4300, Conducting a Follow-Up with an Operation

Revision 23-2, Effective June 26, 2023

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

  1. ensure that the operation is in compliance with any CCR statutes, administrative rules and minimum standards 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 director qualifications at a licensed child care center;
  5. ensure that the operation is in compliance after a corrective action ended;
  6. ensure the operation is no longer operating due to denial of a permit, suspension or revocation;
  7. ensure the operation is no longer operating after an auto revocation;
  8. monitor the operation during the appeal process; or
  9. monitor the operation during a temporary relocation.

When following up with an operation regarding a deficiency that the operation did not correct at inspection (see 4155 Determining When a Deficiency Can Be Corrected at Inspection), the inspector verifies that the operation corrected the deficiency, which may include:

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

Procedure

For each deficiency, the inspector determines whether to follow up on the deficiency with or without an inspection.

To determine whether to follow up with or without an inspection, the inspector considers:

  1. the risk to children;
  2. scope and severity of the deficiency;
  3. time and expense needed to correct the deficiency;
  4. the provider's previous compliance history; and
  5. if an inspection is required to determine whether 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 that an operation is not in compliance during the follow-up, the inspector follows the procedures in 4340 When an Operation Continues to Be Deficient.

40 TAC Section 745.8449

See also:

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 Time Frames for Conducting a Follow-up               
4320  Following Up with an Inspection               
4330  Following Up Without an Inspection    
5132  Evaluating Conditions    
5520  Temporary Relocation    
7636  Follow-Up to Final Notice of Suspension, Revocation, or Denial    
7731  Regulation During Appeal Process    
10410  When a Risk Evaluation is Required    
10510  Types of Eligibility Determinations

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 23-1, Effective Apr. 21, 2023

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 Document Follow-Ups Completed with an Inspection.

See also:

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  
5132 Evaluating Conditions  
10400 Risk Evaluation

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

Revision 23-1, Effective Apr. 21, 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 Homes and 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 23-1, Effective Apr. 21, 2023

Procedure

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

  • reviewing documents, photos 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.

See:

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        
5132 Evaluating Conditions        
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 23-1, Effective Apr. 21, 2023

The inspector 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

If an extension is approved, the inspector:

  • notifies the operation about the approval (unless the extension is based on an administrative review of a citation); 
  • 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 granted;
  • 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.