparing for Inspections

4500 Evaluating Risk to Children

 

4431.1 Citing Deficiencies Based on Random-Sampling Inspection Results

August 2012

 

Procedure

The inspector assigned to the child-placing agency (CPA) cites a deficiency if their evaluation of the CPA's compliance history and sampling information do not reflect substantial compliance with law, administrative rules, and minimum standard rules.

When citing deficiencies that are the result of a random-sampling inspection, the inspector must check the indicator box in CLASS.

If a deficiency is cited without a monitoring inspection of the CPA, the inspector:

  • uses the CLASS Assessment function to notify the CPA; and
  • informs CPA staff about their right to an administrative review of the deficiency.

See:

4200 Citing Deficiencies with an Assessment

7710 Administrative Reviews

 

4432 Selecting CPA Foster Homes for Random-Sampling Inspections

June 2016

 

Each year, Licensing inspects one-third of all agency foster homes. These agency foster homes are selected through a random-sampling process. In addition, Licensing also conducts sampling inspections each year for all active agency foster homes verified to serve children with primary medical needs.

Texas Human Resources Code §42.044(e)

Procedure

Each September, Licensing staff from state office provide each residential licensing district director with the annual random-sampling goals for the fiscal year. The district directors or their designees assign inspections in a way that ensures the region's annual goals are met and the workload is distributed over the fiscal year.

To meet the annual goals, Licensing staff select agency foster homes that have been randomly selected for an inspection from the Agency Home Sampling Report List on the AH (Agency Home) Reports tab in CLASS. This list is generated on the last day of each month and contains a sufficient number of homes for primary and back-up lists.

Homes remain on the list and are available for sampling activities for 60 days, after which they drop off the list and any assigned worker's workload and return to the sampling pool.

If additional homes are needed to meet the assigned number of agency home inspections for the period, the supervisor or district director contacts:

  • the director of Residential Child Care Licensing; or
  • the director's designee.

 

4432.1 Pre-Screening CPA Foster Homes Selected for Random-Sampling Inspections

June 2016

 

Before scheduling a random-sampling inspection of an agency foster home, the inspector must pre-screen the home to ensure that it meets the following criteria:

  • Random-sampling inspections are only conducted on active foster homes.
  • At least 90 percent of random-sampling inspections must be conducted on foster homes that are actively caring for children (including homes verified for respite care only).
  • Random-sampling inspections must be conducted on foster homes that are empty (no children in care, but ready to accept a placement); however, no more than 10 percent of the homes sampled over the annual period may be empty homes.
  • Random-sampling inspections may be unannounced (that is, Licensing staff do not contact the foster home before inspecting the home); however, no more than 10 percent of the inspections conducted over the annual period may be unannounced.

An inspection is not conducted if one or more of the following is true:

  • The home is ruled out because it is closed or inactive (not currently accepting children for care).
  • A random-sampling inspection was conducted on the home within two years before the sample is drawn, unless:
    • the home serves children with primary medical needs;
    • the home has transferred to a different child placing agency (CPA); or
    • all of the CPA's foster homes have been sampled at least once before the end of the two-year period.
  • The home is an adoption-only home (random-sampling inspections are not conducted on adoption-only homes).
  • Conducting a random-sampling inspection would interfere with an ongoing investigation.

Procedure

Before preparing for or conducting a random-sampling inspection of an agency foster home, the inspector ensures that the home is eligible for a random-sampling inspection by gathering information from CLASS, the IMPACT case management system, or the CPA in order to pre-screen the home.

An ineligible home on the Agency Home Sampling Report List in CLASS is not inspected. If conducting a sampling inspection would interfere with an ongoing investigation, staff must consult with the supervisor. See 6540 Investigations Involving Homes Regulated by a Private Child-Placing Agency (CPA) for special considerations when conducting investigations at agency foster homes.

Staff may conduct an unannounced inspection, unless 10 percent of the random-sampling inspections in the director's area during the current fiscal year have been unannounced.

 

4432.2 When a Foster Home is Screened Out

August 2012

 

If the home is not inspected because it has been determined it is ineligible, the inspector:

  • records the reason for not inspecting the home on the AH (Agency Home) Sampling Report page in CLASS; and
  • reassigns the home to the appropriate staff person.

If needed, the inspector asks for a different home from the random-sampling list in CLASS to be assigned for inspection.

 

4433 Preparing for a Random-Sampling Inspection

June 2016

 

Before conducting a random-sampling inspection at an agency foster home, the inspector:

  • requests records about the foster home from the child placing agency (CPA);
  • reviews the records to gain insight into the foster home;
  • completes the Foster Home Screening Review Guide (Form 7291); and
  • contacts the foster home to schedule an inspection, if the inspection is going to be announced.

See:

4433.1 Requesting CPA Foster Home Records in Preparation for a Random-Sampling Inspection

4433.2 Reviewing a CPA's Record on a Foster Home in Preparation for a Random-Sampling Inspection

4434 Scheduling Random-Sampling Inspections

 

4433.1 Requesting CPA Foster Home Records in Preparation for a Random-Sampling Inspection

August 2012

 

Procedure

The inspector contacts the child-placing agency (CPA) to request photocopies or electronic files from the CPA foster home's record. For homes verified by Child Protective Services (CPS), foster home records available electronically must be reviewed in the IMPACT system in lieu of requesting them from the CPS foster/adoptive home development worker.

Photocopies of foster home records received from the CPA become a part of Licensing's hard copy record for the CPA. Inspectors do not keep the records of the homes that they do not inspect. See 4437 Retaining Records of Random-Sampling Inspections.

If a monitoring inspection is planned at the CPA before the random-sampling inspection of the CPA's foster home, the inspector:

  • obtains copies during the monitoring inspection; or
  • reviews the foster home's record as part of the monitoring inspection.

 

4433.11 If Requested Records are Not Received Within Five Days

August 2012

 

Procedure

If Licensing does not receive the child-placing agency's (CPA's) records within five days of requesting the records, the inspector:

  • conducts an unannounced inspection of the CPA; and
  • cites the CPA for not providing the foster home records that were requested.

 

4433.2 Reviewing a CPA's Record on a Foster Home in Preparation for a Random-Sampling Inspection

June 2016

 

Procedure

Inspectors prepare for the random-sampling inspection of an agency foster home by reviewing the following information:

  • The CPA's foster home screening
  • Background check records in CLASS for the foster home
  • Developmental or corrective action plans in place for the foster home
  • Investigation history for the last 12 months, or since the last enforcement team conference, whichever is more recent
  • Inspection reports, the foster home's floor plan, serious incident reports, and other documentation in the CPA's foster home record, if:
    • questions or issues are identified as a result of reviewing the home screening; or
    • the records are being reviewed as a part of a monitoring inspection at the CPA; and
  • The children's records in the IMPACT system if CPS foster children are placed in the home.

After reviewing all of the information, the inspector takes note of any questions or issues that may need to be addressed with:

  • the foster parent during the sampling inspection; or
  • the CPA's staff before the sampling inspection.

If it is determined that information documented in the CLASS system regarding the agency foster home is outdated or incorrect, the inspector conducting the random-sampling inspection:

  • instructs the CPA to update the foster home's information; and
  • notifies the inspector assigned to the CPA.

The inspector assigned to the CPA then considers citing a deficiency, using an assessment, if outdated or incorrect information is a pattern for the CPA. See 4431.1 Citing Deficiencies Based on Random-Sampling Inspection Results.

 

4433.3 Completing the Foster Home Screening Review Guide

June 2016

 

Procedure

After reviewing the CPA's foster home screening, the inspector completes the Foster Home Screening Review Guide (Form 7291).

 

4434 Scheduling Random-Sampling Inspections

August 2012

 

A random-sampling inspection may be:

  • announced (Licensing staff contact the agency foster home before inspecting the home); or
  • unannounced (Licensing staff do not contact the agency foster home before inspecting the home). No more than 10 percent of the random-sampling inspections completed over the annual period may be unannounced.

 

4434.1 Scheduling Announced Inspections

August 2012

 

Procedure

When scheduling an announced random-sampling inspection, the inspector works with the agency foster home to ensure that the visit causes as little disruption to the family routine as possible.

If the foster home does not respond to voice messages left by the inspector, the inspector notifies the child-placing agency (CPA) using Form 2990 Agency Foster Home No Contact Letter.

 

4434.2 Scheduling Unannounced Inspections

August 2012

 

Procedure

Before scheduling an unannounced random-sampling inspection, the inspector determines whether less than 10 percent of random-sampling inspections in the manager's area have been unannounced. If 10 percent have been unannounced, the inspector must conduct an announced inspection.

When scheduling an unannounced inspection, the inspector chooses a time that:

  • is likely to cause as little disruption to the family routine as possible; and
  • is a time when the children in care will likely be at the home during the inspection.

If the inspector makes an unannounced random-sampling inspection and no contact is made, the inspector follows procedures in 4435.3 Attempted Random-Sampling Inspections.

 

4435 Conducting Random-Sampling Inspections at CPA Foster Homes

January 2013

 

  1. Inspect the home using Form 2978 Foster Home Random-Sampling Guide.
  2. Interview at least one foster parent.
  3. Interview all foster children who are present during the inspection who are able and willing to talk.
  4. Point out immediate safety and health hazards to the foster parent or adult who is in charge during the inspection.

See 4435.1 Immediate Hazards.

An adult other than the foster parent may be the primary contact person present during the random-sampling inspection; however, at least one foster parent must be present at some time during the inspection in order to be interviewed.

Procedure

To conduct a random-sampling inspection, inspectors take the following actions:

  1. Present, on arrival, a valid HHSC identification card to the person in charge and explain the purpose of the visit.
  2. Use Form 2978 Foster Home Random-Sampling Guide to conduct the random-sampling inspection.
    The sample interview questions on Form 2978 are suggestions only. They are designed to help the inspector gather information. The inspector reviews the interview questions and tailors them to the circumstances of the inspection in order to ensure that they are appropriate for the child's age, developmental level, and situation.
  3. Determine whether background checks have been completed on all persons at the foster home who are required to have background checks completed. The background checks may be conducted in CLASSMate during the inspection. See 10000 Background Checks.
  4. Interview at least one foster parent in person during the inspection. If another foster parent cannot be present during the inspection and an interview is necessary, the inspector interviews that foster parent by phone.
  5. Interview all foster children who are present during the inspection and are able and willing to talk. When a foster child has not been interviewed, the inspector notes the reason on Form 2978 Foster Home Random-Sampling Guide.
  6. Interview other household members or the staff of the child-placing agency (CPA), as needed, to determine how well the CPA is regulating its foster homes. Obtain written consent before interviewing the foster parent's biological or adopted children. See 6000 Investigations.

If there are any meaningful discrepancies between the results of the home screening and observations made at the foster home during the random-sampling inspection, the inspector notes them on Form 2978 Foster Home Random-Sampling Guide.

If photographs are taken during the inspection, see 1400 State-Issued Equipment, Photographs, and Video.

The sampling inspection is considered complete when both of the following have been addressed through observations and interviews:

  • All of the questions or issues noted during the review of the foster home's record.
  • All topics on Form 2978 Foster Home Random-Sampling Guide.

 

4435.1 Immediate Hazards

January 2013

 

Immediate hazards include, but are not limited to:

  1. unsupervised access to bodies of water, firearms, or medication;
  2. no water or electricity;
  3. structural damage to the home that makes the home uninhabitable;
  4. unsafe equipment; and
  5. construction hazards.

Procedure

When an immediate hazard is observed, the inspector conducting the random-sampling inspection must:

  1. point out immediate safety and health hazards to the foster parent or adult who is in charge during the inspection;
  2. notify the CPA within 24 hours of the inspection about immediate hazards found in the foster home; and
  3. notify the inspector assigned to the CPA within 24 hours of the inspection about immediate hazards found in the foster home.

The CPA must follow up to ensure that:

  • a plan exists for the home to come into compliance; and
  • the home follows the plan for the protection of the children.

The inspector assigned to the CPA follows up with the CPA, as appropriate, to ensure that the CPA has taken the appropriate actions regarding immediate hazards identified during the random-sampling inspection.

 

4435.2 When Abuse or Neglect is Reported or Observed

August 2012

 

See 6200 Assessing and Processing Intake Reports, if abuse or neglect is reported or observed during the inspection.

 

4435.3 Attempted Random-Sampling Inspections

August 2012

 

If a random-sampling inspection of a foster home is attempted but no contact is made, the inspector:

  • documents the attempted random-sampling inspections in CLASS; and
  • conducts another random-sampling inspection.

See:

4435.31 Attempted Announced Inspections

4435.32 Attempted Unannounced Inspections

 

4435.31 Attempted Announced Inspections

August 2012

 

If the family is not home when the inspector makes an announced random-sampling inspection, the inspector:

  • documents the attempted inspection as a Chronology in the foster home's record in CLASS;
  • contacts the family to reschedule the announced inspection; and
  • creates and sends Form 2990 Agency Foster Home No Contact Letter to the child-placing agency and foster home.

See 4434 Scheduling Random-Sampling Inspections.

 

4435.32 Attempted Unannounced Inspections

August 2012

 

First Attempted Unannounced Inspection

If the inspector makes an unannounced random-sampling inspection and no contact is made, the inspector:

  • documents the attempted inspection as a Chronology in the foster home's record in CLASS; and
  • conducts another unannounced inspection within 10 days.

Second Attempted Unannounced Inspection

If the family is not home at the time of the second unannounced random-sampling inspection, the inspector:

  1. documents the attempted inspection as a Chronology in the foster home's record in CLASS;
  2. contacts the family to schedule and complete an announced inspection; and
  3. creates and sends Form 2990 Agency Foster Home No Contact Letter to the child-placing agency and foster home.

See 4434 Scheduling Random-Sampling Inspections.

 

4436 Documenting and Sharing the Results of Random-Sampling Inspections

January 2013

 

Before leaving the foster home, the inspector:

  • completes CLASSMate Form 2979 Foster Home Checklist to document any concerns identified and any technical assistance provided during the random-sampling inspection; and
  • conducts an exit interview with the foster parent or person in charge to:
    • Inform the person about any findings identified as sampling concerns.
    • Provide the person with a copy of the completed CLASSMate Form 2979.

Within 10 days of each inspection or attempted inspection, the inspector who conducted the random-sampling inspection:

  1. resolves any pending sampling concerns and documents the outcomes for any pending sampling concerns in CLASS;
  2. completes the Sampling Letter in CLASS; and
  3. provides a copy of the Sampling Letter to the child-placing agency (CPA) and the Licensing inspector assigned to the CPA to inform them of the inspection results.

Texas Human Resources Code §§42.044; 42.04411

Procedure

Before Leaving the Foster Home

Before leaving the foster home, the inspector completes CLASSMate Form 2979 Foster Home Checklist to document:

  1. any concerns identified while reviewing the CPA's record on the foster home;
  2. any questions or issues identified while reviewing the foster home's agency home record in CLASS, including records related to compliance with background check requirements;
  3. any findings identified as sampling concerns as a result of conducting the random-sampling inspection; and
  4. any technical assistance provided to the foster home (see 4154 Technical Assistance).

After documenting the inspection results on CLASSMate Form 2979, and before leaving the home, the inspector conducts an exit interview with the foster parent or other adult who is in charge, during which the inspector:

  • informs the person about any findings identified as sampling concerns; and
  • provides a copy of the completed Form 2979.

Within 24 Hours After Completing a Random-Sampling Inspection

Within 24 hours after completing the random-sampling inspection, the inspector who conducted the random-sampling inspection notifies the CPA and the Licensing inspector assigned to the CPA about any immediate hazards observed in the foster home. Notification may be made by phone, email, or fax.

See 4435.1 Immediate Hazards.

Within 10 Days After the Random-Sampling Inspection

Within 10 days after the inspection, the inspector that conducted the random-sampling inspection:

  1. resolves any pending sampling concerns, if any, and documents the results in CLASS;
  2. completes the CLASS Sampling Letter; and
  3. sends the Sampling Letter to:
    • the CPA, and
    • the inspector assigned to the CPA.

Documenting an Attempted Random-Sampling Inspection

For information on documenting an attempted random-sampling inspection of a CPA foster home, see 4435.3 Attempted Random-Sampling Inspections.

 

4437 Retaining Records of Random-Sampling Inspections

June 2016

 

Procedure

Documentation collected as part of a random-sampling inspection is retained or destroyed according to the following schedule:

  • The sampling guide, Foster Home Screening Review Guide, and any home records obtained from the child placing agency (CPA) are retained in the case file for one year, or until the enforcement team conference for the CPA has been completed for the year; and
  • The sampling guide, Foster Home Screening Review Guide, and home study record are destroyed after one year, or after the conference has been completed for the year.

Confidential material must be destroyed as outlined in 1330 Records Retention.

 

4440 Enforcement Team Conferences

 

 

4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations

September 2017

 

Licensing staff conduct at least one annual enforcement team conference for each child-placing agency (CPA) main and branch office and general residential operation (GRO), even if the CPA or GRO is on voluntary suspension. These conferences are a part of Licensing's effort to monitor and enforce operations' compliance with law, administrative rules, and minimum standards.

During an enforcement team conference, Licensing staff conduct a comprehensive assessment of the operation by thoroughly reviewing information about the operation in CLASS, including from inspections and investigations that were conducted either by Licensing or DFPS.

The conference may be conducted by phone as a conference call or as a face-to-face meeting.

Texas Human Resources Code (HRC) §42.044(e)(4)

 

4441.1 Completing the Enforcement Team Pre-Conference Synopsis for a CPA or GRO

September 2017

 

Procedure

The assigned inspector completes the Pre-Conference Synopsis Details page in CLASS before conducting the enforcement team conference. If a CPA has a main office and one or more branch offices, a synopsis is completed for each office. The assigned inspector completes a synopsis.

The inspector completes the synopsis by the fifth day of the month in which Licensing issued the full permit. For example, if the operation received its full permit in January, the synopsis is due each year on January 5.

The inspector reviews the following information about the operation in CLASS to complete the synopsis:

  • Compliance/Sampling Report Detail (located under CLASS Tools)
  • Emergency Behavior Intervention Report (located under CLASS Tools)
  • Waiver/Variance List
  • People List
  • Inspection/Assessment List
  • Operation Investigation List
  • Corrective and Adverse Action History

The inspector analyzes the data on these pages and reports to determine if any trends or patterns exist. Once the inspector completes the synopsis, he or she submits it for supervisory approval by selecting the Ready for Supervisor Approval checkbox and saving the Pre-Conference Synopsis Details page in CLASS.

Supervisor Responsibilities

The Licensing supervisor must approve the synopsis by the seventh day of the anniversary month in which Licensing issued the full permit. For example, if the operation received its full permit in January, the synopsis approval is due each year on January 7. After approving the synopsis, the Licensing supervisor schedules the enforcement team conference with the assigned inspector.

 

4441.2 Conducting the Enforcement Team Conference for a CPA or GRO

September 2017

 

The Licensing supervisor is responsible for ensuring that the enforcement team conference is conducted for a CPA's main office or a GRO.

Special Considerations for a CPA's Branch Office

The Licensing supervisor is responsible for ensuring that an enforcement team conference is conducted for a CPA's branch office.

If a CPA's branch office closed since the last conference, Licensing staff review the following information related to the closure of the branch office as part of the conference for the CPA's main office:

  1. Any significant compliance history associated with the branch office.
  2. Reasons for the closure of the branch office.
  3. Significant outcomes of the closure of the branch office.

 

4441.3 Activities After Conducting the Enforcement Team Conference for a CPA or GRO

September 2017

 

Procedure

The inspector documents any identified concerns, follow-up plans, and recommendations in CLASS on the Enforcement Team Conference Details page. The inspector completes this documentation:

  • before the end of the anniversary month of full issuance, for a CPA's main office or a GRO; or
  • before the end of the 15th day of the anniversary month of full issuance, for a CPA's branch office.

Within 15 days of conducting the enforcement team conference, the inspector discusses the previous year's compliance history with the operation's licensed administrator, if appropriate, and documents the discussion or lack thereof in the Review with Administrator section of the Enforcement Team Conference Details page in CLASS. If a discussion did not take place, the inspector documents the reason the discussion did not occur.

Within three days of documenting the discussion with the administrator or lack thereof, the inspector finalizes the conference on the Enforcement Team Conference Details page in CLASS by:

  • selecting Completed as the Final Action;
  • documenting the date the Final Action was entered; and
  • entering any comments if necessary.

 

4500 Evaluating Risk to Children

March 2019

 

Licensing staff must continuously evaluate each operation's performance in terms of risk to children in order to determine appropriate enforcement actions to reduce such risk throughout the duration of an operation's permit. See Appendix 7000-1 Factors to Consider for Enforcement Actions.

Texas Human Resources Code §42.044

4510 The CLASS Risk Review and Enforcement Recommendations

March 2019

 

The CLASS Risk Review is a tool that supplements the professional assessments of Licensing staff. The CLASS Risk Review produces Enforcement Recommendations based upon the type, number, weight, and repetition of violations over the course of an operation's two-year compliance history.

Inspectors must continue to independently evaluate risk to children in addition to reviewing CLASS Enforcement Recommendations.

An inspector's decision to select or reject recommended actions on the Enforcement Recommendation Detail page in CLASS must be based on the overall risk to children exhibited by the operation.

 

4511 Options on the Enforcement Recommendation Page in CLASS

March 2019

 

Procedure

Each option on the Enforcement Recommendation Detail page in CLASS represents an action that Licensing may take with regard to an operation based on the risk presented to children in care. Depending upon the situation, enforcement recommendations may be selected individually or in combination with other enforcement recommendations.

The page layout varies depending upon the operation's current risk as determined by the CLASS Risk Review.

No deficiencies cited. Follow monitoring frequency

This means that no action is being taken at this time. Staff do not select this recommended action if any other enforcement recommendations are selected, even if no deficiencies were cited at the current inspection.

Follow-up without inspection

See 4312 When a Follow-Up Inspection Is Not Required. This recommendation should be selected when:

  • deficiencies cited do not warrant a physical follow-up; and
  • the operation’s compliance history supports a 12-month monitoring frequency.

When this option is selected, CLASS Follow-Up and Chronology entries must clearly document how the inspector determined compliance. The decision to follow-up with or without an inspection should be based upon the nature of the deficiencies cited at the most recent inspection(s).

Follow-up with inspection

See 4311 When a Follow-Up Inspection Is Required. This action indicates that the inspector will conduct a follow-up inspection to determine compliance on specific deficiencies. Staff select this action any time that deficiencies necessitate a physical follow-up, even if this action is not included in the Recommended Actions Based on Risk. A Scheduled Date is required when this option is chosen. This date should be the date upon which the follow-up inspection is planned.

Plan of Action

See 7350 Plan of Action. A plan of action is a voluntary enforcement action that is a collaborative effort between Licensing and an operation. The goal is to develop a plan to reduce risk and help improve the operation’s compliance with Licensing statutes, administrative rules, and minimum standards. Licensing inspects an operation more frequently during a plan of action to evaluation the operation’s compliance with minimum standards.

Warning letter and follow-up with inspection

See 4330 Sending a Warning Letter and Following Up With an Inspection. A warning letter (Form 2939 should be issued to caution the governing body of a child care operation about the risks identified during recent inspections. The warning letter prompts the operation to resolve patterns of deficiencies in a timely manner and to maintain compliance on an ongoing basis.

The inspector is required to conduct a follow-up inspection with this action, and the date of the follow-up inspection must be scheduled in the Scheduled Date field.

Expedite monitoring inspection

Staff select this action when risk at the operation warrants conducting a monitoring inspection prior to the Next Inspection Due Date from the Enforcement Recommendation.

  • The expedited monitoring inspection is an interim inspection. If the operation does not demonstrate improved compliance at the expedited inspection, staff consider additional action.
  • A Scheduled Date is required when this action is chosen. In many cases, if risk warrants an expedited inspection, the date of the expedited inspection should be no more than a few months after the inspection that prompted the action in order to reduce risk.

Evaluation

Evaluation is a type of corrective action for which Licensing imposes a corrective action plan. Conditions are imposed beyond the minimum standards and the basic permit requirements in order to improve an operation’s compliance with minimum standards and reduce risk at the operation. The duration of evaluation is six months and Licensing conducts inspections at least monthly to evaluate compliance with minimum standards and the conditions imposed as part of the corrective action plan. Licensing may recommend imposing evaluation if circumstances described in 7110 Circumstances That May Call for Enforcement Action exist and Licensing determines the operation meets criteria outlined in 7411 Criteria for Imposing Evaluation.

Probation

Probation is a type of corrective action for which Licensing imposes a corrective action plan that is more restrictive and intense than an evaluation. Conditions are imposed beyond the requirements of the minimum standards and the basic permit in order to improve an operation’s compliance with minimum standards and reduce risk at the operation. The duration of probation is 12 months and Licensing conducts inspections at least monthly to evaluate compliance with minimum standards and the conditions imposed as part of the corrective action plan. Licensing may recommend imposing probation if circumstances described in 7110 Circumstances That May Call for Enforcement Action exist and Licensing determines the operation meets criteria outlined in 7412 Criteria for Imposing Probation.

Adverse Amendment

Adverse amendment is a type of adverse action in which an existing permit is voided and the permit is then reissued with new or additional restrictions or conditions. See 7622 Criteria for Imposing an Adverse Amendment.

Involuntary Suspension

In an involuntary suspension, Licensing takes away the permit holder's authority to operate for a specific period of time so that deficiencies may be corrected. The operation must close during a suspension. Suspension may be imposed if circumstances described in 7110 Circumstances That May Call for Enforcement Action exist and Licensing determines the operation meets criteria outlined in 7623 Criteria for Imposing an Involuntary Suspension.

Injunction

If circumstances at the operation are determined to be so extreme that immediate intervention is warranted (there is substantial risk of immediate harm to the health and safety of children in care), the inspector may make a referral for legal action simultaneously with the mailing of the notice of an intent to deny, revoke, or suspend. See 7742 Injunction.

Denial

Denial is the refusal to grant a permit or an amendment to a permit. The inspector only selects denial as an Enforcement Recommendation if intending to deny a permit amendment, as Enforcement Recommendations are not generated for operations that do not have a full permit. See 7621 Criteria for Imposing a Denial.

Revocation

Revocation is the cancellation of a permit, which requires the operation to close. Revocation may be imposed if circumstances described in 7110 Circumstances That May Call for Enforcement Action exist and Licensing determines the operation meets criteria outlined in 7624 Criteria for Imposing a Revocation.

 

4512 Acting on Enforcement Recommendations

March 2019

 

The inspector has five days from the date CLASS generated the Enforcement Recommendation to select one or more recommended actions from the Enforcement Recommendation Details page in CLASS. When acting upon an Enforcement Recommendation, the inspector must:

  • review the action that trigged the recommendation;
  • consider all relevant compliance history for the operation;
  • consult with his or her supervisor if necessary; and
  • select one or more recommended actions based on risk.

See 4500 Evaluating Risk to Children.

Procedure

Any combination of recommended actions can be selected from the three categories on the Enforcement Recommendation Details page. The three categories are:

  1. Recommended Actions Based on Risk;
  2. Actions Not Requiring Supervisory Review; and
  3. Actions Requiring Supervisory Review.

If any alternative actions (those listed in the Actions Not Requiring Supervisory Review and Actions Requiring Supervisory Review categories) are selected, the inspector must also choose the most appropriate reason from the Reason for Alternative Recommendation drop-down menu.

The Licensing Specialist Comments field should include the reasons the inspector selected the alternative actions. Comments are required when the Reason for Alternative Recommendation selection is Other.

4512.1 Actions Requiring Supervisory Approval

March 2019

 

If the inspector selects any recommended action from the Actions Requiring Supervisory Review section of the Enforcement Recommendation Detail page in CLASS, the following actions must be taken within five days of the selection:

  • the inspector must staff the inspector’s assessment of risk and the selected recommendations with the supervisor; and
  • the supervisor reviews the Enforcement Recommendation Details page to:
    • ensure that the selections made on the Enforcement Recommendation Details page accurately reflect the enforcement decisions made during the consultation;
    • remove or add check box selections (or both), if necessary, to only include recommended actions that will be implemented; and
    • describe what actions the inspector originally selected, what (if any) changes were made to recommendations selected, and why in the Supervisor Comments field.

After the supervisor enters the decision in CLASS, the inspector has an additional five days to review the Enforcement Recommendation Details page and initiate the approved actions.

4700 Reviewing Operation Policies

November 2009

 

Licensing reviews certain policies of regulated operations to determine the operation's compliance with law, administrative rules, and minimum standard rules.

Licensing determines whether policies comply with minimum standard rules, but Licensing does not approve policies.

40 TAC §745.243

Procedure

When reviewing an operation's policies, Licensing staff take the following steps:

  • Determine whether the policy is required by, or directly relates to, compliance with law, administrative rules, and minimum standard rules.
  • Decline any request to review a policy that is outside of Licensing's jurisdiction.
  • For example:
    • Licensing staff may not endorse an operation's personnel policy on sexual harassment; and
    • Licensing staff do not review CPS policies related to family based services.
  • Communicate clearly to the operation that Licensing cannot endorse therapeutic techniques or programming. Licensing assesses therapeutic techniques or programming only to the extent that they directly relate to compliance with minimum standard rules.

When an Operation Requests Licensing to Review Its Policy

If an operation requests a policy review, Licensing staff use the following language to inform the operation in writing about whether its policy violates law or minimum standard rules:

Licensing received a request to review your operation's policy or policies on (insert date). Licensing reviewed the policy/policies for compliance with law and minimum standard rules. Licensing cannot otherwise review a policy or assess a clinical or therapeutic technique used by your operation. If Licensing determines that an operation's policies comply with minimum standard rules, this does not imply endorsement of any clinical or therapeutic technique noted within the policies.

The policy or policies you submitted (do or do not) comply with Licensing rules and law.

If the policy or policies do not comply with Licensing rules, Licensing staff include the rationale. For example:

The discipline policy you submitted includes use of corporal punishment. Corporal punishment is prohibited by 26 Texas Administrative Code §748.2303.

 

4800 Risk Analysis

June 2014

 

A risk analysis is an objective report written by a risk analyst that contains:

  1. an analysis of an operation's compliance with Licensing law, rules, and minimum standards;
  2. an identification of indicators associated with the potential of a higher risk of harm to the children in care at an operation; and
  3. recommendations regarding Licensing monitoring or enforcement actions with the operation, based on the risk identified.

Texas Human Resources Code (HRC) §42.0211

A risk analysis does not replace the responsibility of Licensing staff to assess risk after each inspection, investigation, or significant change that occurs at an operation.

 

4810 Requesting a Risk Analysis

June 2014

 

Procedure

To request a risk analysis, the district director, the manager, or the Licensing supervisor emails a completed Form 2875 CCL PMU Risk Analysis to the CCL Performance Management Unit mailbox.

 

4820 Risk Analysis Review Period

June 2014

 

A risk analysis is based upon a review of the operation's compliance history over the last two years.

If the operation had an initial permit within the last two years, the risk analysis includes a review of any compliance history from the initial permit periods that fall within the review period time frame.

If the operation has not had a permit for two years when the risk analysis is completed, the review period begins on the date Licensing issued the permit.

If another risk analysis was completed on the operation within the last two years, the new risk analysis analyzes the operation's two-year compliance history as it relates to the level of risk to children and the recommendation for Licensing's next monitoring and enforcement actions. However, the section of the report that summarizes the operation's compliance history lists only information regarding inspections, assessments, and investigations conducted after the most recent risk analysis was completed.

To request an exception to the review period time frame, Licensing staff complete the appropriate section on Form 2875 CCL PMU Risk Analysis. The Performance Management Unit reviews requests for exceptions on a case-by-case basis.

 

4830 Risk Analyst Responsibilities

June 2014

 

After receiving an assignment to complete a risk analysis, the risk analyst informs the requestor of the projected date by which the analysis will be completed. Under most circumstances, the completed, written analysis is completed within 10 days from the date the risk analyst receives the assignment.

After completing the risk analysis, the risk analyst sends a copy of the risk analysis and Form 1900 PMU Risk Analysis Feedback to the following persons:

  1. The requestor
  2. The district director or manager, as appropriate
  3. The director of field

The risk analyst then documents the following on the operation's Chronology page in CLASS:

  1. Date the risk analysis was completed
  2. Name of the requestor
  3. Name of the risk analyst that completed the risk analysis

 

4840 Licensing Staff Responsibilities After Receiving a Completed Risk Analysis

June 2014

 

After receiving a completed risk analysis, Licensing staff review the written analysis and determine whether Licensing will implement all, some, or none of the recommendations listed in the risk analysis.

Within 10 days of receiving the completed risk analysis, the requestor or designee emails a completed Form 1900 PMU Risk Analysis Feedback to the CCL Performance Management Unit mailbox.

Within 30 days of receiving the completed risk analysis, the Licensing supervisor or his or her designee documents the following in a Chronology in the operation's CLASS record:

  1. The date Licensing staff reviewed the analysis.
  2. If Licensing staff have chosen to follow the recommendations or have chosen alternate actions.
  3. A description of what actions Licensing staff have chosen.
  4. The rationale for the actions that were chosen.