11300, Heightened Monitoring Plan

October 2021

Every operation on Heightened Monitoring (HM) receives an HM plan that is customized to address the individual operation’s patterns and trends identified through the HM plan development meetings and pre-plan inspections.

All HM plans contain:

  1. The operation’s HM start date and anticipated end date;
  2. A listing of the trends and patterns identified through a five-year retrospective analysis of the operations’ CCR licensing and residential contract history with a summary of those areas;
  3. Technical assistance that HHSC, DFPS or a third party will offer to the operation;
  4. Plan tasks and due dates; and
  5. A listing of the HM team members.

The HM development team has four weeks from the Initial FITS coordination meeting to develop and approve the HM plan.  

The approved HM plan is located in the DFPS HM SharePoint site in the operation’s folder.

The HM phase from the date the operation is placed on HM until the date the HM plan is presented to the operation is called the Pre-Plan Development Phase.

 

11310 Point of Contact for Initiating the Heightened Monitoring Plan Meetings

October 2021

The lead HM program specialist initiates the plan development meetings.

 

11320 Heightened Monitoring Development Plan Meeting Preparation

October 2021

After the HM development team is established, the team members complete their respective assigned activities to gather the information necessary to assess the operation’s performance history and identify areas of improvement.

Procedure

In preparation for the HM Development Plan meetings, the HM development team conducts an in-depth review by compiling and analyzing information obtained by:

  1. Reviewing data to identify trends and patterns in the operation’s history;
  2. Reviewing interviews with operation staff and/or children completed during HM inspections/visits;
  3. Contacting the operation’s leadership for their input on areas of improvement or activities that are already in place to address issues identified as part of HM; and
  4. Reviewing current or prior CCR enforcement action documentation, CCR risk analysis documentation or RCC corrective action plan documentation.

The date the operation is placed on Heightened Monitoring is the start date for the HM Pre-Plan Development Phase of the HM episode.

 

11330 Five-Year Review and Assessment of an Operation

October 2021

Procedure

At the HM Plan Development meetings, the team reviews and assesses an operation’s last five years for the following:

  1. Any trends and patterns identified as a result of the analysis conducted by the DSI;
  2. Any trends and patterns identified as a result of the five-year retrospective analysis conducted by the CCR HM program specialist;
  3. The operation’s contract performance both with DFPS and the Single Source Continuum Contractors (SSCC), if applicable;
  4. Any monitoring plans or corrective actions imposed by DFPS Residential Contracts or SSCC contracts;
  5. Any enforcement actions imposed by HHSC; and
  6. Any risk analyses conducted by HHSC or DFPS.

 

11340 Developing the Heightened Monitoring Plan

October 2021

The HM Plan is developed by the HM team and approved by all HM directors. The HM plan must be approved and finalized four weeks after the operation is notified of its placement on Heightened Monitoring.

Procedure

Using the information obtained from the in-depth review and the information reviewed and assessed at the HM Plan Development meetings, the HM team develops a plan that describes:

  1. The pattern of CCR deficiencies and RCC contract violations that led to heightened monitoring;
  2. Any barriers to compliance identified during a review of previous CCR enforcement actions, CCR risk analyses, DFPS RCC corrective action plans or DFPS risk analyses;
  3. Any technical assistance the operation needs from CCR or DFPS (including additional information and guidance for improving program operations that the operation needs to obtain from a third party);
  4. Any ongoing concerns for the health and safety of children; and
  5. The specific steps the operation must take to satisfy the plan.

The due dates for the tasks in the HM plan are staggered to allow time for the operation to implement the required changes.

 

11350 Heightened Monitoring Plan Approval

October 2021

After the HM plan is developed, the HM development team schedules a meeting to present the plan to the HM directors for review and approval.

 

11360 Heightened Monitoring Plan Implementation Plan Meeting

October 2021

Procedure

After the HM directors approve the HM plan, the CCR HM program specialist is responsible for:

  • developing an inspection schedule throughout the period of the HM plan;
  • identifying the location for inspections (for CPAs); and
  • describing the intent behind each task in the HM plan.

The CCR HM program specialist presents the HM plan to the HM inspector and HM supervisor during an implementation plan meeting.

The internal HM implementation plan will include a review of:

  1. The operation’s trends and patterns;
  2. The plan tasks;
  3. What tasks the HM inspectors will review during the HM inspections; and
  4. What deliverables the HM program specialists will review.

The CCR HM program specialist will provide the recommended inspection schedule to the assigned CCR HM supervisor quarterly.

 

11370 Heightened Monitoring Plan Presentation Meeting with the Operation

October 2021

Procedure

Within one business day of the HM plan’s approval, the HM director or HM manager contacts the operation’s leadership and schedules a meeting with the operation’s:

  • licensed administrator;
  • executive director, if applicable;
  • CEO; or
  • any of the above.

During the meeting, HM staff provides a copy of the HM Plan to the operation and presents the five-year retrospective data analysis completed by the DFPS Division of System Improvement. If the operation requests any changes to the HM plan, those changes are discussed and agreed upon during the meeting and within one business day, the final plan is emailed to the operation.

The date the plan is provided to the operation is the start date for the HM Plan in Effect phase of the HM episode.

 

11371 Documenting the Heightened Monitoring Plan Presentation Meeting

October 2021

Procedure

No later than the next business day after the plan presentation meeting, the lead HM program specialist documents the following in a Chronology in CLASS (type Heightened Monitoring):

  • HM presentation meeting date;
  • HM plan start date; and
  • HM plan tasks.

 

11380 Heightened Monitoring Plan Revisions

October 2021

Procedure

When the HM plan is revised to reflect changes in the operation’s performance or to adjust a plan task, all HM directors must approve the changes, and the HM lead director and/or HM lead manager meets with the operation to present the changes.

The lead HM program specialist documents a summary of the HM plan revisions in a Chronology in CLASS (type Heightened Monitoring).

 

11381 Revisions When an Operation Requests an Extension on a Plan Task

October 2021

Procedure

If an operation requests an extension on a plan task due date, the lead HM program specialist consults with the HM development team. If the team agrees to extending the due date, the lead HM program specialist modifies the task due date and documents the modified due date in:

  • a Chronology in CLASS (type Heightened Monitoring); and
  • written correspondence to the operation.

Updating a due date is not considered a plan update and does not require HM director approval.