7300, Plan of Action

Revision 24-1; Effective Feb. 20, 2024

A plan of action is a voluntary enforcement action that is a collaborative effort between CCR and an operation. The goal of a plan of action is to develop a plan to reduce risk and help improve the operation’s compliance with CCR statutes, administrative rules, and minimum standards.

Because a plan of action is voluntary, an operation may decline to develop and follow a plan. CCR may submit a Referral for Enforcement Action to Child Care Enforcement if an operation refuses to participate in a plan of action, and:

  • CCR staff determine that risk cannot be mitigated without a plan; and
  • the operation meets the criteria for another enforcement action.

The maximum time frame for a plan of action is six months. CCR may not extend a plan of action.

Because a plan of action is a voluntary action, it is not eligible for an administrative review.

26 TAC Section 745.8611, 745.8613, 745.8631(1) and 745.8633(c)

7310 Criteria for Recommending a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

An operation is eligible to participate in a plan of action if a circumstance described in 7110 Circumstances That May Call for Enforcement Action exists and CCR determines the operation meets all of the following criteria:

  1. demonstrates the ability to identify risk;
  2. accepts responsibility for correcting deficiencies;
  3. has the ability to make corrections;
  4. has a history of making corrections to maintain compliance, if applicable;
  5. will be able to mitigate risk by following the plan of action; and
  6. has not participated in a voluntary plan of action during the previous 12 months for similar issues.

If the permit holder operates multiple operations, CCR staff may consider the criteria listed above for each operation the permit holder operates when determining the operation’s eligibility to participate in a plan of action.

In determining whether a plan of action is the most appropriate enforcement action for an operation, CCR staff consult Appendix 7000-1: Factors to Consider for Enforcement Actions.

26 TAC Sections 745.8605, 745.8607 and 745.8633

7311 Initiating a Plan of Action

Revision 24-1; Effective Feb. 12, 2024

Procedure

The inspector discusses the recommendation to initiate a plan of action with the supervisor and obtains supervisory approval before recommending a plan of action to the operation. If the inspector receives supervisory approval, then the inspector completes the actions noted in the table below.

ActionWhen Action is Completed
Documents the supervisor's approval in CLASS as a Chronology.By the day after receiving supervisory approval.
  1. prepares a compliance history report which lists the operation’s compliance history for the last 24 months;
  2. completes Section I of Form 7277; and
  3. attaches Form 7277 to the operation’s compliance history.
After receiving supervisory approval to recommend a plan of action to the operation.

Schedules a meeting with:

  • the person in charge of the operation;
  • the permit holder;
  • the applicant or designee;
  • for day care only, the head of the governing body; and
  • each controlling person.
After completing the actions listed above.
Provides the operation with a copy of Form 7277 with the operation’s compliance history report attached.Before or during the meeting with the operation to discuss a plan of action.
  1. discusses the identified compliance issues with the operation;
  2. explains the following to the operation:
    • when CCR may recommend a plan of action (reference 26 TAC 745.8633);
    • the purpose of a plan of action; 
    • the process for developing a plan of action;
    • the benefits of participating in a plan of action; and
    • that a plan of action doesn’t qualify for an administrative review; and
  3. Asks the operation if the operation agrees to complete a plan of action.
During the meeting with the operation to discuss a plan of action.
Documents a summary of the conversation with the operation in CLASS as a Chronology.By the day after the meeting with the operation to discuss the recommendation to participate in a plan of action.

Reference Appendix 3000: Notifying the Operation

7311.1 If the Operation Agrees to Participate in a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

Procedure

If the operation agrees to participate in a plan of action, the inspector takes the following actions:

  • directs the permit holder, director, or administrator to complete Section II of Form 7277, and return to CCR within 10 days of receipt; and
  • explains to the permit holder, director, or administrator that CCR staff will: 
    • review the operation’s plan; and 
    • must agree to action items that the operation documents in Section II of Form 7277 before the plan of action officially begins.

7311.2 If the Operation Does Not Agree to Participate in a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

Procedure

If the operation does not agree to participate in a plan of action, the inspector:

  • discusses with the CCR supervisor, and, if necessary, the program administrator and regional director if CCR should: 
    • take less serious measures to reduce risk at the operation; 
    • submit a Referral for Enforcement Action to Child Care Enforcement (CCE) (7420 Submitting the Referral for Enforcement Action to Child Care Enforcement); or
    • take less serious measures to reduce risk at the operation and submit a referral for Enforcement Action to CCE; and
  • documents a summary of the discussion as a Chronology in CLASS, including the decisions made.

7312 Meeting with an Operation to Review a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

Once CCR receives Form 7277 from the operation, the inspector and supervisor:

  • review Section II of Form 7277;
  • assess if the operation’s proposed plan addresses the deficiencies and mitigates risk to children; and
  • schedule a meeting with the operation’s permit holder, designee, director or administrator to review Section II of Form 7277.

The meeting must take place within 10 days of receiving the completed Form 7277 from the operation.

Procedure

During the plan of action meeting, CCR staff:

  1. review the operation’s compliance history report and discuss areas of concern with the operation;
  2. review how the operation’s plan does or does not:
    • address the areas of concern identified in the operation’s compliance history;
    • reduce or eliminate the recurrence of deficiencies; and
    • mitigate risk to children caused by the deficiencies;
  3. explain to the operation how CCR will follow up on the implementation of the plan; and
  4. discuss the date the operation will implement the plan (the begin date) and the date the plan will end (7314 Starting a Plan of Action and 7316 Ending a Plan of Action).

In the event the action items the operation outlined in the plan do not mitigate risk, the inspector:

  • explains to the operation how the plan fails to reduce risk and correct deficiencies; and
  • works with the operation to develop new action items that reduce risk and address the deficiencies.

7312.1 When CCR and Operation Agree on a Proposed Plan of Action

Revision 24-1; Effective Feb. 12, 2024

Procedure

Once CCR and the operation agree to the plan of action, the administrator, director, or their designee and the inspector and supervisor review and sign the completed Form 7277.

CCR staff upload a copy of the signed Form 7277 in the operation’s record using the CLASS Document Library (1432 Storage of Photographs, Video, Audio, Scanned Documents and Other Digital Files in CLASS Document Library).

At least 15 days before the start date of the plan, CCR staff send notification of the plan’s start date, along with a signed copy of Form 7277, to:

  • the person in charge of the operation;
  • the permit holder;
  • the applicant or designee;
  • for day care only, the head of the governing body; and
  • each controlling person.

CCR staff document the plan in CLASS (7313 Documenting the Plan of Action in CLASS).

7312.2 When CCR and Operation Cannot Agree on a Proposed Plan of Action

Revision 24-1; Effective Feb. 12, 2024

Procedure

If CCR staff and the operation cannot agree on the proposed plan of action, the inspector consults with the supervisor, and, if necessary, the program administrator, regional director, or both to determine if CCR should:

  1. implement the plan as written by the operation;
  2. collaborate further with the operation; or
  3. submit a Referral for Enforcement Action to CCE (7420 Submitting the Referral for Enforcement Action to Child Care Enforcement).

CCR staff document the consultation and resulting recommendations in CLASS as a Chronology.

26 TAC Section 745.8631(1)

7313 Documenting the Plan of Action in CLASS

Revision 24-1; Effective Feb. 20, 2024

CCR staff document the plan of action in the CLASS Plan of Action List located under the Monitoring tab as follows:

What to DocumentWhen to DocumentCLASS Field(s)
Planned Start DateBefore plan of action beginsBegin Date
Planned Completion DateBefore plan of action beginsEnd Date (must be 6 months from the Begin Date)
Actual Completion DateWhen plan of action endsActual End Date
List of deficiencies within the last 24 months that are the basis for recommending the plan. This may or may not include all deficiencies cited within the past 24 months.Before plan of action begins
  • Basis for Plan of Action - Investigation
  • Basis for Plan of Action - Inspection
  • Basis for Plan of Action - Assessment
The operation’s action items listed in Section II, Subsection B, of the finalized Form 7277

Before plan of action begins

During plan of 
action to modify 
or delete an 
action item

Action Items
If implementation of the plan was successful or not successfulWhen plan of action endsStatus dropdown

If CCR staff modify or delete an action item during the plan of action, CCR staff enter the following as a Chronology in CLASS:

  • a summary of what was modified or deleted; and
  • why the modification or deletion occurred.

7314 Starting a Plan of Action

Revision 24-1; Effective Feb. 12, 2024

A plan of action starts 15 days from the date CCR sends written notification to the operation with the plan’s start date and a signed copy of Form 7277, unless the operation sends CCR a written request to begin the plan earlier.

Procedure

If an operation requests to begin the plan of action early, the inspector:

  • documents the revised start date in the Begin Date field in the Plan of Action Details page in CLASS; and
  • updates the planned end date in the Planned End Date field in the Plan of Action Details page in CLASS.

References:

7312.1 When CCR and Operation Agree on a Proposed Plan of Action
7313 Documenting the Plan of Action in CLASS

7315 Inspecting an Operation During a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

During a plan of action, CCR staff conduct at least two unannounced monitoring inspections while children are in care. These inspections are to determine if the operation has come into and maintained compliance with statutes, administrative rules, and minimum standards.

CCR staff may conduct more inspections based on the compliance of the operation and risk to children determined during the required inspections.

Before the end of the plan of action, CCR staff evaluate the operation’s compliance with the entire subchapter associated with each minimum standard listed in the Basis for Plan of Action section of the Plan of Action Details page in CLASS.

26 TAC Section 745.8631(1)

Procedure

The inspector conducts the monitoring inspections at appropriate intervals during the plan of action to:

  • evaluate the operation’s progress in implementing the plan; and
  • determine if the operation successfully completed the plan or a more serious action may be necessary.

During each monitoring inspection completed during the plan of action, the inspector:

  1. evaluates the operation’s compliance with at least one entire subchapter of the minimum standards associated with the plan of action;
  2. evaluates the operation's compliance with one additional entire subchapter of the minimum standards to ensure overall compliance;
  3. documents that the plan of action was evaluated during the inspection by selecting the Plan of Action action items were evaluated checkbox in the Other Items Evaluated section on the Inspection Details page;
  4. provides technical assistance: 
    1. for any statute, administrative rule, or minimum standard where the operation is deficient; and
    2. per 4154 Technical Assistance and 4161.24 Technical Assistance for Violations Recommended for an Administrative Penalty; and
  5. completes all other tasks required during a monitoring inspection (4126 Monitoring Inspections).

The inspector may evaluate if the operation is following the plan of action, but only cites a deficiency if the operation violates a statute, administrative rule, or minimum standard. If the operation is still deficient in the areas identified in the plan, the inspector: 

  • reviews the specific action items in the plan related to the deficiencies with the person in charge at the time of the inspection; and
  • uses this review to reevaluate the plan and determine the appropriateness of its terms if the operation has not established or maintained compliance.

7316 Ending a Plan of Action

Revision 24-1; Effective Feb. 20, 2024

7316.1 Consultation with Supervisor Before a Plan of Action Ends

Revision 24-1; Effective Feb. 20, 2024

Before a plan of action ends, the inspector consults the supervisor to review the operation’s compliance with the statutes, administrative rules, and minimum standards evaluated during the plan of action. The inspector consults with the supervisor based on the operation’s progress on the plan of action and overall compliance.

Procedure

During the plan of action, the inspector and supervisor discuss:

  1. the operation’s progress on the plan of action and overall compliance with statutes, administrative rules, and minimum standards; and
  2. if:
    • the plan remains appropriate, such as if CCR should recommend the operation modify or add action items;
    • the plan should end early;
    • more inspections are needed; or
    • a more serious enforcement action would be more appropriate.

Before ending the plan, the inspector and supervisor must also discuss whether the plan of action has been successful.

CCR staff document a summary of the staffing and any recommendations as a Chronology in CLASS.

References:

7316.2 Ending a Plan of Action Early
7316.3 When the Operation Has Been Established and Maintained Compliance During the Plan of Action
7316.4 When the Operation Has Not Been Established or Maintained Compliance During the Plan of Action

7316.2 Ending a Plan of Action Early

Revision 24-1; Effective Feb. 20, 2024

CCR may end a plan of action early if CCR determines that:

  • the operation has reduced risk and come into and maintained compliance with statutes, administrative rules and minimum standards; or
  • the operation’s compliance has worsened and CCE has imposed a more serious enforcement action.

26 TAC Sections 745.8611, 745.8643   

References: 

7316.3 When the Operation Has Established and Maintained Compliance During the Plan of Action
7316.4 When the Operation Has Not Established or Maintained Compliance During the Plan of Action

7316.3 When the Operation Has Established and Maintained Compliance During the Plan of Action

Revision 24-1; Effective Feb. 20, 2024

Procedure

When the operation has come into and maintained compliance with all statutes, administrative rules, and minimum standards associated with the plan, and any additional statutes, administrative rules, and minimum standards evaluated during the plan of action, the inspector sends the operation a letter on HHSC letterhead in CLASS. This is done using the appropriate plan of action results letter template located on CCR’s SharePoint site, stating:

  1. compliance with statutes, administrative rules, minimum standards has been established;
  2. the plan of action has ended; and
  3. compliance with statutes, administrative rules, the minimum standards, and any restrictions or conditions on the operation’s permit must be maintained.

To document the end to the plan of action in CLASS, the inspector follows the procedure in 7316.5 Documenting the End to a Plan of Action in CLASS.

7316.4 When the Operation Has Not Established or Maintained Compliance During the Plan of Action

Revision 24-1; Effective Feb. 20, 2024

If the operation’s compliance with statutes, administrative rules, and minimum standards does not improve sufficiently to reduce risk at the operation because of the plan of action or the operation’s compliance worsens, CCR staff may:

  • recommend additional action items, modify action items, increase inspections; or
  • submit a Referral for Enforcement Action to CCE.

26 TAC Section 745.8643

Procedure

If the operation has not met compliance with statutes, administrative rules, and minimum standards, CCR staff:

  • reevaluate the plan to determine the appropriateness of its terms and determine whether CCR should:
    • recommend an amendment to the plan’s action items, 
    • increase inspections if the term of the plan of action is not expiring within the next 60 days, 
    • recommend an amendment to the plan’s action items and increase inspections if the term of the plan of action is not expiring within the next 60 days, or
    • submit a Referral for Enforcement Action to CCE; and
  • send the operation written notification on HHSC letterhead in CLASS, using the appropriate plan of action results letter template located on CCR’s SharePoint site, that the operation has not met compliance and CCR may proceed with the decided upon action.

If CCR staff are also ending the plan, the inspector follows the procedure in 7316.5 Documenting the End to a Plan of Action in CLASS.

Reference 7316.2 Ending a Plan of Action Early

7316.5 Documenting the End to a Plan of Action in CLASS

Revision 24-1; Effective Feb. 20, 2024

Procedure

To end the plan of action in CLASS, the inspector updates the Status dropdown on the Plan of Action Details page in CLASS as follows:

IfThen

the operation has: 

  • corrected the deficiencies and reduced risk through compliance with the plan of action; and 
  • maintained compliance with all other statutes, administrative rules, and minimum standards. 
the inspector changes the Status dropdown from In Progress to Successful.

the operation’s compliance with statutes, administrative rules, and minimum standards: 

  • does not improve sufficiently to reduce risk at the operation because of the plan of action; or 
  • worsened.
the inspector changes the Status dropdown from In Progress to Not Successful.