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4300 Conducting a Follow-Up With an Operation

LPPH February 2013

Policy

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

a.   ensure that the operation is in compliance with any standards or other laws that were cited because of deficiencies during an inspection, investigation, or assessment;

b.   determine whether an operation is complying with the conditions of a waiver or variance;

c.   determine whether an operation is complying with the conditions of a risk evaluation;

d.   conduct the annual review of qualifications of the designated director of a licensed child care center;

e.   ensure that all background check matches have been completed;

f.    ensure that an operation that is closed due to suspension, revocation, or denial of a permit is no longer operating;

g.   monitor the operation during the appeal process;

h.   monitor the operation during a temporary relocation; or

i.    determine whether an operation is operating after an annual fee notice is returned to DFPS.

See:

4133.3 Child Day Care – Annual Meeting With the Designated Director

4152 Reviewing Restrictions and Conditions

5120 Setting and Monitoring Conditions for the Waiver or Variance

5270 When a Fee Notice Is Returned

5300 Central Registry and Criminal History Searches

5373 When a Risk Evaluation Is Required

7320 Temporary Relocation

7636 Follow-Up to Suspension, Revocation, or Denial

7731 Regulation During Appeal Process

DFPS Rules, 40 TAC §745.8449

Procedure

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

a.   the risk to children;

b.   the scope and severity of the deficiency;

c.   the time and expense needed to correct the deficiency; and

d.   the provider’s previous compliance history.

4310 How to Conduct a Follow-Up With an Operation

LPPH November 2017

Policy

When following up with an operation is required due to deficiencies, Licensing staff verify that deficiencies were corrected, which may include:

  a. reviewing records that had deficiencies;

  b. inspecting areas of the physical plant that had deficiencies; and

  c. observing activities related to health and safety.

Corrections of deficiencies must be documented within 15 days after the latest compliance date has passed.

4311 Following Up With an Inspection

LPPH November 2017

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 15 days after the latest compliance date noted on CLASS Form 2936 Child-Care Facility Inspection. 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

5370 Risk Evaluation of Criminal History or Findings of Abuse or Neglect

4311.1 Documenting Follow-Up Inspections

LPPH December 2015

Policy

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

LPPH November 2017

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; and

  •  submitting the information within 15 days after the latest compliance date noted on CLASS Form 2936 Child-Care Facility Inspection.

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

LPPH 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:

  •  the 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);

  •  the 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

  •  the 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:

a.   the citation is not being evaluated during the current follow-up inspection,

b.   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

c.   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:

a.   enters Deficiency in the Finding field,

b.   enters the new compliance date in the Compliance Date field, and

c.   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

LPPH 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:

  a.  issue a warning letter and conduct a follow-up with an inspection;

  b.  expedite the next monitoring inspection; or

  c.  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

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

LPPH November 2017

Policy

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

LPPH November 2017

Policy

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:

  a.  Open the inspection or assessment where the citation was originally issued;

  b.  Change the date in the Compliance Date field to the new compliance date;

  c.  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

  d.  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

LPPH March 2017

Policy

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 the CLASS system:

a.  Alert the operation about the risks by sending a warning letter (Form 2939 Warning Letter).

b.  Compile a compliance history of the operation, using the CLASS system or CLASSMate.

c.  Set a date for a follow-up inspection on the Enforcement Recommendation page.

d.  Review the compliance history report with the director or person in charge of the operation, during the follow-up inspection.

e.  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

4410 Monitoring Certified (State-Operated) Child-Care Operations

LPPH November 2009

Policy

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 assistant commissioner of Licensing notifies the DFPS commissioner.

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

Licensing staff send the assistant 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

LPPH December 2011

Policy

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 DFPS 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

DFPS Rules, 40 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, the CLASS system 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 the CLASS system:

a.   the location and effective date of each of the CPA’s branch offices;

b.   the CPA’s records;

c.   the CPA’s foster homes; and

d.   the names of the CPA’s staff

4421 Monitoring CPAs That Conduct International Adoptions

LPPH December 2011

Policy

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

LPPH December 2011

Policy

A child-placing agency (CPA) licensed in Texas may request that DFPS 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:

a.   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.

b.   Complete a reply letter (Form 2983 Certification of a CPA License Status Letter).

The letter requires:

  •  supervisor approval; and

  •  a notarized signature.

c.   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.

d.   Document the request in the CLASS system, in the Chronology field, and note the date the reply letter (Form 2983) is sent.

e.   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

LPPH August 2012

Policy

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

a.   is complying with applicable law, administrative rules, and minimum standard rules;

b.   has correctly determined that a foster home meets the requirements for verification; and

c.   has made appropriate decisions regarding:

  •  the foster home’s ability to work with children of a certain age or gender,

  •  the foster home’s ability to care for children who have special needs or supervision requirements,

  •  the services the foster home is able to provide, and

  •  the foster home’s capacity.

Texas Human Resources Code §42.044(e)

DFPS Rules, 40 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

LPPH August 2012

Policy

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:

a.  Each Form 2979 Foster Home Checklist received from the Licensing staff who conduct the random-sampling inspections of foster homes verified by the CPA

b.  Any investigation results

c.  Compliance history report for random-sampling in the CLASS system

d.  Other compliance information

Inspectors must be alert to indicators such as:

a.  patterns or repetition found in the concerns noted during sampling inspections;

b.  falsification of CPA records;

c.  non-compliance with background check rules;

d.  immediate hazards observed during an inspection;

e.  conflict-of-care issues (disagreements between the family and the CPA about the method or quality of care expected); and

f.  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

LPPH 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

LPPH June 2016

Policy

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 DFPS 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 the CLASS system. 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

LPPH June 2016

Policy

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

LPPH 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

LPPH June 2016

Policy

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

LPPH 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 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

LPPH 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

LPPH 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.

  •  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

LPPH 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

LPPH August 2012

Policy

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

LPPH 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

LPPH 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

LPPH January 2013

Policy

a.   Inspect the home using Form 2978 Foster Home Random-Sampling Guide.

b.   Interview at least one foster parent.

c.   Interview all foster children who are present during the inspection who are able and willing to talk.

d.   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:

a.   Present, on arrival, a valid DFPS identification card to the person in charge and explain the purpose of the visit.

b.   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.

c.   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 5300 Central Registry and Criminal History Searches.

d.   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.

e.   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.

f.    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

LPPH January 2013

Immediate hazards include, but are not limited to:

a.   unsupervised access to bodies of water, firearms, or medication;

b.   no water or electricity;

c.   structural damage to the home that makes the home uninhabitable;

d.   unsafe equipment; and

e.   construction hazards.

Procedure

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

a.   point out immediate safety and health hazards to the foster parent or adult who is in charge during the inspection;

b.   notify the CPA within 24 hours of the inspection about immediate hazards found in the foster home; and

c.   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

LPPH 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

LPPH 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

LPPH 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 the CLASS system;

  •  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

LPPH 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 the CLASS system; 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:

a.  documents the attempted inspection as a Chronology in the foster home’s record in the CLASS system;

b.  contacts the family to schedule and complete an announced inspection; and

c.  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

LPPH January 2013

Policy

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:

a.   resolves any pending sampling concerns and documents the outcomes for any pending sampling concerns in the CLASS system;

b.   completes the Sampling Letter in CLASS; and

c.   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:

a.   any concerns identified while reviewing the CPA’s record on the foster home;

b.   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;

c.   any findings identified as sampling concerns as a result of conducting the random-sampling inspection; and

d.   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:

a.   resolves any pending sampling concerns, if any, and documents the results in CLASS;

b.   completes the CLASS Sampling Letter; and

c.   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

LPPH 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

LPPH September 2017

Policy

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

LPPH 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

LPPH September 2017

Policy

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:

  a. Any significant compliance history associated with the branch office.

  b. Reasons for the closure of the branch office.

  c. Significant outcomes of the closure of the branch office.

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

LPPH 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

LPPH March 2017

Policy

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.

Texas Human Resources Code §42.044

When evaluating risk to children, Licensing staff consider the following:

a.  The nature of the activity (inspection or investigation) that generated the current Enforcement Recommendation, including any associated deficiencies

b.  The compliance history of the operation during the most recent two-year period, including:

  •  the total number of deficiencies;

  •  the weight associated with each deficiency;

  •  repetition of particular standard deficiencies; and

  •  patterns of deficiencies (for example deficiencies mainly concentrated in a particular subchapter)

c.  The scope and severity of each deficiency, including:

  •  ages of children involved;

  •  number of staff involved;

  •  any injury or harm caused;

  •  the effect of any injury or harm; and

  •  similarities with previous deficiencies

d.  Any pending investigations

e.  The history of abuse or neglect investigations, especially those that resulted in a disposition of either Reason-to-Believe or Unable-to-Determine

f.   Any investigations of serious incidents, especially those that resulted in an injury

g.  Response to past technical assistance offered, including warning letters and provider plans of action

h.  Any prior enforcement actions (see 7000 Voluntary Actions and Enforcement Actions)

If Licensing staff discover a threat of immediate danger to children in care at an operation, staff must take action. See 7200 Handling Immediate Danger to Children.

Procedure

Here are some questions (by area) to consider when assessing risk:

Population and Services

a.  What age range does the operation serve?

b.  What are the hours of operation?

c.  What services does the operation provide?

d.  Were children in care during the last inspection?

Personnel

a.  Are the director, administrator, and the operation’s professional staff qualified to hold their respective positions at the operation?

b.  Does the director or administrator maintain an adequate presence at the operation?

c.  Are the director, or administrator, and the operation’s staff and caregivers aware of and knowledgeable about the minimum standard rules?

d.  Does the person in charge have the authority to make changes or corrections? Is the person in charge knowledgeable about the minimum standard rules?

e.  What is the level of experience of the staff?

f.   Is adequate staff training and orientation provided?

g.  What is the frequency of staff turnover?

h.  Are approved risk evaluations in effect? If so, how many approved risk evaluations are in effect and for what type of background check findings? Are there any patterns in the type of charges or abuse or neglect allegations upon which the risk evaluations were conducted? Are conditions of the approved risk evaluations met?

Physical Facilities

a.  Are repairs to the physical building and outdoor equipment made promptly?

b.  Are staff mindful of environmental factors (location, physical facilities, proximity to sex offenders, and so on) that may present a hazard to children in care?

c.  Are fire and health inspections kept current and are corrections made promptly?

Compliance History

a.  Are waivers or variances in effect and, if so, how many? Are conditions of the waivers or variances met?

b.  Have there been significant changes in the operation’s compliance history? If so, do changes in performance correlate with any specific factors at the operation (for example, a new director, change in season, staff shortage)?

c.  Are deficiencies that have been recently cited related to high-risk standards (such as infant care, quality of supervision, child/caregiver ratio, and emergency behavior intervention)?

d.  Have deficiencies been addressed appropriately and in a timely manner? Are there repeated deficiencies?

e.  Do the staff or caregivers appear to recognize how continued deficiencies will affect the children?

f.   Is the operation responsive to technical assistance?

g.  Has the operation historically initiated corrections on its own, or waited for additional regulatory action to be implemented before correcting deficiencies?

h.  How many warning letters has Licensing sent to the operation during the past 24 months?

i.   Has the operation previously completed and implemented a Plan of Action (Form 7277)?

j.   Have monetary penalties been assessed against the operation?

k.  Is the operation on or has it ever been on evaluation or probation?

l.   Were previous Licensing actions successful at reducing risk?

Investigation History

a.  How many reports of potential problems (investigations) has Licensing received about the operation? Did Licensing ultimately cite the operation for deficiencies?

b.  What percentage of the reports received were self-reports? How many reports should have been self-reported but were not?

c.  Is there a trend in the type of allegations or serious incidents reported?

d.  What are the ages of the children involved in any deficiencies or questionable situations?

e.  Did any of the reports result in substantiated determinations of abuse or neglect?

4510 The CLASS Risk Review and Enforcement Recommendations

LPPH January 2011

Policy

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.

Quality Assurance Measure: Inspections #24

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 enforcement actions must be based on the overall risk to children exhibited by the operation.

4511 Enforcement Action Options

LPPH March 2017

Procedure

Each enforcement action option 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 actions may be selected individually or in combination with other enforcement actions.

All of the following options are available in every Enforcement Recommendation. 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 actions 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 used when deficiencies were cited but do not warrant a physical follow-up. 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 Licensing recommends to an operation in order to encourage the operation to actively participate in developing a plan to correct compliance with Licensing statues, administrative rules, or 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.

Monetary Penalties

See 7500 Administrative Penalties. Monetary, or administrative, penalties are fines that Licensing may impose against certain operation types or the controlling person of any residential operation. Monetary penalties can be assessed when the operation:

a.  violates a standard based in law as provided in Human Resources Code (HRC) Chapter 42;

b.  makes a false statement about a material fact either on an application or in response to a matter under investigation;

c.  refuses to allow an inspection;

d.  purposefully interferes with an inspection or investigation;

e.  fails to pay a penalty assessed under HRC 42;

f.   commits repeated deficiencies that present low to medium risk; or

g.  fails to comply with an evaluation or probation plan after time limits for correction have expired.

Evaluation

See 7400 Corrective Action. 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, and inspections are conducted monthly.

Probation

See 7400 Corrective Action. 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, and inspections are conducted monthly.

Adverse Amendment

See 7600 Adverse Actions. Adverse amendments are 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. An adverse amendment may be imposed when the permit holder fails to make corrections to deficiencies and does not agree to a change that the inspector is recommending as an enforcement action.

Involuntary Suspension

See 7600 Adverse Actions. 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 following criteria in the 7000 Voluntary Actions and Enforcement Actions section when deficiencies create an endangering situation, an immediate threat or danger to the health and safety of children, or when there are indications of a continued failure to comply with the rules or law.

Injunction

See 7740 Injunctive Relief. 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 (injunctive relief) simultaneously with the mailing of the notice of an intent to deny, revoke, or suspend.

Denial

See 7600 Adverse Actions. Denial is the refusal to grant a permit or an amendment to a permit. Denial would typically only be used in an Enforcement Recommendation if the operation has applied for a permit amendment, since no Enforcement Recommendation will be generated until after an operation’s full permit has been issued.

Revocation

See 7600 Adverse Actions. Revocation is the cancellation of a permit, and the operation must close. Revocation may be imposed following criteria in the 7000 Voluntary Actions and Enforcement Actions section when deficiencies create an endangering situation, an immediate threat or danger to the health and safety of children, or when there are indications of a continued failure to comply with the rules or law. Although revocation may be pursued after a single serious incident, revocation typically occurs after other enforcement action options have been exhausted.

4512 Acting on Enforcement Recommendations

LPPH January 2011

When an Enforcement Recommendation is generated, a To Do of the type REC is created in CLASS instructing the inspector to View Recommended Action.

Upon receiving the View Recommended Action To Do, the inspector has five days to select an enforcement action from the Enforcement Recommendation Details page in CLASS. When acting upon an Enforcement Recommendation, the inspector must:

a.   review the action that trigged the recommendation;

b.   consider all relevant compliance history for the operation;

c.   consult with his or her supervisor if necessary; and

d.   select the most appropriate enforcement action based on risk. 

See 4500 Evaluating Risk to Children.

4512.1 Actions Requiring Supervisory Approval

LPPH January 2011

If any enforcement actions requiring supervisory review are selected, two To Do items of the type REC are created simultaneously in CLASS.

  •  The inspector receives a To Do that states Staff Recommendation with Supervisor.

  •  The supervisor receives a To Do that reads Risk-based action selected. Your review is needed for this action to take place.

The inspector and supervisor have five days to complete this consultation. The To Do items are removed when the supervisor enters a decision on the Enforcement Recommendation Details page.

Once the supervisor has completed his or her documentation, the inspector receives a To Do item that reads Supervisor has reviewed recommended action. The inspector then has an additional five days to review the Enforcement Recommendation Details page and initiate the associated enforcement actions. The To Do is removed once the recommendation has been reviewed by the inspector.

Documenting Enforcement Recommendations

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

a.   Recommended Actions Based on Risk;

b.   Actions Not Requiring Supervisory Review; and

c.   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 documentation to support the enforcement action decision. Comments are required when the Reason for Alternative Recommendation selection is Other.

4512.2 Supervisor Responsibilities

LPPH January 2011

In addition to the routine consultation that occurs between staff and their supervisors, when actions are selected on the Enforcement Recommendation Details page from the Actions Requiring Supervisory Review section, the inspector is required to discuss his or her assessment of risk and the associated enforcement actions with the supervisor. After completing this consultation, the supervisor must ensure that the selections made on the Enforcement Recommendation Details page accurately reflect the enforcement decisions made during the consultation.

Supervisor Documentation

The supervisor may need to remove or add check-box selections (or both) depending upon whether or not the agreed decision is different from the inspector’s original selection. After supervisory review, the page should only include action selections that will be implemented.

In the Supervisor Comments field, the supervisor should describe what actions the inspector originally selected, what (if any) changes were made to enforcement actions selected, and why.

4700 Reviewing Operation Policies

LPPH November 2009

Policy

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.

DFPS Rules, 40 TAC §§745.243; 748.231; 749.331

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 40 Texas Administrative Code §748.2303.

4800 Risk Analysis

LPPH June 2014

Policy

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

a.   an analysis of an operation’s compliance with Licensing law, rules, and minimum standards;

b.   an identification of indicators associated with the potential of a higher risk of harm to the children in care at an operation; and

c.   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

LPPH 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 DFPS CCL Performance Management Unit mailbox.

4820 Risk Analysis Review Period

LPPH June 2014

Policy

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

LPPH 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:

a.   The requestor

b.   The district director or manager, as appropriate

c.   The director of field

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

a.   Date the risk analysis was completed

b.   Name of the requestor

c.   Name of the risk analyst that completed the risk analysis

4840 Licensing Staff Responsibilities After Receiving a Completed Risk Analysis

LPPH 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 DFPS 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:

a.   The date Licensing staff reviewed the analysis

b.   If Licensing staff have chosen to follow the recommendations or have chosen alternate actions

c.   A description of what actions Licensing staff have chosen

d.   The rationale for the actions that were chosen

 

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