4100, Inspecting Child-Care Operations

Revision 23-4; Effective Nov. 30, 2023

CCR staff inspect child care operations to assess the risk to children in those operations, in accordance with statutes, administrative rules, and minimum standards.

To determine an operation’s compliance, CCR 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 statutes, administrative rules and minimum standards;
  4. document observations to capture scope and severity;
  5. consider the risks posed by violations of statutes, administrative rules and 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 with statutes, administrative rules and minimum standards; and
  8. consider all 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.

CCR staff are not responsible for managing the operation.

26 TAC Sections 745.8401; 745.8403

Procedure

CCR staff evaluate the risk associated with deficiencies and help the permit holder understand that he or she must comply with statute, administrative rules and minimum standards.

Documenting Findings

Once compliance is determined, CCR 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, including results of inspections and technical assistance provided, must be documented in 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

Revision 23-4; Effective Nov. 30, 2023

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

Human Resources Code Section 42.044(a)

26 TAC Sections 745.8401; 745.8403; 745.8405; 745.8407

CCR staff have the authority to:

  1. determine whether an operation is subject to regulation;
  2. conduct a walkthrough of the operation;
  3. verify the operation’s compliance with statutes, administrative rules and minimum standards; 
  4. assess the risk to children in the operation; 
  5. assist the operation with identifying problems contributing to deficiencies in statutes, administrative rules and minimum standards;
  6. offer technical assistance; 
  7. gather information; 
  8. make a fair, accurate and impartial decision regarding the operation’s compliance with statutes, administrative rules and minimum standards; and
  9. 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

Revision 24-2; Effective May 22, 2024

Procedure

Follow-up inspections include evaluating individual minimum standards, conditions, or restrictions, instead of evaluating an entire subchapter of minimum standards or all conditions or restrictions on the operation’s permit. 

Examples of reasons for follow-up inspections include:

  1. Making sure the operation addressed recent deficiencies or a pattern of repeated deficiencies that may be followed up on without an inspection. Reference 4300 Conducting a Follow-Up with an Operation.
  2. Meeting with the designated director at a licensed day care center. Reference 4131.3 Child Day Care Annual Meeting with the Designated Director at a Licensed Child Care Center.
  3. Amending a permit or certificate. Reference 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. Reference 4152 Reviewing Restrictions, Conditions, Waivers, and Variances, and 10000 Background Checks.
  5. Following up on suspension, revocation, or denial. References 7631.5 Follow-Up After Delivery of Notice of Intent to Take Adverse Action When Operation Required to Close Immediately and 7636 Follow-Up to Final Notice of Suspension, Revocation, or Denial. 
  6. Monitoring during the appeal process. Reference 5720 Regulating Pending the Due Process Hearing for Denial, Refusal to Renew, Revocation, or Suspension.
  7. Following up on a waiver-variance condition. References 4152 Reviewing Restrictions, Conditions, Waivers, and Variances and 5120 Decision Guidelines for Recommending to Grant or Deny a Waiver or Variance. 
  8. Monitoring the temporary relocation of an operation. Reference 5520 Temporary Relocation.

Reference

Conducting a Follow-Up With an Operation, 4300

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

Revision 24-2; Effective May 22, 2024

Other types of inspections are conducted for such purposes as:

  1. consulting with an operation’s administrator or director;
  2. hand-delivering a corrective or adverse action notice;
  3. conducting an investigation interview; or
  4. conducting a heightened monitoring (HM) inspection, including an HM follow-up inspection.
     

4130 Minimum Requirements for Monitoring Inspections

Revision 24-1; Effective Feb. 20, 2024

The operation’s permit type determines:

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

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

References:

4131 Minimum Requirements for Licensed Operations                       
4132 Minimum Inspection Requirements for Registered Child Care Homes                       
4133 Operations That Are Not Regularly Inspected                       
4150 Conducting Inspections                       
4500 Evaluating Risk to Children and Handling Immediate Danger                
7441 Inspecting an Operation During Probation

4131 Minimum Requirements for Licensed Operations

August 2020

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 OperationWhat 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 Collection of Ratio Data for Licensed Child Care Centers

Licensed residential operationsAll minimum standards every two years.

Texas Human Resources Code Section 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, CCR staff must inspect a residential operation (other than a child-placing agency) after 7 p.m. on a weekday or anytime on the weekend. 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 Nighttime Care is Provided

At least once every two years, staff must inspect a day care operation that provides nighttime care during the hours that the operation provides nighttime care. 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, 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 CCR 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.

Selecting Subchapters on CLASS Form 2936 Child-Care Facility Inspection

Procedure

Within the first 12 months of issuance and within each subsequent two-year period, the inspector selects all checkboxes that are available for selection in CLASS that pertain to minimum standard subchapters. If the inspector cannot complete an evaluation of the operation’s compliance with all subchapters during the final inspection of the period, the inspector documents in the Narrative box of CLASS Form 2936 any specific subchapter that the inspector did not evaluate compliance with and explains why the evaluation of the operation’s compliance with that subchapter was not necessary or possible during the inspection.

Example: When the Evaluation of an Operation’s Compliance is Not Necessary

A school-age program does not transport children, but the checkbox for Subchapter Q (Transportation) is available for selection on CLASS Form 2936. The final monitoring inspection of the current two-year period is being conducted and the inspector selects all remaining subchapters (including Subchapter Q) that had not previously been selected in the two-year period. Because Subchapter Q does not apply to the operation, the inspector also documents the following in the Narrative box: “Although Subchapter Q was selected for this inspection, the operation does not provide transportation services; therefore, compliance could not be evaluated with that subchapter.”  

Example: When the Evaluation of an Operation’s Compliance is Not Possible

A child-placing agency is licensed to provide foster care and adoptive services; however, no adoptive placements occurred in the current two-year period. The final monitoring inspection of the current two-year period is being conducted and the inspector selects Subchapters Q (Adoptive Services: Children), R (Adoptive Services: Birth Parents), and S (Adoption Services: Adoptive Parents) on CLASS Form 2936, but also documents the following in the Narrative box: “Although Subchapters Q, R, and S were selected for this inspection, the operation has not provided any adoption services during this two-year period; therefore, compliance could not be evaluated with those subchapters.”

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

August 2021

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 inspector is unable to evaluate director qualifications because the director is not present during at least one of the unannounced inspections within a 12-month period, the inspector conducts a follow-up inspection. If the director is not present during the follow-up inspection, the inspector schedules a follow-up meeting at the operation to meet with the director to review the director’s qualifications.

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 Section 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 each 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 an unannounced monitoring inspection that requires the inspector to complete the annual review of the director’s qualifications, the inspector meets with the director during a follow-up inspection at the operation as follows:

Deficiency Cited at the Last Monitoring Inspection?Complete the Annual Review of Director Qualifications During…
High-weighted only,an unannounced follow-up inspection conducted no later than 15 days after the latest compliance date of the deficiencies.
Non-high-weighted only (that is, medium-high, medium, medium-low and low),an unannounced follow-up inspection conducted no later than 30 days after the latest compliance date of the deficiencies.
High- and non-high-weighted,an unannounced follow-up inspection within 15 days of the latest compliance date of the high-weighted deficiencies.
No,an announced or unannounced follow-up inspection conducted no later than 30 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 at the operation.

If the director does not respond to a request to meet, the inspector cites the operation for a violation of minimum standard, 26 TAC Section 746.1011, 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 Collection of Ratio Data for Licensed Child Care Centers

April 2021

Child Care Regulation (CCR) staff will gather certain ratio data for each classroom during a monitoring or monitoring/investigation inspection at a licensed child care center when there are children four years of age or younger present during the inspection.

Texas Human Resource Code Section 42.0412(c)

Procedure

During the walk-through of a monitoring or monitoring/investigation inspection of a licensed child care center, CCR staff will document the following in the Classroom Information section on the Inspection Details page of CLASS Form 2936 for each classroom with children four years of age and younger present:

  • the total number of children;
  • the specified age of children in each group;
  • the number of caregivers supervising the group of children;
  • classroom type;
  • a name exclusive to each classroom;
  • activities observed in the classroom during the inspection; and
  • if child/caregiver ratio is not met (this information does not replace a citation for ratio).

Staff selects the Add Classroom button to add classroom details in the Classroom Information section for each classroom that has children age four years old or younger present during the inspection.

If no children age four years old or younger are present at the operation during the inspection, staff will select The operation has zero classrooms where children age four years old or younger are present check box.

This information can be modified in CLASS until the inspection is frozen.

See 4161.2 Documenting Inspection Results on CLASS Form 2936

4131.5 Health and Safety Audits for Licensed Child Day Care Operations

April 2021

Child Care Regulation (CCR) 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 Section 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 CCR 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 Inspection Requirements for Registered Child Care Homes

Revision 23-4; Effective Nov. 30, 2023

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.

45 Code of Federal Regulations Section 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 CCR issued the registration and counting in two-year increments. For example, if a registration was issued on Sept. 10, the two-year period would begin on Sept. 1 and end on Aug. 31 two years later.

26 TAC Section 745.8405(a)(3)

Selecting Subchapters on CLASS Form 2936 Child-Care Facility Inspection

Procedure

Within the first 12 months of issuance and within each subsequent two-year period, the inspector selects either:

  • the Standard x Standard Inspection checkbox if only one monitoring inspection is planned; or
  • all checkboxes available for selection in CLASS that pertain to minimum standard subchapters.

If the inspector cannot complete an evaluation of the operation’s compliance with all subchapters during the final inspection of the period, the inspector documents in the Narrative box of CLASS Form 2936 any specific subchapter that the inspector did not evaluate compliance with and explains why the evaluation of the operation’s compliance with that subchapter was not possible or necessary during the inspection.

Example: When the Evaluation of an Operation’s Compliance is Not Necessary

A home does not transport children, but the checkbox for Subchapter X (Transportation) is available for selection on CLASS Form 2936. The final monitoring inspection of the current two-year period is being conducted and the inspector selects all remaining subchapters (including Subchapter X) that had not previously been selected in the two-year period. Because Subchapter X does not apply to the operation, the inspector also documents the following in the Narrative box: “Although Subchapter X was selected for this inspection, the operation does not provide transportation services; therefore, compliance could not be evaluated with that subchapter.”

Example: When the Evaluation of an Operation’s Compliance is Not Possible

A home is approved to provide field trips as one of its services; however, the primary caregiver has indicated no field trips have occurred in the current two-year period. The final monitoring inspection of the current two-year period is being conducted and the inspector selects Subchapter N (Field Trips) on CLASS Form 2936, but also documents the following in the Narrative box: “Although Subchapter N was selected for this inspection, the operation has not had any field trips during this two-year period; therefore, compliance could not be evaluated with that subchapter.”

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 x 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.

Additional Requirements for All Inspections on Registered Child Care Homes

Procedure

If CCR staff find any of 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 available on the CCR SharePoint site:

  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.

4133 Operations that are Not Regularly Inspected

Revision 23-4; Effective Nov. 30, 2023

Listed Family Homes

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

See:

6231.1 Intake Reports to Be Investigated by CCR                       
6231.11 Reports Received for Listed Family Homes Caring for Related Children Only

Human Resources Code Section 42.044(b)

26 TAC Sections 745.8405(a)(1) and (2)

Small Employer-Based Child Care and Temporary Shelter Programs

CCR staff do not conduct regular monitoring inspections on small employer-based child care or temporary shelter programs. However, CCR 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

Human Resources Code Sections 42.153, 42.162, 42.203, 42.209

26 TAC Sections 745.8405(a)(7) and (8)

4140 Preparing for Inspections

4141 Preparing for Application, Initial, and Monitoring Inspections

Revision 24-2; Effective May 22, 2024

CCR 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 documented in CLASS;
  • operation’s fee payment history;
  • operation’s background check records documented in CLASS;
  • operation’s controlling person list documented in CLASS;
  • recommendations from enforcement team conferences for residential operations inspections; and
  • results of random-sampling inspections of CPAs if preparing to inspect a CPA.

CCR staff also complete an extended compliance history review for residential child care operation inspections per 4143 Conducting an Extended Compliance History Review (RCCR Only).

CCR staff use information obtained during the review to decide 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 or investigation, CCR staff must reevaluate the same and related standards at the inspection.

Procedure

Reviewing Background Materials

To prepare for an inspection, CCR staff review the following:

  1. the most recent information in CLASS on enforcement recommendations for the operation, including:
    • the recommendation;
    • any other enforcement actions taken in the past year by other HHSC staff; and
    • the operation’s recommended monitoring frequency;
  2. the capacity of the operation, the ages of the children served, the days, months, and hours of operation, and the services provided;
  3. the operation’s address, including the Location Address Validation Status and Mailing Address Validation Status, to determine if 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:
    • 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 of CPA foster homes for inspections of child-placing agencies only as outlined in 4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency; and
    • prior extended compliance history reviews for residential operations;
  9. the operation’s fee payment history to determine if the operation is current on all applicable fees unless the operation is exempt from paying all fees per 5240 Verification of Fee Payments;
  10. the operation’s background check records in CLASS to verify the operation has complied with all background check requirements as outlined in 10000 Background Checks;
  11. the operation’s controlling person list in CLASS to determine if any person on the list has a status of Review per 5430 Processing and Reviewing the Information on Controlling Persons Submitted by an Operation and the relevant subsections;
  12. recommendations from enforcement team conferences for inspections of CPAs and GROs as outlined in 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations;
  13.  optional checklists, forms, reading guides, and applicable technical assistance materials.

Draft Form 2936 Child-Care Facility Inspection

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

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

Staff refer to 4142 Preparing for Investigation Inspections for information on preparing for investigation inspections.

Reference

Completing CLASS Form 2936 Child-Care Facility Inspection, 4161

4141.1 Monitoring Inspections During an Investigation

May 2020

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

4142 Preparing for Investigation Inspections

May 2020

Child Care Regulation (CCR) 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.

CCR staff also complete an extended compliance history review for residential child care operations. See 4143 Conducting an Extended Compliance History Review (RCCR Only).

Draft Form 2936 Child-Care Facility Inspection

After reviewing the information listed above, but before conducting the inspection, CCR 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.

Procedure

Reviewing Background Materials

To prepare for an inspection, CCR 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 CCR 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
    • prior extended compliance history reviews (for residential operations);
  6. the operation’s background check records in CLASS to verify that the operation has complied with all background check requirements (see 6470 Reviewing Background Check Records During Investigations and 10700 Monitoring Operations for Compliance with Background Check Requirements); 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, CCR 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.

4143 Conducting an Extended Compliance History Review (RCCR Only)

Revision 24-1; Effective Feb. 20, 2024

An inspector conducts an extended compliance history review (ECHR) as part of inspecting a residential child care operation. This requirement applies to the following types of inspections: monitoring, investigation, and monitoring and investigation. 

The inspector completes a review and assessment of certain high-risk areas that occurred in the past five years while preparing for the inspection. These include:

  1. the number of abuse, neglect or exploitation intakes;
  2. the number of confirmed abuse, neglect or exploitation findings; and
  3. the number of citations issued for corporal punishment.

When conducting this review and assessment, the inspector reviews data for the current operation and all prior operation numbers listed under the Issuance History section on the Operation Main page in CLASS. 

After reviewing all the information gathered and before conducting the inspection, the inspector completes and documents a written narrative analysis that describes their evaluation of the operation’s compliance history, and any risks identified. 

Before finalizing the inspection, the inspector also documents the steps the inspector took during the inspection to mitigate any risk identified during the assessment, inspection, or both.

Procedure

To complete the review and assessment of certain high-risk areas noted above, the inspector does the following:

Type of Information to be ReviewedCLASS Page on Which this Information is ListedHow CLASS Page is Accessed
Number of abuse, neglect, or exploitation intakes at the operation and all prior operation numbers listed under the Issuance History section on the Operation Main page in CLASS.ANE Intake and Finding DetailsBy clicking the View Compliance History button in the Extended Compliance History Review section on the Inspection Details page.
Number of confirmed abuse, neglect, or exploitation findings at the operation and all prior operation numbers listed under the Issuance History section on the Operation Main page in CLASS.ANE Intake and Finding DetailsBy clicking the View Compliance History button in the Extended Compliance History Review section on the Inspection Details page.
Number of citations issued for corporal punishment at the operation and all prior operation numbers listed under the Issuance History section on the Operation Main page in CLASS.Corporal Punishment Citation DetailsBy clicking the View Compliance History button in the Extended Compliance History Review section on the Inspection Details page.

The inspector must review the investigation or inspection with the finding(s) if their review of this history shows findings of abuse, neglect or exploitation, or a violation of a minimum standard related to corporal punishment, and consider:

  1. the Explanation of the Disposition Based on Preponderance narrative box located on the Investigation Conclusion page, if applicable;
  2. the allegation narrative for the citation if applicable;
  3. whether the allegations involved a child under 6 years;
  4. any follow-up activity that was completed; and
  5. any patterns of: 
    • investigations; or 
    • the agency homes involved in the investigations.

During the inspection, the inspector addresses with the person in charge any risks identified during:

  • the inspector’s review of the ANE Intake and Finding Details and Corporal Punishment Citation Details pages in CLASS;
  • the inspection; or
  • both.

4143.1 Assessing the Extended Compliance History

August 2020

Procedure

The inspector conducts an overall assessment of the information to determine if any of the following actions are necessary:

  1. a discussion with the operation regarding patterns or trends;
  2. a review of additional training records or serious incident reports;
  3. a review of additional agency home history; or
  4. recommend enforcement action.

4143.2 Documenting an Extended Compliance History Review

Revision 24-1; Effective Feb. 20, 2024

Procedure

The inspector does the following for each inspection requiring an ECHR:

ActionWhen Action is Completed
  1. Documents the following information in the Extended Compliance History Review section on the Inspection Details page in CLASS:
    1. the date the inspector reviewed the ECHR;
    2. the total number of the following for the current operation and all prior operation numbers identified on the Operation Main page under the Issuance History section:
      1. abuse, neglect, or exploitation intakes received;
      2. the number of confirmed findings of abuse, neglect, or exploitation;
      3. the number of citations issued for corporal punishment; and
    3. the inspector’s assessment of the information reviewed, including risks identified, by completing each applicable field on the Extended Compliance History Assessment page, accessed by clicking the Complete/View Assessment button in the Extended Compliance History Review section on the Inspection Details page.
No earlier than five days before the inspection.
  1. Notifies the appropriate supervisor by email that the Extended Compliance History Review section has been completed if the ECHR is for an inspection at a foster home.
  • P1 and P2 investigations when CCR is required to initiate by conducting an inspection: As early as possible before the inspection.
  • P1 and P2 investigations when CCR is not required to initiate by conducting an inspection: At least two days before the inspection.
  • P3 investigations: At least two days before the inspection.
  • P4 Investigations: At least two days before the inspection.
  1. Creates a draft of CLASS Form 2936 Child Care Facility Inspection and downloads the saved draft to CLASSMate.

If the ECHR is for a foster home, after the supervisor replies to the inspector by email that the ECHR has been approved.

If the ECHR is not for a foster home, after the inspector completes the Extended Compliance History Review section.

  1. Documents a summary of the steps taken to mitigate risk at the operation in the Steps Taken to Mitigate Risk field on the Inspection Details page in CLASSMate.
During the inspection and before signing and finalizing CLASS Form 2936.

References: 

Completing CLASS Form 2936 Child-Care Facility Inspection, 4161 

Extended Compliance History Review Guide on the CCR SharePoint site.

4143.21 Supervisor Oversight of Extended Compliance History Review Documentation

Revision 24-1; Effective Feb. 20, 2024

Procedure

A supervisor ensures compliance with the ECHR documentation requirements outlined in 4143.2 Documenting an Extended Compliance History Review by:

  • verifying the inspector is completing an ECHR in the required time frame, for each inspection that requires an ECHR;
  • reviewing, providing feedback, and approving the completed ECHR in CLASS for all inspections of foster homes before the inspector conducts the inspection; and
  • if case reading errors are identified on any ECHR, meeting with the inspector within five days of receiving the case reading results to review: 
    • the results of the case reading; and
    • applicable policy and procedures.

4143.22 Documenting Supervisory Approval of an Extended Compliance History Review for an Inspection of a Foster Home

Revision 24-1; Effective Feb. 20, 2024

A supervisor documents approval of an ECHR for an inspection of a foster home within one day of approving the ECHR.

Procedure

To document approval of an ECHR for an inspection of a foster home, the supervisor enters the following information as a Chronology in CLASS using the Investigation category type:

  • Inspection Id for the associated inspection, listed on the Inspection Details page;
  • date listed in the Inspection Start Date field on the Inspection Details page;
  • name of the inspector completing the inspection; and
  • date the supervisor approved the ECHR.

4150 Conducting Inspections

Revision 23-4; Effective Nov. 30, 2023

When conducting any type of inspection, CCR staff must:

  1. identify themselves as HHSC CCR 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 CCR 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 statutes, administrative rules and minimum standards and understand how to comply with the requirements.

26 TAC Section 745.8401; 745.8403

Procedure

CCR 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 relevant statutes, administrative rules and minimum standards by which compliance will be evaluated;
    3. that compliance with additional statutes, administrative rules and  minimum standards may be evaluated as the situation demands; 
    4. that photographs and video may be taken by CCR during the inspection; and
    5. the operation may not record or listen to any CCR interview with staff, caregivers, or children or internal discussion between CCR staff, but an individual may record their own interview.
  3. Obtain written consent before interviewing owner’s biological or adopted children, even when the owner’s or operator’s children are in care at the operation. Other children in care may be interviewed, provided the child’s parent has not previously refused to allow CCR staff to interview his or her children. See 6000 Investigations.
  4. Terminate the inspection at any time when CCR 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 4520 Handling Immediate Danger to Children, if children are at risk.
  6. Follow the procedures in 4156, When an Inspection is Attempted, if there is no one at the operation or no children are in care.
  7. Follow the procedures in 6231.21 Upgrading an Intake Report to an Abuse, Neglect, or Exploitation Intake Report, if abuse or neglect is reported or is observed during the inspection.

4150.1 Additional Requirements for Investigation Inspections

Revision 23-4; Effective Nov. 30, 2023

The investigator conducts an unannounced investigation inspection at an operation that is the subject of the investigation according to the time frames in 6431 Requirements for Conducting Unannounced Inspections.

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; and
    • 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).

See 6241 Classifying the Priority of the Intake Report.

26 TAC Section 745.8405

4150.2 Additional Requirements for Initial and Monitoring Inspections

April 2021

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

See 10730 Validating the Employee List for an Operation

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 4320 Following Up With an Inspection, CCR 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 4310 Time Frames for Conducting Follow-Up. CCR 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

Revision 24-1; Effective Feb. 20, 2024

CCR staff document an operation’s deficiencies in CLASS after reviewing the restrictions and conditions.

Procedure

CCR staff document any violations of restrictions or conditions on CLASS Form 2936 Child Care Facility Inspection for each inspection where restrictions or conditions are reviewed, by:

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

References:

Completing CLASS Form 2936 Child Care Facility Inspection, 4161                  
Inspecting an Operation During Probation, 7441

4152.2 When an Operation Repeatedly Fails to Meet Restrictions or Conditions

Revision 24-1; Effective Feb. 20, 2024

CCR staff consult with the supervisor on what action to take if the operation repeatedly fails to meet the restrictions or conditions.

References:

Handling Changes in an Operation, Type of Permit, Location, and Ownership, 3800 
Revoking a Waiver or Variance, 5180 
Amending Conditions of a Waiver or Variance, 5181 
Voluntary Actions and Enforcement Actions, 7000 
Background Checks, 10000

4152.3 Discussing Waivers and Variances

Revision 24-1; Effective Feb. 20, 2024

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

Reference: 5190 Documenting Outcomes for Waiver and Variance.

4153 Reviewing Records at an Operation or a Central Administrative Location

Revision 23-4; Effective Nov. 30, 2023

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

CCR 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. If a Child-Placing Agency (CPA) operates at a main office or branch office that is not open between 8:00 a.m. and 5:00 p.m. Monday through Friday, the CPA must ensure that the office and employees are available upon CCR’s request for the purpose of inspecting or investigating the CPA. CCR staff may make copies of documents, as needed, but they do not remove original records from the operation.

26 TAC Section 745.8405(c); 745.8413(c)  

After evaluating records as part of an inspection, CCR 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.
4153.4 Reviewing Records at a Central Administrative Location.

4153.1 Selecting a Sample of Records During Each Two-Year Period

Revision 23-2; Effective June 26, 2023

Procedure

CCR staff must read records that relate to:

  1. children enrolled in or admitted to the operation;
  2. personnel; and
  3. serious incident reports (for residential operations).

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

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

Additional Requirements for Child-Placing Agencies

In addition to the types of records listed above, staff read CPA records that relate to:

  • verified foster homes;
  • approved adoptive homes; and 
  • birth parents who have applied for services (for CPAs that do private adoptions).

When evaluating for standards related to transfers and agency home closure requirements, including agency home closure recommendations, staff select a sample of homes that within the past two years:

  • transferred to another CPA;
  • transferred to the CPA from another CPA; and 
  • closed.

Exception for personnel records at a CPA: If a CPA maintains personnel records only at the main office and the records are not available electronically at the branch office(s), the CCR staff assigned to the main office is responsible for selecting and reading personnel records for both the main office and all branch offices.

4153.11 Determining the Number of Records to Read at a Monitoring Inspection (All Record Types except Serious Injury Reports)

October 2020

Procedure

During at least one monitoring inspection during the operation’s two-year compliance period, CCR staff read records associated with the subchapter(s) being evaluated during the inspection (as indicated on the Inspections Details page in CLASS). The minimum number of each type of record that staff must evaluate is based on:

  • the operation’s capacity, if the operation is not a child-placing agency; or
  • the total number of verified foster homes and/or approved adoptive homes, if the operation is a child-placing agency. If reading personnel records for the main office and all branch offices, staff must base the number of personnel records on the total number of homes for all CPA office locations.
Capacity or Number of HomesMinimum Number of Each Type of Record to Review During the Two-Year Compliance Period (Except Serious Injury Reports)
44 or less4
45-746
75-948
95 or more10

CCR 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.

If a CPA maintains personnel records only at the main office, and the records are not available electronically at the branch office(s), CCR staff must review personnel records from each branch during the two-year compliance period. To help ensure that all records are reviewed, CCR staff document in a Chronology the number of records reviewed from each branch office.

4153.12 Determining the Number of Serious Incident Reports to Read at a Monitoring Inspection (Residential Child Care Only)

October 2021

During each monitoring inspection of a general residential operation or child-placing agency, CCR staff read the minimum number of serious incident reports according to the operation’s capacity or number of homes indicated in the following chart:

Capacity or Number of HomesMinimum Number of Serious Injury Reports to Review During Each Inspection
44 or less4
45-746
75-948
95 or more10

When conducting a Heightened Monitoring (HM) inspection, the HM inspector follows the procedures outlined in 11454 Determining the Type and Number of Records to Review at a Heightened Monitoring Inspection of a GRO or CPA Office.

4153.13 Sampling Additional Records During a Follow-Up Inspection

October 2020

During a follow-up inspection conducted to confirm that the operation is now in compliance, CCR 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 ApplicationInitial, 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

December 2019

If an operation, other than a child-placing agency, maintains records at a central administrative location, the inspector must visit the central location to review records within seven days before or after conducting an Initial or Monitoring inspection.  

Reviewing records at a central administrative location is not documented as an inspection in CLASS.

Licensing staff documents the review of records in the following manner:

  1. documents the visit to the central administrative location in CLASS Chronology;
  2. selects subchapter(s) applicable to the review of records on CLASS Form 2936 Child Care Facility Inspection for the inspection that precedes or follows the review of records;
  3. cites deficiencies:
    1. as an assessment in CLASS; or
    2. on CLASS Form 2936 associated with the inspection, if reviewing records before conducting the inspection at the operation and deficiencies do not present high risk to children in care.

Licensing staff follows up on deficiencies with the operation that were cited or with the person who maintains records at the central administrative location.

4154 Technical Assistance

4154.1 Providing Technical Assistance

Revision 23-4; Effective Nov. 30, 2023

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

CCR staff provide technical assistance for each high-weighted violation.

Technical assistance supplements CCR's regulatory requirements by providing additional information or clarification. Technical assistance does not repeat the language as written in statutes, administrative rules or minimum standards.

All technical assistance provided by CCR staff must be documented in CLASS (4154.2 Documenting Technical Assistance).

Procedure

CCR 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 statute, administrative rule or minimum standard.

Technical assistance may be provided orally or in writing: 

  • at any time during or at the conclusion of an inspection or investigation, including on the inspection form or investigation letter, regardless of whether the operation is deficient or in compliance with a particular statute, administrative rule or minimum standard; 
  • as part of an ongoing regulatory process; or 
  • at the operation’s request. 

26 TAC Sections 745.8581 and 745.8583 

Distributing Documents as Part of Providing Technical Assistance

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

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

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

4154.2 Documenting Technical Assistance

May 2020

Child Care Regulation (CCR) 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, CCR staff enter the following information on the Standards Detail page of the inspection in CLASSMate or CLASS:

  1. Select an individual CCR 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 CCR 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

CCR staff evaluate certain criteria to determine whether a deficiency may be corrected at inspection or whether CCR staff must follow up on a deficiency with or without an inspection. CCR 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 Time Frames for Conducting a Follow-Up

Procedure

CCR staff may indicate that the operation corrected the deficiency at the inspection if CCR staff determine 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, CCR staff document that the operation corrected the deficiency at inspection. On the CLASS Form 2936 Child-Care Facility Inspection, CCR staff:

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

4156 When an Inspection is Attempted

Revision 23-2; Effective June 26, 2023

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 CCR staff arrives to conduct the inspection, CCR 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. CCR 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 Final Notice of Suspension, Revocation, or Denial.

Procedure

Licensed, Certified, Registered, or Listed Operations

CCR 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 CCR statutes, administrative rules, or minimum standards, if appropriate.
  2. If mailing the form would not impede an ongoing investigation, CCR staff include in the form:
    • a request that the operation contact CCR staff within 10 days of receiving the form or letter, and
    • a warning that failure to respond may be interpreted by CCR as an indication that the operation has voluntarily closed.
  3. Mail a copy of the form to the operator, applicant, or designee by regular mail.
  4. If mailing the form would impede an ongoing investigation, CCR staff consult with the supervisor on when to mail the form to the operator, applicant, or designee.

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

If …then …
the operation does not respond on or before the first workday after 13 calendar days from the date CLASS 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 5540 Voluntary Closure); and
  • close the operation in CLASS.
the operation notifies CCR 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 CCR statute, administrative rules, or minimum standards, unless the person in charge chooses to close temporarily. See 5530 Voluntary Suspension.
the operation responds and notifies CCR 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), CCR staff do as follows:

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

After completing CLASS Form 2936, CCR 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

Child Care Regulation (CCR) 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 §§42.044242.0443.

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

May 2021

To eliminate redundancy, CCR reviews documentation from other state agencies and political subdivisions that inspect the same operations as CCR. CCR 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 CCR 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.

CCR 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 CCR’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 CCR

If a state agency or political subdivision finds that an operation is not in compliance with a requirement that is equivalent to a CCR law, administrative rules, or minimum standards and the operation does not correct the deficiency, CCR 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, CCR 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 §42.0442; §42.0443

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

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

CCR 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 TypeMinimum 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

§§744.2401-2407; 744.2411-2421

§§746.3301-3303; 746.3319

§§747.3101-2103; 747.3119

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

CCR 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.

TopicMinimum 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

Revision 23-4; Effective Nov. 30, 2023

An operation’s employees must admit CCR staff and not delay or interfere with CCR staff from making inspections during its hours of operation.

Human Resources Code Sections 42.044(a) and 42.04412 

26 TAC Sections 745.8411; 745.8413

Procedure

If the employees of an operation refuse to allow, delay or interfere with an inspection during the operation’s business hours, CCR staff follow the procedures outlined below.

If …then …

the operation’s employees:

  • refuse to admit CCR staff to the operation;
  • attempt to delay or interfere with CCR staff from inspecting the operation during its business hours;
  • refuse to allow CCR staff to inspect an area of the operation that affects or could affect the children’s health, safety or well-being; or
  • delay or interfere with an attempt to inspect or investigate, so that CCR staff cannot carry out their responsibilities…

CCR staff:

  1. advise the person in charge of the operation that the inspection or investigation is authorized by Human Resources Code Sections 42.044(a) and 42.04412 and HHSC may take any or all of the following actions if the resistance continues:
    • issue the operation a deficiency;
    • take an enforcement action against the operation; or
    • seek a court order granting access to the operation and records.
  2. obtain the name of the person in charge at the operation, if possible;
  3. cite interference of the inspection or investigation and violation of rules using CLASS Form 2936 Child-Care Facility Inspection. Include documentation on the form that, if CCR inspections are further denied, interfered or delayed, CCE may take enforcement action against the operation’s permit under Human Resources Code Sections 42.071 and 42.072;
  4. consult with the CCR supervisor about the necessary follow-up actions;
  5. see 4520 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 7600 Adverse Actions.

4159.1 Attempted Interference by a Licensed Administrator or Applicant for an Administrator’s License

Revision 23-4; Effective Nov. 30, 2023

A licensed administrator or applicant for an administrator's license may not attempt to interfere with HHSC’s ability to conduct agency business.   

Conduct that constitutes an attempt to interfere with HHSC ability to conduct agency business includes: 

  • interfering with, coercing, threatening, intimidating, retaliating against or harassing an HHSC staff member in connection with the person's exercise of HHSC regulatory duties; or
  • engaging in conduct or directing language at HHSC staff that a reasonable person would find to be harassing, intimidating or threatening to HHSC staff.

26 TAC Sections 745.8411, 745.8929 and 745.8930

Procedure

If the Attempted Interference Occurs During Routine Monitoring

During an inspection, investigation or while evaluating an operation, if CCR staff encounter an attempt by a licensed administrator or applicant for an administrator’s license to interfere with staff’s ability to monitor the operation, CCR staff:

  1. consult with the supervisor to determine whether the underlying action or behavior supports a citation for either 26 TAC Section 745.8411 or 745.8929. When determining whether a citation is warranted, staff consider:
    1. the action or behavior observed such as unauthorized recording outside of normal operation surveillance or not allowing CCR staff to interview operation staff or children as part of an investigation; 
    2. the impact the action or behavior had on staff’s ability to complete regulatory activities; and
    3. whether there is evidence available to support a citation for attempted interference;
  2. if the supervisor approves, cite either 26 TAC Section 745.8411 or 745.8929, whichever is most appropriate;
  3. document details of the incident including specifics on how the incident impacted the staff’s ability to conduct regulatory activities in a Chronology in CLASS; and
  4. upload any evidence to support the incident of attempted interference in the CLASS Document Library.

The supervisor notifies the Licensed Administrator Program Specialist of the incident for review and possible referral to Child Care Enforcement. 

See 9710 Handling Attempts to Interfere or Interference by a Licensed Administrator

Job Aid “Addressing Attempted Interference by a Licensed Administrator or Applicant for an Administrator’s License (RCCR Only),” available on CCR SharePoint site.

If the Attempted Interference Occurs Outside of Routine Monitoring

If CCR staff become aware of an action or behavior by a licensed administrator or applicant for an administrator’s license that occurs outside of routine monitoring, CCR staff:

  1. consult with a supervisor to determine if a referral to CCE is appropriate. When determining whether a referral to CCE is appropriate, the supervisor considers:
    1. the action or behavior observed such as making online threats against CCR staff or coercing CCR staff to release confidential information; 
    2. the impact the action or behavior had on staff’s ability to carry out regulatory activities, including attending meetings; and
    3. whether there is evidence available to support the interference or attempted interference;
  2. document details of the incident in an email; and 
  3. email any evidence to support the incident to the Licensed Administrator Program Specialist. See 9710 Handling Attempts to Interfere by a Licensed Administrator. 

4160 Documenting the Results of an Inspection

Revision 23-4; Effective Nov. 30, 2023

When documenting the results of an inspection, CCR staff:

  1. document deficiencies clearly and concisely;
  2. cite the specific CCR statutes, administrative rules or minimum standards for which compliance was evaluated and describe the deficiencies observed;
  3. document any technical assistance given for each CCR statute, administrative rule or minimum standard;
  4. state the date for compliance. Compliance dates must be reasonable and based on the risk to children. See 4500 Evaluating Risk to Children and Handling Immediate Danger;
  5. complete the Photo Taken at Inspection radio button as applicable; and
  6. complete the Supporting Documents/Photos Obtained radio button on each Standard Details page in CLASS for each standard marked as:
    • deficiency;
    • compliance;
    • sampling concern; or
    • not a sampling concern; and
  7. provide the inspection results at the conclusion of the inspection, on CLASS Form 2936 Child-Care Facility Inspection.

CCR staff create a supplemental CLASS Form 2936 to finalize inspection results left pending or to make corrections.

See:

1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files    
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files    
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library    
4161  Completing CLASS Form 2936 Child-Care Facility Inspection    
4162  Finalizing Form 2936 and Synchronizing CLASSMate with CLASS    
4163  Final Determination of Findings Left Pending During an Inspection    
4165  Completing a Supplemental Inspection Form                      
4200  Assessments

4161 Completing CLASS Form 2936 Child-Care Facility Inspection

Revision 23-4; Effective Nov. 30, 2023

After reviewing the background materials related to the operation (see 4140 Preparing for Inspections), CCR staff create a draft of CLASS Form 2936 Child-Care Facility Inspection.

On the same day as the inspection, after the inspection is completed, CCR staff complete CLASS Form 2936 to document inspection results.

Documenting a Possible Deficiency as Pending on Form 2936

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

CCR 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. (4163 Final Determination of Findings Left Pending During an Inspection).

Signing and Providing a Copy of Form 2936

After conducting the exit conference, CCR staff provide a copy of Form 2936 to the:

  • designee, director, administrator or primary caregiver; and
  • person in charge, if the designee, director, administrator or primary caregiver is not available during the exit interview.

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

26 TAC Section 745.8443(a)

4161.1 Creating a Draft CLASS Form 2936

April 2021

CCR 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, CCR 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 4321 Documenting Follow-Ups Completed During an Inspection Unrelated to Heightened Monitoring Activities

4161.2 Documenting Inspection Results on CLASS Form 2936

Revision 24-1; Effective Feb. 20, 2024

Procedure

The inspector uses CLASS Form 2936 to document the inspection. The inspector documents the results of an inspection per the table below.

Operation TypeInspection TypeWhat to DocumentHow to Document in CLASS
All Day Care and Residential Care OperationsAll InspectionsThe finding (Deficiency, Compliance or Pending) for each CCR statute, administrative rule or minimum standard that was evaluated during the inspection.Complete the Standard Details page.

References:    
4161.21 Documentation of the Findings Evaluated from the Inspection    
4300 Conducting a Follow-Up with an Operation    
4323 Documenting Follow-up Results on CLASS Form 2936
All Day Care and Residential Care OperationsAll InspectionsThe technical assistance provided.Complete the Standard Details page.    

Reference 4154.2 Documenting Technical Assistance
All Day Care and Residential Care OperationsAll InspectionsA list of any hazards that the operation must correct immediately.Complete the Narrative text box on the Inspection Details page.
All Day Care and Residential Care OperationsAll InspectionsIf the inspector obtained any documents or photos to support a regulatory decision.Select the appropriate Supporting Documents and/or Photos Obtained radio button on the Standard Details page.
All Day Care and Residential Care OperationsAll InspectionsIf the inspector took any photos during the inspection.Select the appropriate Photos Taken During Inspection radio button on the Inspection Details page.
All Day Care and Residential Care Operations
  • Monitoring 
  • Monitoring and Investigation
The inspector’s evaluation of all corrective action conditions.Select the Probation conditions were evaluated checkbox in the Other Items Evaluated section on the Inspection Details page.    

References:
7315 Inspecting an Operation During a Plan of Action
7441 Inspecting an Operation During a Probation
All Day Care and Residential Care Operations
  • Monitoring 
  • Monitoring and Investigation
The inspector’s evaluation of all action items for a plan of action.Select the Plan of Action action items were evaluated checkbox in the Other Items Evaluated section on the Inspection Details page.   

References:
7315 Inspecting an Operation During a Plan of Action
7441 Inspecting an Operation During a Probation
All Day Care and Residential Care Operations
  • Monitoring 
  • Monitoring and Investigation
The number of each record type reviewed during the inspection, based on the operation type and capacity.In the Records Evaluated section on the Inspection Details page, enter the number of records evaluated in the field which corresponds to the record type.   

Reference 4153 Reviewing Records at an Operation or a Central Administrative Location
All Day Care and Residential Care Operations
  • Initial
  • Monitoring
  • Monitoring and Investigation
The inspector’s review of permit restrictions and permit conditions.Select the …items regarding risk to children… check box on the Inspection Details page.   

Reference 4152 Reviewing Restrictions, Conditions, Waivers, and Variances
All Day Care and Residential Care Operations
  • Application
  • Initial
  • Monitoring 
  • Monitoring and Investigation
The inspector’s assessment of risk to children during the operation walk-through.Select the …items regarding risk to children… check box on the Inspection Details page.   

References:   
4151 Operation Walk-Throughs
4157 Visiting an Operation to Conduct an Investigation Interview When the Operation is Not the Subject of the Investigation
All Day Care and Residential Care Operations
  • Application
  • Initial
  • Monitoring
  • Monitoring and Investigation
The inspector’s evaluation of the operation’s compliance with background check requirements.Select the Background Checks have been Verified/Evaluated check box on the Inspection Details page.   

Reference 10700 Monitoring Operations for Compliance with Background Check Requirements
All Day Care and Residential Care Operations
  • Application
  • Initial
  • Monitoring
  • Monitoring and Investigation
The inspector’s review of the operation’s Controlling Persons List in CLASS with the person in charge. This is to determines if the list is correct and in compliance with CCR statutes, administrative rules and minimum standards.Select the Controlling Persons Have Been Verified check box on the Inspection Details Page.   

References:
4153.3 Reviewing Information on Controlling Persons   
4164 Procedures When the Operation’s List of Controlling Persons Cannot Be Verified During the Inspection   
4171 Discussing the Results of an Inspection   
5400 Controlling Person
All Day Care and Residential Care OperationsInvestigationThe inspector’s evaluation of the operation’s compliance with background check requirements for principals and collaterals known at time of the investigation inspection.Select the Background Checks have been Verified/Evaluated check box on the Inspection Details page.   

Reference 10700 Monitoring Operations for Compliance with Background Check Requirements
All Residential Care Operations
  • Monitoring
  • Investigation
  • Monitoring and Investigation
A summary of the steps the inspector took to mitigate risk during the inspection. This is part of the Extended Compliance History Review.   

Reference: Extended Compliance History Review Guide and Extended Compliance History Review Documentation Template Form 7292 on the CCR SharePoint site.
In the Steps Taken to Mitigate Risk field on the Inspection Details page.
  • Licensed Child Care Centers
  • Before- or After-School Programs
  • School-Age Programs
All InspectionsIf the designated director is present during the inspection.If the director is present, select the Director Present check box on the Inspection Details page.   

Reference 4131.3 Child Day Care Annual Meeting with the Designated Director at a Licensed Child Care Center
  • Licensed Child Care Centers
  • School-Age Programs
  • Before- or After-School Programs
  • Licensed Child Care Homes
  • Monitoring
  • Monitoring and Investigation
The inspector conducted a health and safety audit (HASA) using the Health and Safety Audit Checklist or a standard-by-standard evaluation during an unannounced annual inspection.Select the Health and Safety Audit conducted checkbox on the Inspection Details page.   

Reference 4131.5 Health and Safety Audits for Licensed Child Day Care Operations
Registered Child Care Homes (with a TWC Subsidy Agreement)
  • Monitoring
  • Monitoring and Investigation

The inspector conducted an unannounced annual inspection:

  • using the Health and Safety Audit Checklist; or
  • by conducting a standard-by-standard evaluation.
Select the Health and Safety Audit conducted checkbox on the Inspection Details page.   

Reference 4132 Minimum Inspection Requirements for Registered Child Care Homes
Licensed Child Care Centers Only
  • Monitoring
  • Monitoring and Investigation
Ratio data for each classroom that is caring for children 0-4 years old during the inspection.Complete the Classroom Information section on the Inspection Details page.   

The finalized CLASS Form 2936 does not display the ratio data, but the ratio data will display in CLASS.   

Reference 4131.4 Collection of Ratio Data for Licensed Child Care Centers
 
Licensed Child Care Centers OnlyAnnual Inspection (once every 12 months)The inspector’s evaluation of the director's qualifications during the inspection.If the inspector evaluated the director’s qualifications during the inspection, select the Dir Qual Eval check box on the Inspection Details page.   

References: 
3331 Evaluating Director and Primary Caregiver Qualifications for Licensed Child Day Care Operations    
4131.3 Child Day Care Annual Meeting with the Designated Director at a Licensed Child Care Center
All Day Care and Residential Care Operations
  • Follow Up
  • Other
The reason for the inspection if the reason does not fall into any of the situations listed above.In the Narrative text box on the Inspection Details page, document a summary of the reason for the inspection.   

References:
4123 Follow-Up Inspections   
4128 Other Types of Inspections

4161.21 Documentation of the Findings Evaluated from the Inspection

Revision 23-3; Effective Sept. 22, 2023

If documenting a deficiency, the inspector documents the following in the Narrative text box on the Standard Details page in CLASS or CLASSMate:

  • Explains how the operation is deficient. (Describe observations in detail. Do not merely repeat the requirement in the CCR statute, administrative rule, or minimum standard.)
  • Describes 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 CCR statute, administrative rule or minimum standard, the inspector documents the finding as Pending.

Staff complete the Photo Taken During the Inspection radio button as appropriate on the Inspections Details page in CLASS prior to saving the applicable final form to indicate whether a photo was, or was not, taken by the inspector during the investigation.

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.

See: 

1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library   
4160  Documenting the Results of an Inspection

4161.22 Limits to Documenting Names of Children

Revision 23-4; Effective Nov. 30, 2023

When documenting inspection results, the inspector does not include the names of children when entering information that could be published on the public website. For example, deficiency narratives, follow-up documentation or information in the Narrative text box on the Inspection Details page may not include the name of any child.

CCR 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 Investigation Conclusion pages.

See 8210 Confidential Information Not for Release to the Public.

4161.23 Limits to Documenting Names of Persons in CLASS

Revision 23-3; Effective Sept. 22, 2023

When documenting inspection results, the inspector does not include the name of any person in documentation that will be published on the public website or that the operation must post. For example, deficiency narratives, follow-up documentation or information in the Narrative text box on the Inspection Details page may not include the name of any person.

CCR staff may include names on paper copies of forms, such as inspection guides, and in CLASS fields that are not published on the public website, such as fields on the Chronology and Investigation Conclusion pages.

Exception for Listed Family Homes or Registered Child Care Homes: A person’s name may be automatically included on certain public forms if the person’s name is the same as the name of the operation. 

See 8210 Confidential Information Not for Release to the Public.

4161.24 Technical Assistance for Violations Recommended for an Administrative Penalty

Revision 23-3; Effective Sept. 22, 2023

When citing a deficiency for a CCR statute, administrative rule or minimum standard that requires the immediate assessment of an administrative penalty, the inspector provides and documents technical assistance in CLASS (see: Protocol for Administrative Penalties for Single High-Risk Violations (Immediate Enforcement) job aid located on the CCR SharePoint site).

The technical assistance the inspector documents must include both:

  • the statement “HHSC will recommend an administrative penalty as a result of this citation, per HRC Section 42.078”; and
  • guidance on how to comply with the CCR statute, administrative rule or minimum standard that was violated.

See 7521 A Single High Risk Violation

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

Revision 23-4; Effective Nov. 30, 2023

Within 10 days after completing an inspection, CCR staff:

  • 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.

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

Revision 23-3; Effective Sept. 22, 2023

The CCR inspector creates a supplemental CLASS Form 2936 Child-Care Facility Inspection only to:

  • document the final determination about an operation’s compliance with 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, the CCR inspector uses CLASS Form 2939 Child-Care Facility Assessment.

See: 

4200 Assessments.

Procedure

To complete a supplemental CLASS Form 2936 Child-Care Facility Inspection, the CCR inspector follows these steps:

  1. Selects the appropriate inspection in CLASS.
  2. Updates pending findings to NC (noncompliant) or CO (compliant).
  3. Enters the following information in the Narrative field on the supplemental CLASS Form 2936:
    1. A description of the change that is being made.
    2. A statement that the supplemental CLASS Form 2936 replaces the original CLASS Form 2936 that was left at the operation on the date of the inspection.
    3. The date of the previous inspection.
  4. Changes the date of notification in CLASS to the date the supplemental CLASS Form 2936 is created.
  5. Saves and finalizes the second version of CLASS Form 2936 by selecting Save Final and Lock.

See: 

1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library  
4160  Documenting the Results of an Inspection

4165.1 Contacting the Permit Holder

Revision 23-3; Effective Sept. 22, 2023

Before mailing the supplemental CLASS Form 2936, CCR 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 5600 Administrative Reviews.

4170 Conducting the Exit Conference

Revision 24-1; Effective Feb. 20, 2024

After completing an inspection, CCR 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 help the operation to address 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 designee, director, administrator or primary caregiver, and the person in charge if none of these persons were available during the exit interview.

References:

5611  Explaining the Right to an Administrative Review 
8230  Confidential Information Not for Release to the Public 

26 TAC Sections 745.8443(a), 745.8483(8), 745.8491 and 745.8801–8811

Human Resources Code Section 42.0441

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

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

References:

1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files 
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files 
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library 
4160  Documenting the Results of an Inspection 

4171 Discussing the Results of an Inspection

Revision 24-2; Effective May 22, 2024

Procedure

During each exit conference, CCR staff:

  • 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 identified and documented during the inspection. Reference 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 CCR Inspection Feedback Survey. The Web address for the survey is printed on CLASS Form 2936 Child-Care Inspection Form, which CCR 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. Reference 5614 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, Monitoring, or Monitoring and Investigation CCR 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, CCR staff must review the address with the person in charge. If the person in charge indicates either the location or mailing address in CLASS is inaccurate, the inspector:

  • documents the correct information in a Chronology, under category Operation General; and
  • enters the corrected address in CLASS and attempts to validate the address per 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

Revision 24-1; Effective Feb. 20, 2024

The following must display the most recent CLASS Form 2936 Child-Care Facility Inspection or CLASS Form 2939 Child-Care Facility Assessment:

  • Licensed child care center
  • School-age program
  • Before or after-school program 
  • Licensed child care home 
  • Registered child care home

The most recent CLASS Form 2936 or CLASS Form 2939 must be displayed in a prominent place for viewing by staff, parents, and others.

Confidential information must not be posted.

26 TAC Sections 744.403, 746.403, 745.8801 and 747.401 

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

References:

Assessments, 4200 
Administrative Reviews, 5600

Procedure

CCR 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 to be viewed by staff, parents and other people.

If CCR staff document part of the inspection on CLASS Form 2936 and document the rest of the inspection on a supplemental inspection form, CCR 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. References: 8210 Confidential Information Not for Release to the Public 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.

Reference: 6630 Notifying the Operation of the Results of an Investigation.

4200, Assessments

Revision 23-3, Effective Sept. 22, 2023

CCR uses an assessment as a regulatory tool to do the following when CCR is not required to conduct an inspection or investigation:

  • cite and notify an operation of a deficiency when an inspector learns about a violation unrelated to an inspection or investigation; or
  • document findings from a follow-up without an inspection when the operation is being re-cited (see 4330 Following Up Without an Inspection).

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

CCR staff follow up on deficiencies cited by assessment according to 4220 Documenting an Assessment and Notifying the Operation, or 4300 Conducting a Follow-up with an Operation.

Procedure

When an inspector determines a monitoring assessment is needed to cite a deficiency, the inspector has 10 days from the date CCR learned about the violation to complete all the following tasks:

  1. consult with a supervisor, program administrator or regional director to discuss the inspector’s recommendation to cite a deficiency by assessment;
  2. document the decision in a Chronology in CLASS; and
  3. if the supervisor, program administrator or regional director approves citing the deficiency, complete the procedures in 4220 Documenting an Assessment and Notifying the Operation. 

The inspector documents photos or other records received in support of the assessment according to 1430 Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files and the associated subsections.

4210 Assessment Types

Revision 23-1, Effective Apr. 21, 2023

When citing by assessment, inspectors choose from two types of assessments. Inspectors refer to the following table when deciding which assessment type to use:

Assessment TypeUse to Cite a Deficiency when:See CCRH Section(s):
Monitoring Assessment
  1. DFPS reported a monitoring violation related to:
    • a DFPS investigation (see 6940 Citing Deficiencies for a DFPS Investigation), or
    • Heightened Monitoring visit;
  2. CCR identified a violation during CCR activities other than an inspection or investigation. Examples:
    • enforcement team conference (see 4441 Enforcement Team Conferences for Child-Placing Agencies and General Residential Operations);
    • random-sampling inspection of a CPA’s foster homes (see 4431 Using Random-Sampling Inspections to Regulate a Child-Placing Agency);
    • background check(s) not submitted as required (see 10110 Overview of Background Checks and 10120 Background Check Requests); or
    • an inspection or investigation that reveals a deficiency at a different operation (for example: during an interview);
  3. Another agency (other than DFPS) or a political subdivision reported a violation; or
  4. The operation self-reports a violation (see 6275 Incidents Reported by an Operation (Self-Reports).
4211 Citing a Deficiency with a Monitoring Assessment
Follow-up AssessmentFollowing up on deficiencies from a previous inspection, assessment or investigation without conducting an inspection to re-cite the operation for one or more deficiencies that were not corrected as required.4212 Follow-Up Assessments, 4300 Conducting a Follow-Up with an Operation, and 4330 Following Up Without an Inspection

4211 Citing a Deficiency with a Monitoring Assessment

Revision 23-1, Effective Apr. 21, 2023

Procedure

When an inspector determines a monitoring assessment is needed to cite a deficiency, the inspector has 10 days from the date CCR learned about the violation to complete all the following tasks:

  1. consult with a supervisor, program administrator or regional director to discuss the inspector’s recommendation to cite a deficiency by assessment;
  2. document the decision in a Chronology in CLASS; and
  3. if the supervisor, program administrator or regional director approves citing the deficiency, complete the procedures in 4220 Documenting an Assessment and Notifying the Operation.

4212 Follow-Up Assessments

Revision 23-1, Effective Apr. 21, 2023

Procedure

When an inspector re-cites a deficiency during a follow-up without an inspection, the inspector documents the outcome of the follow-up using an assessment (type Follow-up) in CLASS.

See also: 

4220 Documenting an Assessment and Notifying the Operation       
4310 Time Frames for Conducting a Follow-Up       
4330 Following Up Without an Inspection

4220 Documenting an Assessment and Notifying the Operation

Revision 23-1, Effective Apr. 21, 2023

Procedure

The inspector:

  • documents assessment results on CLASS Form 2939 Child-Care Facility Assessment;
  • notifies the operation; and
  • sends a copy of CLASS Form 2939 to the operation.

Corrections

If the inspector needs to correct the original CLASS Form 2939, the inspector creates a supplemental CLASS Form 2939 according to 4223 Completing a Supplemental Assessment Form.

See also:

4210 Assessment Types       
4211 Citing a Deficiency with a Monitoring Assessment        
4212 Follow-Up Assessments

4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment

Revision 23-4, Effective Nov. 30, 2023

Procedure

When creating a monitoring assessment or follow-up assessment, the inspector chooses the assessment type from the Assessment Type field in the General section of the Assessment Details page (see 4210 Assessment Types).

For both types of assessments, on CLASS Form 2939 Child-Care Facility Assessment, the inspector:

  1. documents compliance with the evaluated CCR statutes, administrative rules and minimum standards; 
  2. documents any technical assistance given; and
  3. for each deficiency cited, documents:
    • the deficiency clearly and concisely; and
    • the compliance date.

The inspector ensures compliance dates are reasonable and based on the risk to children (see 4500 Evaluating Risk to Children and Handling Immediate Danger).

The inspector documents photographs and other records related to the deficiency according to 1431 Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files.

4221.1 Additional Requirements for Documenting Follow-Up Assessments

Revision 23-1, Effective Apr. 21, 2023

Procedure

When creating a follow-up assessment, the inspector completes the following additional steps:

  • if the purpose of the follow-up assessment is for a Heightened Monitoring (HM) inspector to document a follow-up on a HM-related deficiency, the HM inspector completes the Heightened Monitoring section;
  • links the follow-up assessment to the appropriate previous inspection(s), investigation(s) without an inspection, assessment(s) or a combination of these activities;
  • deletes any linked deficiencies that automatically prefill on the Inspection Summary page if:
    • the deficiency is not evaluated during the current follow-up assessment; or
    • the operation requested an extension during the current follow-up assessment, and CCR granted an extension (Note: the inspector documents the extension in the original inspection or assessment in CLASS. See 4350 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency); and
  • consults the table below for remaining linked deficiencies:
If...Then...
the operation is in compliance…

the inspector:

  • selects 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 operation corrected the deficiency.
the operation is still deficient…

the inspector:

  • selects 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.  
     

CLASS Updates the Follow Up Information section for the Original Deficiency

For each deficiency linked to the follow-up assessment and documented as Compliance or Deficiency, CLASS automatically updates the Follow Up Information section on the Standard Details page for the original inspection, investigation or assessment. Therefore, the inspector does not take any further steps to update the Follow Up Information section for the linked deficiency.

4222 Notifying the Permit Holder or Designee

Revision 23-3, Effective Sept. 22, 2023

Procedure

Before mailing CLASS Form 2939 Child-Care Facility Assessment, the inspector contacts the permit holder or designee to:

  • discuss the assessment findings; and
  • inform the permit holder or designee of the right to request an administrative review within 15 days from the date of receiving CLASS Form 2939 (see 4170 Conducting the Exit Conference and 5600 Administrative Reviews).

4223 Completing a Supplemental Assessment Form

Revision 23-1, Effective Apr. 21, 2023

The CCR inspector creates a supplemental assessment form to correct errors in spelling, grammar or content on the original CLASS Form 2939 Child-Care Facility Assessment.

Procedure

To complete a supplemental CLASS Form 2939, the inspector:

  1. selects the appropriate assessment in CLASS.
  2. makes the corrections.
  3. enters all the following information in the Narrative field on the supplemental CLASS Form 2939:
    1. description of the change that the inspector is making.
    2. statement that the supplemental CLASS Form 2939 replaces the original CLASS Form 2939.
    3. the date the previous CLASS Form 2939 was sent to the operation.
  4. changes the date in the Date Notification Sent field to the date the supplemental CLASS Form 2939 is created.
  5. saves and finalizes the supplemental CLASS Form 2939.

4300, Conducting a Follow-Up with an Operation

Revision 24-2; Effective May 22, 2024

An inspector conducts a follow-up with an operation to:

  1. make sure that the operation is in compliance with any statutes, administrative rules and minimum standards that were cited during an inspection, investigation or assessment;
  2. determine if operation is complying with the conditions of a waiver or variance;
  3. determine if the operation is complying with the conditions of a risk evaluation;
  4. conduct the annual review of director qualifications at a licensed child care center;
  5. make sure the operation is in compliance after a probation ended;
  6. make sure the operation is no longer operating because denial of a permit, suspension or revocation;
  7. make sure the operation is no longer operating after an auto revocation;
  8. monitor the operation during the appeal process; 
  9. monitor the operation during a temporary relocation;
  10. evaluate a foster home’s record and have a discussion with the administrator or person in charge after sending notification to the CPA of an approved agency home closure recommendation; or 
  11. discuss the warning letter with the director, administrator, or person in charge of the operation after sending the letter.

When following up with an operation about a deficiency the operation did not correct at inspection the inspector verifies the operation corrected the deficiency. This may include:

  1. reviewing records about the deficiency;
  2. inspecting areas of the physical plant about the deficiency; and
  3. observing activities about health and safety.

Reference 

Determining When a Deficiency Can Be Corrected at Inspection, 4155  

Procedure

For each deficiency, the inspector decides to follow up on the deficiency with or without an inspection based on:

  1. the risk to children;
  2. the scope and severity of the deficiency;
  3. the time and expense needed to correct the deficiency;
  4. the provider's previous compliance history; and
  5. if an inspection is required to determine if the provider corrected the deficiency.

When following up on more than one deficiency, the inspector does not re-cite a deficiency if the compliance date for the deficiency is in the future. When documenting follow-up, the inspector follows procedures in 4221.1 Additional Requirements for Documenting Follow-Up Assessments and 4323 Documenting Follow-Up Results on CLASS Form 2936.

If the inspector determines an operation is not in compliance with a previously cited deficiency during the follow-up, the inspector follows the procedures in  4340 When an Operation Continues to Be Deficient.

References

Child Day Care Annual Meeting with the Designated Director at a Licensed Child Care Center, 4131.3 
Reviewing Restrictions, Conditions, Waivers, and Variances, 4152 
Time Frames for Conducting a Follow-up, 4310 
Following Up with an Inspection, 4320
Following Up Without an Inspection, 4330
Inspecting a CPA after Sending Notification of an Approved Closure Recommendation, 4454
Evaluating the Conditions of a Waiver or Variance, 5160 
Following-Up to a Warning Letter, 5313
Temporary Relocation, 5520
Regulating Pending the Due Process Hearing for Denial, Refusal to Renew, Revocation or Suspension, 5720 
Follow-Up to Final Notice of Suspension, Revocation, or Denial, 7636
When a Risk Evaluation is Required, 10410
Types of Eligibility Determinations, 10510

26 TAC Section 745.8447 

4310 Time Frames for Conducting a Follow-Up

Revision 23-1, Effective Apr. 21, 2023

The inspector verifies and documents corrections of deficiencies within the time frames outlined in the following chart for deficiencies cited in the same inspection, investigation or assessment.

Weights of Standards Cited in a Single Inspection, Investigation or AssessmentTime Frame for Completing Follow Up
High-weighted onlyWithin 15 days of the latest compliance date
Non-high-weighted only (that is, medium-high, medium, medium-low and low)Within 30 days of the latest compliance date
High- and non-high-weighted

Within 15 days of the latest compliance date for the high-weighted standards.              

Exception: If the compliance date for a non-high-weighted deficiency is a future date and the operation has not yet corrected the deficiency, the inspector:

  • does not re-cite the deficiency; and
  • follows up on the deficiency no later than 30 days after the latest compliance date of all non-high-weighted deficiencies.

4311 Granting Staff Additional Time to Complete a Follow-Up with an Operation

Revision 23-1, Effective Apr. 21, 2023

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

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

The inspector obtains approval from a supervisor, program administrator or regional director to extend the follow-up time frame.

Procedure

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

If the request to extend the time frame is approved, the inspector documents the following in the Additional Documentation field on the Standard Details page in CLASS:

  • the extension date; 
  • the date the supervisor, program administrator or regional director approved the extension; 
  • the name and title of the person who approved the extension; and 
  • the reason for the extension.

4320 Following Up with an Inspection

Revision 24-1, Effective Feb. 20, 2024

Procedure

If the inspector determines following up on a deficiency requires a follow-up inspection, the inspector conducts the inspection as soon as possible, but no later than the time frames outlined in 4310 Time Frames for Conducting a Follow-Up. 

If the inspection is a Heightened Monitoring (HM) inspection, the HM inspector also follows procedures in 4322 How Heightened Monitoring Staff Completed and Document Follow-Ups Completed with an Inspection.

References:

4120 Types of Inspections   
4152 Reviewing Restrictions, Conditions, Waivers, and Variances   
4311 Granting Staff Additional Time to Complete a Follow-Up with an Operation   
4350 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency  
4510 CLASS Enforcement Recommendations  
5160 Evaluating the Conditions of a Waiver or Variance
10400 Risk Evaluation

4321 Documenting a Follow-Up Completed During an Inspection Unrelated to Heightened Monitoring Activities

Revision 23-4, Effective Nov. 30, 2023

Procedure

When an inspector conducts an inspection to follow up on a deficiency cited during a previous inspection, investigation or assessment, and the inspection and deficiencies are unrelated to Heightened Monitoring (HM) activities, the inspector:

  • creates a new CLASS Form 2936 Child-Care Facility Inspection;
  • selects the appropriate inspection type:
    • Follow-up;
    • Monitoring;
    • Investigation;
    • Monitoring and Investigation; or
    • Initial;
  • documents the follow-up for each deficiency according to procedures in 4323 Documenting Follow-Up Results on CLASS Form 2936; and
  • documents findings unrelated to the follow-up according to procedures in 4100 Inspecting Child Care Operations.

4322 How Heightened Monitoring Staff Complete and Document Follow-Up Completed with an Inspection

Revision 23-1, Effective Apr. 21, 2023

Heightened Monitoring (HM) staff follow up on HM deficiencies and non-HM deficiencies by conducting inspections (type Follow-up or Other), assessments (type Follow-up), or a combination of the two. How HM staff document these follow-ups depends on:

  • the type of deficiency staff is evaluating during the follow-up; and
  • whether staff are completing the follow-up during an HM inspection.

When completing a follow-up by an assessment, HM staff follow the procedures in 4212 Follow-Up Assessments and 4220 Documenting an Assessment and Notifying the Operation.

Procedure

When conducting a follow-up to evaluate deficiencies, the HM inspector may do any a combination of the following activities: 

  • evaluate HM-related deficiencies;
  • evaluate non-HM-related deficiencies;
  • conduct an HM inspection to evaluate the HM plan tasks; or
  • conduct a non-HM inspection to evaluate CCR statutes, administrative rules and minimum standards not included in the HM plan tasks. 

When conducting a combination of follow-ups or inspections at the same time, staff must complete the appropriate CLASS forms 2936 Child-Care Facility Inspection and 2939 Child-Care Facility Assessment indicated in the sections below.

The HM inspector also refers to the Heightened Monitoring CLASS Release 3 HM Inspections Job Aid and the Heightened Monitoring CLASS Release 4 HM Assessments Job Aid, located on the Heightened Monitoring SharePoint site.

4322.1 Conducting Follow-Up While Completing a Weekly HM Inspection

Revision 23-1, Effective Apr. 21, 2023

Procedure

When conducting a follow-up to evaluate deficiencies while conducting a weekly HM inspection, the HM inspector follows the procedures in the table below:

Type(s) of Deficiencies Being Evaluated in the Follow-UpProcedures
Only HM-related deficiencies
  1. In CLASS, create an inspection (type Follow-up) and complete the Heightened Monitoring section.
  2. Conduct and document results of the weekly HM inspection according to existing policies and procedures.
  3. Follow up on deficiencies being evaluated.
  4. Document the follow-up on the HM-related deficiencies being followed up on in CLASS as outlined in 4323 Documenting Follow-Up Results on CLASS Form 2936.
Only non-HM-related deficiencies
  1. In CLASS, create an inspection (type Other) and complete the Heightened Monitoring section.
  2. Conduct and document results of the weekly HM inspection according to existing policies and procedures.
  3. Follow up on the non-HM-related deficiencies being evaluated.
    • Document the follow-up on the HM-related deficiencies in CLASS as outlined in 4323 Documenting Follow-Up Results on CLASS Form 2936.
    • Document the follow-up on non-HM deficiencies in a separate follow-up assessment as outlined in 4212 Follow-Up Assessments. 
  4. When conducting the exit interview, explain to the person in charge:
    1. the results of the weekly HM inspection;
    2. the results of the follow-up on the non-HM-related deficiencies evaluated; and
    3. that the follow-up results will be sent on an assessment form (CLASS Form 2939 Child-Care Facility Assessment).
  5. No later than the next day, document the follow-up on the non-HM related deficiencies in an assessment (type Follow-up) as outlined in:
    1. 4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment; and 
    2. 4221.1 Additional Requirements for Documenting Follow-Up Assessments.
Both HM-related and non-HM-related deficiencies
  1. In CLASS, create an inspection (type Follow-up) and complete the Heightened Monitoring section.
  2. Conduct and document results of the weekly HM inspection according to existing policies and procedures.
  3. Follow up on HM-related and non-HM-related deficiencies being evaluated.
    • Document the follow-up on the HM-related deficiencies in CLASS as outlined in 4323 Documenting Follow-Up Results on CLASS Form 2936.
    • Document the follow-up on non-HM deficiencies in a separate follow-up assessment as outlined in 4212 Follow-Up Assessments.
  4. When conducting the exit interview, explain to the person in charge:
    1. the results of the weekly HM inspection;
    2. the results of all follow-ups on deficiencies evaluated;
    3. that the follow-up results for the HM-related deficiencies are documented on CLASS Form 2936; and
    4. that the follow-up results for the non-HM-related deficiencies will be sent on an assessment form (CLASS Form 2939 Child-Care Facility Assessment).
  5. No later than the next day, document the follow-up for the non-HM related deficiencies in an assessment (type Follow-up) as outlined in:
    1. 4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment; and 
    2. 4221.1 Additional Requirements for Documenting Follow-Up Assessments.

4322.2 Conducting Follow-Up Without Completing a Weekly HM Inspection

Revision 23-1, Effective Apr. 21, 2023

Procedure

When conducting follow-up to evaluate deficiencies without a weekly HM inspection to evaluate HM plan tasks, the HM inspector follows the procedures in the table below:

Type(s) of Deficiencies Being Evaluated in the Follow-UpProcedures
Only HM-related deficiencies
  1. In CLASS, create an inspection (type: Follow-up) and complete the Heightened Monitoring section.
  2. Conduct the inspection without evaluating HM plan tasks.
  3. Follow up on the HM-related deficiencies being evaluated.
  4. Document the follow-up to the HM-related deficiencies in CLASS as outlined in 4323 Documenting Follow-Up Results on CLASS Form 2936.
Only non-HM-related deficiencies
  1. In CLASS, create an inspection (type: Follow-up).
  2. Conduct the inspection without evaluating HM plan tasks.
  3. Follow up on the non-HM-related deficiencies being evaluated.
  4. Document the follow-up for the non-HM deficiencies as outlined in 4321 Documenting Follow-Ups Completed During an Inspection Unrelated to Heightened Monitoring Activities.
Both HM-related and non-HM-related deficiencies
  1. In CLASS, create an inspection (type Follow-up) and complete the Heightened Monitoring section.
  2. Conduct and document the inspection without evaluating HM plan tasks.
  3. Follow up on HM-related and non-HM-related deficiencies being evaluated.
    • Document the follow-up to the HM-related deficiencies in CLASS as outlined in 4323 Documenting Follow-Up Results on CLASS Form 2936.
    • Document the follow-up on non-HM deficiencies in a separate follow-up assessment as outlined in 4212 Follow-Up Assessments.
  4. When conducting the exit interview, explain to the person in charge:
    1. the results of the inspection;
    2. the results of all follow-ups being evaluated;
    3. that the follow-up results for the HM-related deficiencies are documented on CLASS Form 2936 Child-Care Facility Inspection; and
    4. that the follow-up results for the non-HM-related deficiencies will be sent on an assessment form (CLASS Form 2939 Child-Care Facility Assessment).
  5. No later than the next day, document the follow-up for the non-HM-related deficiencies in an assessment (type Follow-up) as outlined in:
    1. 4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment; and
    2. 4221.1 Additional Requirements for Documenting Follow-Up Assessments.

4323 Documenting Follow-Up Results on CLASS Form 2936

Revision 23-1, Effective Apr. 21, 2023

Procedure

The inspector follows the steps below when documenting the results of a follow-up completed during an inspection on CLASS Form 2936 Child-Care Facility Inspection:

  • selects the appropriate inspection type; 
  • links the inspection to the appropriate previous inspection(s), investigation(s) without inspection(s), assessment(s) or a combination of these activities (see 4321 Documenting Follow-Ups Completed During an Inspection Unrelated to Heightened Monitoring Activities and 4322 How Heightened Monitoring Staff Document Follow-Ups Completed with an Inspection);
  • deletes any linked deficiencies that automatically prefill on the Inspection Summary page if:
    • the deficiency is not evaluated during the current follow-up inspection; or
    • the operation requested an extension during the current follow-up inspection and the extension was granted (the inspector documents the extension in the original inspection in CLASS; see 4350 Granting an Operation Additional Time to Comply With a Requirement Cited as a Deficiency);
  • consults the table below for the remaining linked deficiencies:
If...Then...
the operation is in compliance…

The inspector: 

  • 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…

the inspector:

  • 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 replace it with information about how the operation continues to be deficient.

CLASS Updates the Follow Up Information section for the Original Deficiency

For each deficiency that was linked to the inspection and documented as Compliance or Deficiency, CLASS automatically updates the Follow Up Information section on the Standards Details page for the original inspection, investigation or assessment. Therefore, the inspector does not take any further steps to update the Follow Up Information section for the linked deficiency.

4330 Following Up Without an Inspection

Revision 24-4, Effective Feb. 20, 2024

Procedure

The inspector may follow up without an inspection when the they can assess compliance by:

  • reviewing documents, photographs or videos the operation submits; or
  • participating in video calls with the permit holder, designee, director or administrator. 

If the inspector determines the operation has corrected all deficiencies evaluated during the follow-up, the inspector follows the procedures explained in 4331.1 Documenting a Follow-Up Without an Inspection When the Operation Corrected All Deficiencies. 

If the inspector determines the operation has not corrected all deficiencies evaluated during the follow-up, the inspector follows the procedures explained in 4331.2 Documenting a Follow-Up Without an Inspection When CCR Re-cites One or More Deficiencies and 4340 When an Operation Continues to be Deficient.

References:

1430 Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files
1431 Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files
1432 Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library
4120  Types of Inspections        
4152  Reviewing Restrictions, Conditions, Waivers, and Variances
4310  Time Frames for Conducting a Follow-Up        
4311  Granting Staff Additional Time to Complete a Follow-Up with an Operation
4350  Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency
4510  CLASS Enforcement Recommendations        
5160  Evaluating the Conditions of a Waiver or Variance   
10400  Risk Evaluation

4331 Documenting Follow-Ups Completed Without an Inspection

Revision 23-1, Effective Apr. 21, 2023

Procedure

When following up without conducting an inspection, the inspector refers to the table below to determine how to document the follow-up:

Deficiencies Being EvaluatedFollow Procedures in
Operation corrected all deficiencies4331.1 Documenting a Follow-Up Without an Inspection When the Operation Corrected All Deficiencies
Inspector will re-cite one or more deficiencies4331.2 Documenting a Follow-Up Without an Inspection When CCR Re-cites One or More Deficiencies

4331.1 Documenting a Follow-Up Without an Inspection When the Operation Corrected All Deficiencies

Revision 23-1, Effective Apr. 21, 2023

Procedure

If the operation has corrected all deficiencies being evaluated during the follow-up without an inspection, the inspector updates the Follow Up Information section of the Standard Details page in CLASS for each deficiency the inspector is evaluating as follows:

FieldWhat to Document
Follow Up DateThe date the information was received from the operation.
Follow Up MethodThe method the inspector used to complete the follow-up.
ResultsSelect Compliance Met.
Additional Documentation
  • a description of how the operation corrected the deficiency;
  • a description of the evidence the inspector used to determine how the operation corrected the deficiency (for example, the operation submitted a copy of the fire inspection or the inspector viewed the repair to the wall on a video call); and
  • the position or title of the person submitting the information.

If the compliance date had been extended, the documentation is added above the extension documentation.

4331.2 Documenting a Follow-Up Without an Inspection When CCR Re-cites One or More Deficiencies

Revision 23-1, Effective Apr. 21, 2023

Procedure

When the result of the follow-up without inspection is that the inspector will re-cite one or more deficiencies, the inspector: 

  • documents the results of all follow-ups (both deficiencies re-cited and deficiencies found in compliance) using an assessment (type Follow-up); and
  • follows the procedures in:
    • 4221 Documenting an Assessment Using CLASS From 2939 Child-Care Facility Assessment ; and
    • 4221.1 Additional Requirements for Documenting Follow-Up Assessments.

See also:

4212 Follow-Up Assessments        
4220 Documenting an Assessment and Notifying the Operation       
4221 Documenting an Assessment Using CLASS Form 2939 Child-Care Facility Assessment          
4221.1 Additional Requirements for Documenting Follow-Up Assessments

4340 When an Operation Continues to be Deficient

Revision 23-1, Effective Apr. 21, 2023

Procedure

When the inspector conducts a follow-up and determines the operation continues to be deficient according to 4310 Time Frames for Conducting a Follow-Up, the inspector re-cites the deficiency. 

In addition to re-citing the deficiency, the inspector may: 

  1. issue a warning letter and conduct a follow-up with an inspection; 
  2. expedite the next monitoring inspection;  
  3. recommend the operation go on a plan of action; or 
  4. recommend making a referral to HHSC Regulatory Enforcement for an enforcement action. 

See also: 

4320 Following Up with an Inspection       
4330 Following Up Without an Inspection       
4510 CLASS Enforcement Recommendations       
5310 When to Issue a Warning Letter      
7000 Voluntary Actions and Enforcement Actions      
Appendix 7000-1: Factors to Consider for Enforcement Actions

4350 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency

Revision 23-4, Effective Nov. 30, 2023

The inspector may extend the time an operation has to comply with a cited deficiency if:

  • the operation provides the reasons that an extension is being requested and CCR staff determine that: 
    • there is cause for the extension; and 
    • extending the time frame would not pose an immediate danger to children in care; or
  • the operation 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).

26 TAC Section 745.8447

Procedure

If an Extension is Approved

If an extension is approved, the inspector:

  • notifies the operation about the approval and the new compliance date;
  • manually creates a To-Do in CLASS to notify the inspector to follow up by the compliance date; and
  • documents the extension on the Standards Details page for the applicable deficiency in CLASS according to the following table:
FieldWhat to Document
Compliance DateChange the date to the new compliance date.
Follow Up MethodSelect the method inspector used to complete the follow-up.
Follow Up DateEnter the date of the extension approval.
ResultsSelect Extension Granted.
Additional Documentation

Document the following in the text box:

  • the date of the follow-up;
  • the follow-up method;
  • a statement that the extension was approved;
  • the date that CCR staff approved the extension;
  • the original compliance date; and
  • the new compliance date.

If an Extension is Denied

If an extension is denied, the inspector:

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

If the compliance date has passed and the inspector determines that the operation is still not in compliance, the inspector follows the procedures explained in 4340 When an Operation Continues to be Deficient.

4400, Additional Regulatory Activities for Certain Types of Operations

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 Residential Child Care Operations

 

4421 Monitoring Child-Placing Agencies

Revision 23-4; Effective Nov. 30, 2023

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

For the purposes of CCR, 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 relevant statutes, administrative rules or minimum standards, CCR may do one or both of the following:

  • Cite the CPA (including a branch office) for deficiencies.
  • Submit a Referral for Enforcement Action to Child Care Enforcement.

If a CPA operates at a main office or branch office that is not open between 8:00 a.m. and 5:00 p.m. Monday through Friday, the CPA must ensure that the office and employees are available upon CCR’s request for the purpose of inspecting or investigating the CPA.

Human Resources Code Section 42.053

26 TAC Sections 745.8405(c); 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 statutes, administrative rules and minimum standards; and
    • is following the policies it submitted to CCR.

Human Resources Code Section 42.044

See 4100 Inspecting Child Care Homes and Operations.

Branch Offices

Branch offices must comply with all relevant statutes, administrative rules and minimum 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.

4422 Monitoring CPAs That Conduct International Adoptions

October 2020

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)42.07242.044(e)(4)

Procedure

Child Care Regulation (CCR) 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.

CCR 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). CCR 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.

4423 Certifying the Licensing Status of a Child-Placing Agency for International Adoptions

October 2020

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 Child Care Regulation (CCR) record to confirm that the CPA is in good standing.

Procedure

When CCR 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 CCR record to ensure that the CPA is in good standing.
    • An operation with a valid permit is considered in good standing with CCR, 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 CCR or a CCR 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 Child Care Regulation Information.
  • Requests for information not addressed in Form 2983 Certification of a CPA License Status Letter, require approval from the director of residential CCR or a CCR attorney.

4430 Random-Sample Monitoring of CPA Foster Homes

Revision 23-4; Effective Nov. 30, 2023

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

  1. is complying with applicable statutes, administrative rules and minimum standards;
  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 providing; and
    • foster home's capacity.

Human Resources Code Section 42.044(e)

26 TAC Sections 745.8405(a)(5) and 749.2470

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

Revision 23-4; Effective Nov. 30, 2023

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 statutes, administrative rules and minimum standards.

Inspectors assigned to the CPA cite the CPA for a deficiency if the CPA fails to maintain substantial compliance with statutes, administrative rules and minimum standards 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 statue, administrative rules and minimum standards. 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 CCR 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 and Handling Immediate Danger

4431.1 Citing Deficiencies Based on Random-Sampling Inspection Results

Revision 23-3; Effective Sept. 22, 2023

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  Assessments   
5600  Administrative Reviews

4432 Selecting CPA Foster Homes for Random-Sampling Inspections

April 2022

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

Texas Human Resources Code §42.044(e)

40 TAC §745.8407(4)

Procedure

Each September, CCR staff from state office provide each regional director in the residential care program with the annual random-sampling goals for the fiscal year. The regional 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, CCR staff select 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 home inspections for the period, the supervisor or regional director contacts:

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

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

May 2022

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

  • An active foster home actively caring for children (including homes verified for respite care only); or
  • An active foster home that is empty, but ready to accept placement.

Foster homes with children placed in the home are priority for random-sampling selections.

A random-sampling inspection is not conducted on a home if one or more of the following is true:

  • A foster home is closed or inactive (not currently accepting children for care).
  • A random-sampling inspection was conducted on the foster 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.
  • A CCR supervisor determines that conducting a random-sampling inspection on the foster home would interfere with an ongoing investigation. 
  • CCR staff determine the home is an adoption-only home (random-sampling inspections are not conducted on adoption-only homes).

Procedure

Before preparing for or conducting a random-sampling inspection of a foster home, the inspector ensures that the home is eligible for a random-sampling inspection by pre-screening the home by reviewing information in CLASS, in IMPACT or from the CPA.

If DFPS or CCR has an open investigation on a foster home on the Agency Home Sampling Report List in CLASS, CCR staff consult with the supervisor to determine if conducting a random sampling inspection would interfere with the ongoing investigation. If a random-sampling inspection would interfere with the ongoing investigation, CCR staff select another foster home. See 6510 Investigations Involving Homes Regulated by a Child-Placing Agency (CPA) for special considerations when conducting investigations at agency foster homes.

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

Revision 23-3; Effective Sept. 22, 2023

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 are available electronically and must be reviewed in the IMPACT system instead of requesting them from the CPS foster or adoptive home development worker. The inspector converts any paper copies of records received to PDF files and uploads them to CLASS Document Library when conducting the sampling inspection of the home.

Inspectors do not keep the records for 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.

See:

1330  Records Retention   
1427  Using Scanned Documents and Other Digital Files as a Regulatory Tool   
1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files   
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library 

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

April 2022

A random-sampling inspection may be:

  • announced (CCR staff contact the foster home before inspecting the home); or
  • unannounced (CCR staff do not contact the foster home before inspecting the home). A minimum of 25 percent of the random-sampling inspections CCR conducts over the annual period must 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

April 2022

Procedure

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

December 2019

  1. Inspect the home using Form 2978 Foster Home Random-Sampling Guide located on the CCL SharePoint site.
  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. Observe all non-verbal foster children who are present during the inspection.
  5. 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. Observe all non-verbal foster children who are present during the inspection. 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 6421.2 Observing and Interviewing a Child Related to a Child Care Provider.

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, Video, Audio and Digital Files.

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 CLASS 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

Revision 23-3; Effective Sept. 22, 2023

Before leaving the foster home, the inspector:

  • completes CLASS Form 2979 Agency Home Inspection 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;
    • inform the person of any photographs taken during the inspection and completes the Photo Taken by CCR During the Inspection radio button as appropriate; 
    • complete the Supporting Documents/Photos Obtained indicator as appropriate; and
    • provide the person with a copy of the completed 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 CCR inspector assigned to the CPA to inform them of the inspection results.

Texas Human Resources Code Sections 42.044; 42.04411

Procedure

Before Leaving the Foster Home

Before leaving the foster home, the inspector completes CLASS Form 2979 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 due to conducting the random-sampling inspection;  
  4. any technical assistance provided to the foster home (see 4154 Technical Assistance); and 
  5. any photographs taken by CCR during the inspection. 

After documenting the inspection results on CLASS 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;  
  • reviews, but does not provide copies of, any photographs taken during the inspection; 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 CCR 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 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.

See:

1430  Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files
1431  Documenting Photographs, Video, Audio, Scanned Documents and Other Digital Files
1432  Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library
4160  Documenting the Results of an Inspection

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

September 2017

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.

4450 Foster Family Home Closure Recommendations

Revision 24-1; Effective Feb. 20, 2024

CCR staff recommends the closure of a foster family home when:

  • there is a high degree of risk to children; and
  • the risk cannot be mitigated.

The associate commissioner of CCR has final approval authority for foster family home closure recommendations.

4451 Assessing a Foster Family Home for Closure

Revision 24-1; Effective Feb. 20, 2024

When CCR staff identifies risk at a foster family home they use one or more of the following criteria to assess the home for closure:

  • patterns of violations of high risk deficiencies;
  • repeat violations of high risk deficiencies;
  • number and patterns of allegations;
  • if the home was previously closed for deficiencies by another CPA; and
  • if CCR approved a closure recommendation for the home while the home was verified by another CPA.

4451.1 Foster Family Home Compliance History Considerations

Revision 24-1; Effective Feb. 20, 2024

When evaluating the compliance history of the foster family home, CCR staff considers if there is a pattern or repeat violations of high-risk deficiencies, or pattern of allegations, related to:

  1. inappropriate discipline;
  2. inadequate supervision;
  3. unsafe living conditions;
  4. safe sleep violations;
  5. children's rights;
  6. interference with an investigation; or
  7. failure to report any of the following persons to the CPA for a background check:
    • a household member; or
    • frequent visitor to the home.

Additional resources for evaluating the compliance history are on the CCR SharePoint site.

4452 Recommending a Foster Family Home for Closure and Documenting the Closure Recommendation in CLASS

Revision 24-1; Effective Feb. 20, 2024

When CCR staff determine that a foster family home presents a high degree of risk to children that cannot be mitigated, CCR staff recommend closure of the home within 24 hours of identifying the risk.

Procedure

CCR staff complete the actions outlined in the table below to recommend a foster family home for closure, and document the closure recommendation in CLASS.

Staff ResponsibleActionWhen Action is Due
Regional CCR Staff
  • complete Form 2980a, available on the CCR SharePoint site;
  • gather supporting documentation such as photographs, or external documentation gathered for an investigation;
  • email Form 2980a and supporting documentation to RCCRFCL@hhs.texas.gov, or indicate if supporting documentation was uploaded to the CLASS Document Library or CCR SharePoint site; and
  • ensure the inspector, supervisor, program administrator, regional director, and state office director are included on the email.
As soon as possible but no later than 24 hours after identifying risk in an agency home.
FCL Project Manager or DesigneeAdds the closure recommendation to the Agency Home Closure Recommendation page in CLASS.Three business days after Form 2980a is received in the RCCRFCL@hhs.texas.gov mailbox.
FCL Project Manager or Designee

Schedules an internal meeting to discuss the recommendation with the agency home review team, which includes:

  • associate commissioner of CCR; 
  • deputy associate commissioner of quality and compliance;
  • director of FCL quality and compliance;
  • FCL project manager;
  • HHSC legal; and
  • as necessary:
    • deputy associate commissioner of regional operations;
    • director of residential care operations; and
    • director of heightened monitoring
After Form 2980a is received in the RCCRFCL@hhs.texas.gov mailbox.
Associate Commissioner of CCR

Meet with the agency home review team to: 

  • discuss the details of the closure recommendation;  
  • decide whether to approve, deny, or withdraw the recommendation; and
  • decide which director will be responsible for notifying the CPA of the decision.

Within 14 days from the date entered in the Received Date field on the Agency Home Closure Recommendation page.
FCL Project Manager or Designee

If the recommendation for closure is approved by the associate commissioner of CCR:

  • updates the Decision Status dropdown on the Agency Home Closure Recommendation Details page; and
  • enters the name of the director responsible for notifying the CPA of the decision in the Notification Assigned To field.

Within 14 days from the date entered in the Received Date field on the Agency Home Closure Recommendation page.

Find more resources for completing Form 2980a on the CCR SharePoint site.

Reference the Agency Home Closure Recommendation Job Aid on the CCR SharePoint site for more details on documenting the closure recommendation in CLASS.

4453 Notifying a CPA of an Approved Closure Recommendation and Documenting the CPA’s Response in CLASS

Revision 24-1; Effective Feb. 20, 2024

If the associate commissioner of CCR approves the closure recommendation, the director responsible for notifying the CPA of the decision sends the CPA notification.

Procedure

The director responsible for notification:

ActionDur Date
  • generates and sends the Agency Home Closure Recommendation Approved – AC1 letter to the CPA by email, with the inspector and supervisor copied on the email; 
  • enters the date the Agency Home Closure Recommendation Approved – AC1 letter was sent to the CPA in the Notification Date field on the Agency Home Closure Recommendation Details page; and
  • notifies the DFPS CPS director for placement services to assess for disallowance of placement.
The same date the decision was entered in the Decision Date field on the Agency Home Closure Recommendation page.
updates the CPA Response dropdown on the Agency Home Closure Recommendation Details page to show that the CPA relinquished the home.Within seven days from the date entered in the Notification Date field on the Agency Home Closure Recommendation page.

4453.1 Documenting the Relinquishment Reason in CLASS

Revision 24-1; Effective Feb. 20, 2024

Procedure

The inspector may document CCR Recommended Closure in the Reason for Relinquishment field in the Operation Services section of the Agency Home page in CLASS if:

  • a foster family home has an approved closure recommendation documented in CLASS; and
  • the CPA decides to close the home with the CCR Recommended Closure relinquishment reason but is unable to enter the reason due to technical difficulties.

Reference the Agency Home Closure Recommendation Job Aid on the CCR SharePoint site for more details on how to generate and document the notification in CLASS.

4454 Inspecting a CPA after Sending Notification of an Approved Closure Recommendation

Revision 24-1; Effective Feb. 20, 2024

The inspector conducts a follow up inspection at the CPA between 30 and 45 days after the date the CPA was notified of the approved closure recommendation. This inspection is to review the foster home record and evaluate: 

  • the verification status of the foster family home and the status of any placements in the home;
  • if the Agency Home Closure Recommendation Approved – AC1 letter has been filed in the home’s record per 749.535
  • if the foster family home transferred to another CPA or was closed, the home’s transfer or closing summary for compliance with 749.2497; and
  • If the CPA did not close the home, the inspector discusses with the administrator or person in charge: 
    • the steps the operation has taken to address CCR’s concerns about the foster family home since receiving the Agency Home Closure Recommendation Approved – AC1 letter; and 
    • the steps the operation will take or continue to take in the future to address CCR’s concerns about the foster family home. 

In the Narrative text box on the Inspection Details page, the inspector summarizes the reason for the inspection. For example, “Inspector [insert inspector name] conducted an inspection at [insert CPA name] to follow up on the operation being sent an Agency Home Closure Recommendation Approved letter on [insert date letter sent].

4500, Evaluating Risk to Children and Handling Immediate Danger

Revision 23-3; Effective Sept. 22, 2023

CCR staff continuously evaluate each operation's performance in terms of risk to children 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.

Human Resources Code Section 42.044

4510 CLASS Enforcement Recommendations

May 2020

CLASS Enforcement Recommendations help supplement the professional assessments of CCR staff. CLASS 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 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 is based on the overall risk to children exhibited by the operation.

4511 Options on the Enforcement Recommendation Page in CLASS

Revision 24-2; Effective May 22, 2024

Procedure

Each option on the Enforcement Recommendation Detail page in CLASS represents an action CCR may take on 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 Enforcement Recommendations.

No deficiencies cited. Follow monitoring frequency

This means no action is currently being taken. 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

Reference 4330 Following Up Without an Inspection. Select this recommendation when deficiencies cited 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

Reference 4320 Following Up with an Inspection. This action indicates the inspector will conduct a follow-up inspection to determine compliance on specific deficiencies. Staff select this action any time 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 the follow-up inspection is planned.

Plan of Action

Reference 7300 Plan of Action. A plan of action is a voluntary enforcement action that is a collaborative effort between CCR and an operation. The goal is to work with the operation to develop a plan to reduce risk and help improve the operation’s compliance with CCR statutes, administrative rules and minimum standards. CCR inspects an operation more frequently during a plan of action to evaluate the operation’s compliance with minimum standards.

Warning letter and follow-up with inspection

Reference 5310 When to Issue a Warning Letter. 

CLASS Form 2999 Warning Letter is issued to notify the governing body of a child care operation that CCR has identified risks and may recommend enforcement action if the operation’s compliance history does not improve. 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 conducts a follow-up inspection within 60 days of sending a warning letter, and the date of the follow-up inspection is entered in the Follow Up Date field on the Warning Letter Detail page.

Expedite monitoring inspection

Staff select this action when risk at the operation warrants conducting a monitoring inspection before 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 to reduce risk.

Probation

Probation is a type of corrective action where CCR imposes conditions beyond the requirements of the minimum standards and the basic permit to improve an operation’s compliance with minimum standards and reduce risk at the operation. The probation is 12 months and CCR conducts inspections at least monthly to evaluate compliance with minimum standards and the conditions imposed as part of the corrective action plan. CCR may recommend imposing probation if circumstances described in 7110 Circumstances That May Call for Enforcement Action exist and CCR determines the operation meets criteria outlined in 7410 Criteria for Imposing Probation.

Adverse Amendment

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

Involuntary Suspension

In an involuntary suspension, CCR takes away the permit holder's authority to operate for a specific period so 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 CCR determines the operation meets criteria outlined in 7623 Criteria for Imposing an Involuntary Suspension.

Injunction

If CCR determines circumstances at the operation are extreme enough to warrant immediate intervention, such as when risk of immediate harm to the health and safety of children in care is substantial, the CCR inspector may make a referral for legal action simultaneously with the mailing of the notice of an intent to deny, revoke or suspend. Reference 7710 Injunction, Including Temporary Injunction and 7631.1 When Immediate Intervention Is Warranted at an Operation.

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. Reference 7621 Criteria for Imposing a Denial and 7630 Taking Adverse Action..

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 CCR determines the operation meets criteria outlined in 7624 Criteria for Imposing a Revocation.
 

4512 Acting on Enforcement Recommendations

Revision 23-3; Effective Sept. 22, 2023

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

  • review the action that triggered 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 and Handling Immediate Danger

4512.1 Documenting Enforcement Recommendations

May 2020

Any combination of 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.

Actions in the Recommended Actions Based on Risk section correspond with the risk level of the Recommended Monitoring Frequency.

Actions in the Actions Not Requiring Supervisory Review or Actions Requiring Supervisory Review sections correspond with either a higher or lower risk level than is associated with the Recommended Monitoring Frequency. Choosing an action in one of these sections will change the Recommended Monitoring Frequency and the due date of the associated inspection To-Do.

If the inspector selects an alternative action (those listed in the Actions Not Requiring Supervisory Review and Actions Requiring Supervisory Review categories), the inspector must also:

  1. choose the most appropriate reason from the Reason for Alternative Recommendation drop-down menu; and
  2. document the reasons to support the enforcement action decision in the Licensing Specialist Comments field.

Also see the CLASS Enforcement Recommendations Tip Sheet on the CCR SharePoint site for additional information.

4512.11 When to Allow CLASS to System Close the Recommendation

May 2020

If the inspector agrees with the recommended monitoring frequency on the Enforcement Recommendation Detail page in CLASS but does not find it appropriate to select an enforcement action in the Recommended Actions Based on Risk section, then the inspector should take no action and allow the enforcement action recommendation to "system close."

Within five days of receiving the recommended action, the inspector documents in a CLASS Chronology (type Recommendation) why the inspector did not take the recommended enforcement action. The documentation includes:

  • why the inspector agrees with the recommended monitoring frequency; and
  • what action(s) will be taken even though they were not noted on the Enforcement Recommendation Detail page.

Also see the CLASS Enforcement Recommendations Tip Sheet located on the CCR SharePoint site for additional information.

4512.2 Actions Requiring Supervisory Approval

May 2020

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 are taken within five days of the selection:

  • the inspector staffs 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 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.

4520 Handling Immediate Danger to Children

Revision 23-4; Effective Nov. 30, 2023

Procedure

During an inspection or investigation, staff may discover conditions in a regulated or unregulated operation that pose a threat of immediate danger to children because of violations of the minimum standards, administrative rules or statutes.

If this occurs, the inspector or investigator consults with the supervisor, program administrator and regional director to determine whether it is necessary to take one or more of the following actions:

  1. Request assistance from the Department of Family and Protective Services.
  2. Request assistance from fire, health or law enforcement officials.
  3. Remain at the operation until parents or managing conservators arrive or the dangerous situation is corrected.
  4. Request that the permit holder or person in charge notify parents or managing conservators of the situation. If that person fails to do so, notify the parents or managing conservators.
  5. Submit a referral to Child Care Enforcement.
  6. Remove the child or children from a residential operation if there is a substantial risk of harm and if the removal is approved by a CCR director.

See:

Appendix 7000-1:  Factors to Consider for Enforcement Actions  
7637  Emergency Suspension and Closure  
7740  Injunctive Relief

4521 Immediate Danger in a State-Operated Facility

Revision 23-3; Effective Sept. 22, 2023

If conditions are found that pose an immediate threat or danger to children in care in a state-operated operation because of violations of minimum standards, administrative rules or statutes, the appropriate CCR director notifies the associate commissioner of CCR, who then notifies the commissioner.

The commissioner may notify the governor at his or her discretion.

4600, Evaluating Compliance with Liability Insurance Requirements

July 2021

Licensed, registered and listed operations are required to maintain liability insurance as specified in minimum standards and Texas Administrative Code Chapter 745. Annually, these operations must verify their liability insurance by the following time frames:

  • Licensed operations: by the anniversary date of the initial license; and
  • Registered and listed operations: by the anniversary date of the full permit.

Certified (state-operated) operations, small employer-based child care programs, shelter care programs and relative-only listed family homes are not required to maintain liability insurance.

Texas Human Resources Code Sections 42.04942.0495

26 TAC Sections 745.249745.251745.253

4610 When to Evaluate for Compliance with Liability Insurance Requirements

July 2021

CCR staff annually evaluate compliance with liability insurance requirements for each licensed, registered or listed operation. The method and timing of the evaluation is determined by the operation type.

4611 When to Evaluate Liability Insurance Requirements for Licensed Operations

July 2021

Procedure

The CCR inspector evaluates whether a licensed operation is in compliance with the liability insurance requirements during the first routine monitoring inspection that is conducted after the anniversary date of the operation’s initial license.

See 4620 How to Evaluate for Compliance with Annual Verification of Liability Insurance Requirements

26 TAC Sections 744.203744.205744.207746.203746.205746.207748.158748.159748.160749.155749.157; and 749.159

4612 When to Evaluate Liability Insurance Requirements for Registered Child Care Homes

July 2021

Procedure

The CCR inspector evaluates whether a registered child care home is in compliance with the liability insurance requirements on an annual basis. The method and timing depend on whether a routine monitoring inspection will occur before the next anniversary date of the home’s permit. When a routine monitoring inspection will occur before the next anniversary date of the home’s permit, the CCR inspector evaluates the operation for compliance during the routine monitoring inspection.

When a routine monitoring inspection will not occur before the next anniversary date of the home’s permit, the CCR inspector completes the evaluation no later than 30 days after the verification of liability insurance was due. The CCR inspector may create in CLASS a manual To-Do reminder for completing this evaluation.

See 4620 How to Evaluate for Compliance with Annual Verification of Liability Insurance Requirements

26 TAC Sections 747.209747.211747.213

4613 When to Evaluate Liability Insurance Requirements for Listed Family Homes

July 2021

Procedure

Within 30 days after the anniversary date of the permit for the listed family home, CCR staff determine whether the home is in compliance with the liability insurance requirements.

Listed family homes that care for related children only are not required to maintain liability insurance.

See: 4620 How to Evaluate for Compliance with Annual Verification of Liability Insurance Requirements

26 TAC Sections 742.403742.405742.407

4620 How to Evaluate for Compliance with Liability Insurance Requirements

Revision 23-3; Effective Sept. 22, 2023

CCR staff review CLASS, digital records on the CCR Digital Storage SharePoint site, CLASS Document Library, and the operation’s hard copy record to evaluate whether the operation is in compliance. If the operation is not in compliance, CCR staff take steps to ensure the operation comes into compliance.

Procedure

CCR staff determine if the operation did one of the following by the anniversary date of the operation’s initial permit (licensed operations) or full permit (registered, certified or listed operations):

  • updated liability insurance information through the operation’s online provider account (this submission will update the Liability Insurance History page in CLASS for the operation);
  • submitted the information on a completed Form 2962, Verification of Liability Insurance; or
  • submitted the information required by Form 2962 in a manner other than completing Form 2962.

If a provider submits Form 2962 or submits the information required by Form 2962 in another manner, staff document the information submitted on the Liability Insurance History page in CLASS.

If the Operation Has Liability Insurance

If the operation has liability insurance, CCR staff verify that the operation provided written proof of insurance coverage from the insurance company. CCR staff upload the proof of insurance to CLASS Document Library, according to 1430 Documenting and Storing Photographs, Video, Audio, Scanned Documents and Other Digital Files.

If an Operation Does Not Have Liability Insurance

If staff are evaluating liability insurance requirements during an inspection or investigation and the operation does not have liability insurance, CCR staff evaluate whether the operation notified parents as required. If the operation is not in compliance, CCR staff take steps to ensure the operation comes into compliance.

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

Revision 23-2; Effective June 26, 2023

A risk analysis is an objective report written by the Performance Management Unit (PMU) that contains:

  1. an analysis of an operation's compliance with CCR statutes, administrative 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 monitoring or enforcement actions with the operation, based on the risk identified.

Human Resources Code (HRC) Section 42.0211

A risk analysis supplements the assessment of risk at an operation, but it does not replace CCR’s responsibility to assess risk before and after each inspection, investigation, assessment or significant change that occurs at an operation.

Additional information on the Risk Analysis process can be found on the CCR PMU SharePoint site.

4810 Risk Analysis Review Period

Revision 23-2; Effective June 26, 2023

Procedure

PMU identifies an operation for a risk analysis based on the operation’s two-year compliance history; however, the assigned PMU risk analyst completes the risk analysis by assessing the operation's compliance history over the last five years. The five-year time frame is determined as follows:

If …then …
the operation has had a permit for five or more years when the PMU initiates the risk analysis, and the PMU has not previously completed a risk analysis on the operation …the review period begins five years prior to the date when the PMU initiates the risk analysis.
the operation has had a permit for less than five years when the PMU initiates the risk analysis …the review period begins on the date when CCR issued the initial permit.
the PMU previously completed a risk analysis on the operation within the last five years, and PMU is no longer tracking the operation through the risk review process …the PMU completes a new risk analysis by analyzing only the operation's compliance history since the most recent risk analysis was completed.

4811 Identifying an Operation for a Risk Analysis

Revision 23-2; Effective June 26, 2023

PMU identifies operations for a risk analysis monthly, based on rates of non-compliance in high-risk areas over the preceding two years as compared to other operations: 

  • of similar type and size;
  • located in the same region; and 
  • which have been in operation for a similar length of time.

High-risk areas include:

  • deficiencies by weight of the standard;
  • reason to believe (RTB) findings;
  • RTB findings resulting from a child fatality;
  • enforcement actions previously imposed;
  • serious injuries; and
  • day care director or residential care licensed administrator vacancies reported.

Operations not operating, currently on probation, placed on heightened monitoring, or pending adverse action are exempt from being the subject of a risk analysis.

Procedure

PMU assigns the risk analysis by the 15th day of the month that an operation is identified for a risk analysis. The risk analysis is completed by the 15th day of the following month. For example, a risk analysis assigned between Jan. 1-15 is due to be completed by Feb. 15.

When an operation is identified for a risk analysis, PMU sends an email notification to the administrative assistant (if the operation is a listed family home), inspector, supervisor, program administrator and regional director assigned to the operation. This notification contains: 

  • information about the operation; and 
  • the assigned PMU risk analyst.

If regional CCR staff receive a risk analysis notification for an operation that is actively being considered for probation or adverse action, then regional CCR staff notify the assigned risk analyst via email within two days of being notified of the risk analysis assignment.

4812 CCR Staff Responsibilities after an Operation is Identified for a Risk Analysis

Revision 23-2; Effective June 26, 2023

Procedure

CCR staff complete the following tasks after the PMU identifies an operation for a risk analysis:

TaskWho is ResponsibleWhen Task is Completed

Review the operation's compliance history and all documentation in the operation’s CLASS record within the designated review period (includes reviewing abuse and neglect investigations completed by DFPS). 

See:

4811 Risk Analysis Review Period

PMU Risk AnalystUpon being assigned a risk analysis to complete.

Review any enforcement actions imposed on the operation within the designated review period.

See: 

4811 Risk Analysis Review Period

PMU Risk AnalystUpon being assigned a risk analysis to complete.
Analyze the information reviewed and recommend a monitoring or enforcement action in accordance with relevant administrative rules and CCR policy.PMU Risk AnalystAfter conducting a review of the operation’s history and record.
Draft a written report which summarizes the information reviewed and analyzed.PMU Risk AnalystBy the 15th day of the following month.
Document a summary of the risk analysis on the operation’s CLASS Chronology page.PMU Risk AnalystBy the 15th day of the following month.
Upload a copy of the written report to the operation’s record in CLASS.PMU Risk AnalystBy the 15th day of the following month.

Send the completed written report to the following regional CCR staff assigned to the operation, via email:

  • administrative assistant (listed family homes only)
  • inspector
  • supervisor
  • program administrator
  • regional director
  • director of regional operations
  • deputy associate commissioner for regional operations
  • deputy associate commissioner for quality and compliance
PMU Risk AnalystBy the 15th day of the following month.
Review the written report.Regional CCR staffUpon receiving the written report.
Determine whether to implement all, some or none of the recommendations.Regional CCR staffUpon receiving the written report.

4820 Risk Review Overview

Revision 23-2; Effective June 26, 2023

A risk review is an objective report written by the PMU that contains:  

  • a high-level overview of:  
    • the most recent risk analysis completed on the operation; or 
    • the most recent probation imposed on the operation; 
  • a summary of the operation's compliance history; and   
  • an assessment of this information to evaluate the impact of an action taken against an operation.  

A PMU risk analyst completes a risk review for an open operation: 

  • with a completed risk analysis on file;  
  • that is placed on probation; or 
  • that the director of PMU determines requires a review. 

Procedure

A risk analyst completes a risk review every six months after the completion date of the risk analysis, the probation actual begin date, or the date determined by the director of PMU. A risk review is completed every six months until: 

  • three risk reviews have been completed (even if a probation period has ended); or  
  • the operation is closed in CLASS. 

After each risk review is complete, the risk analyst sends a written copy of the results to the following regional CCR staff assigned to the operation, via email:  

  • administrative assistant (listed family homes only); 
  • inspector;  
  • supervisor;  
  • program administrator;  
  • regional director; 
  • director of regional operations;  
  • deputy associate commissioner for regional operations; and 
  • deputy associate commissioner for quality and compliance. 

The PMU risk analyst also uploads a copy of the risk review to the operation's record in CLASS.