4300, Conducting a Follow-Up with an Operation

February 2020

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

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

Licensing staff may follow up on deficiencies with or without an inspection.

See:

4131.3 Child Day Care – Annual Meeting with the Designated Director at a Licensed Child Care Center
4152 Reviewing Restrictions, Conditions, Waivers, and Variances
4310 How and When to Conduct a Follow-up When There are Deficiencies
4311 Following Up with an Inspection
4312 Following Up Without an Inspection
5120 Setting and Monitoring Conditions for the Waiver or Variance
7320 Temporary Relocation
7636 Follow-Up to Final Notice of Suspension, Revocation, or Denial
7731 Regulation During Appeal Process
10000 Background Checks
10412 When a Risk Evaluation May Be Requested
40 TAC §745.8449

Procedure

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

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

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

February 2020

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

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

When Licensing Must Conduct a Follow-Up

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

Types of Violations	Follow-Up Required
High-weighted only	Within 15 days of the latest compliance date of high-weighted deficiencies.
Non-high-weighted only (that is, medium-high, medium, medium-low, and low)	Within 30 days of the latest compliance date of non-high-weighted deficiencies.
High- and non-high-weighted	Within 15 days of the latest compliance date of the high-weighted deficiencies. Licensing staff evaluate compliance with all high and non-high-weighted deficiencies. However, if the compliance date for a non-high-weighted deficiency is a future date, the inspector does not re-cite the deficiency and must follow up no later than 30 days after the latest compliance date of non-high-weighted deficiencies.

4311 Following Up with an Inspection

May 2020

Procedure

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

See also:

4152 Reviewing Restrictions, Conditions, Waivers, and Variances
4320 Exceptions to Time Frames for Completing a Follow-Up With an Operation
4322 Granting an Operation Additional Time to Comply with a Requirement Cited as a Deficiency
4510 CLASS Enforcement Recommendations
5120 Setting and Monitoring Conditions for the Waiver or Variance
10400 Risk Evaluation of Criminal History or Findings of Child Abuse or Neglect

4311.1 Documenting Follow-Up Inspections

October 2021

For a follow-up inspection other than a Heightened Monitoring follow-up inspection, CCR staff:

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

Procedure

If CCR staff are conducting a follow-up inspection for a reason other than evaluating compliance of a deficiency, staff document the inspection as outlined in 4160 Documenting the Results of an Inspection. If CCR staff are conducting a Heightened Monitoring follow-up inspection, staff document the inspection as outlined in 4311.11 Documenting Heightened Monitoring Follow-Up Inspections (HM Staff Only).

If CCR staff are conducting the follow-up inspection as a result of a deficiency cited during a previous inspection or assessment, Licensing staff document the results of the follow-up on CLASS Form 2936 Child-Care Facility Inspection as follows:

1. CCR staff link the current inspection to the appropriate previous inspection(s) or assessment(s).
2. CCR staff delete any linked citations that automatically prefill on the Inspection Summary page if:
   • Staff are not evaluating the citation during the current follow-up inspection; or
   • the operation requested an extension during the current follow-up inspection and staff granted the extension (staff will document the extension in the original inspection in CLASS; see 4322 Granting an Operation Additional Time to Comply With a Requirement Cited as a Deficiency).
3. For the remaining linked citations, CCR staff consult the table below:

   If…	Then…
   the operation is in compliance…	CCR staff: enter Compliance in the Finding field; delete the date in the Compliance Date field; and delete the text in the Narrative text box and replace it with a statement outlining how the deficiency was corrected.
   the operation is still deficient…	CCR staff: enter Deficiency in the Finding field; enter the new compliance date in the Compliance Date field; and delete the text in the Narrative text box and replace it with information about how the operation continues to be deficient.

4311.11 Documenting Heightened Monitoring Follow-Up Inspections (HM staff only)

October 2021

Procedure

If CCR HM staff are conducting the HM follow-up inspection as a result of a deficiency cited during a previous HM inspection, CCR HM staff document the results of the follow-up on CLASS Form 2936 Child-Care Facility Inspection as follows:

1. Create a new CLASS Form 2936 Child-Care Facility Inspection with the inspection type of “Other” (see 4161 Completing CLASS Form 2936 Child-Care Facility Inspection);
2. Manually add the standards that staff are evaluating during the current HM follow-up inspection (the previous inspection cannot be linked);
3. Document on the Standard Details page for the current HM follow-up inspection, the finding for each standard evaluated;
4. Document one of the following statements in the Narrative box on the Inspection Details page for the current HM follow-up inspection:
   • If the purpose of the inspection is only to conduct a follow-up, CCR staff document “Follow-up to HM inspection [insert ID#] completed”;
   • If the purpose of the inspection is to complete both a routine HM inspection and an HM follow-up inspection, staff document “HM visit conducted at operation and follow-up to HM inspection [insert ID#] completed”; and
5. Complete the Follow-Up Information section of the Standard Details page for the original deficiency.

4312 Following Up Without an Inspection

October 2019

Procedure

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

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

4312.1 Documenting Follow-Ups When an Inspection is Not Required

May 2020

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

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

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

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

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

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

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

4313 When an Operation Continues to be Deficient

May 2020

Procedure

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

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

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

See:

4510 CLASS Enforcement Recommendations
5310 Sending a Warning Letter and Following Up with an Inspection
7000 Voluntary Actions and Enforcement Actions
Appendix 7000-1: Factors to Consider for Enforcement Actions

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

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

November 2017

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

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

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

Procedure

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

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

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

November 2017

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

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

Procedure

If an Extension is Approved

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

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

If an Extension is Denied

Licensing staff:

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

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