Revision 23-2, Effective June 26, 2023
An inspector conducts a follow-up with an operation to:
- 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;
- determine whether the operation is complying with the conditions of a waiver or variance;
- determine whether the operation is complying with the conditions of a risk evaluation;
- conduct the annual review of director qualifications at a licensed child care center;
- ensure that the operation is in compliance after a corrective action ended;
- ensure the operation is no longer operating due to denial of a permit, suspension or revocation;
- ensure the operation is no longer operating after an auto revocation;
- monitor the operation during the appeal process; or
- 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:
- reviewing records related to the deficiency;
- inspecting areas of the physical plant related to the deficiency; and
- 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:
- the risk to children;
- scope and severity of the deficiency;
- time and expense needed to correct the deficiency;
- the provider's previous compliance history; and
- 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 Assessment | Time Frame for Completing Follow Up |
---|---|
High-weighted only | Within 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.
|
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-Up | Procedures |
---|---|
Only HM-related deficiencies |
|
Only non-HM-related deficiencies |
|
Both HM-related and non-HM-related deficiencies |
|
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-Up | Procedures |
---|---|
Only HM-related deficiencies |
|
Only non-HM-related deficiencies |
|
Both HM-related and non-HM-related deficiencies |
|
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:
|
the operation is still deficient… | the inspector:
|
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 Evaluated | Follow Procedures in |
---|---|
Operation corrected all deficiencies | 4331.1 Documenting a Follow-Up Without an Inspection When the Operation Corrected All Deficiencies |
Inspector will re-cite one or more deficiencies | 4331.2 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:
Field | What to Document |
---|---|
Follow Up Date | The date the information was received from the operation. |
Follow Up Method | The method the inspector used to complete the follow-up. |
Results | Select Compliance Met. |
Additional Documentation |
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:
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:
- issue a warning letter and conduct a follow-up with an inspection;
- expedite the next monitoring inspection;
- recommend the operation go on a plan of action; or
- 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:
Field | What to Document |
---|---|
Compliance Date | Change the date to the new compliance date. |
Follow Up Method | Select the method inspector used to complete the follow-up. |
Follow Up Date | Enter the date of the extension approval. |
Results | Select Extension Granted. |
Additional Documentation | Document the following in the text box:
|
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.