4700, Reviewing Operation Policies

November 2009

Licensing reviews certain policies of regulated operations to determine the operation's compliance with law, administrative rules, and minimum standard rules.

Licensing determines whether policies comply with minimum standard rules, but Licensing does not approve policies.

40 TAC §745.243


When reviewing an operation's policies, Licensing staff take the following steps:

  • Determine whether the policy is required by, or directly relates to, compliance with law, administrative rules, and minimum standard rules.
  • Decline any request to review a policy that is outside of Licensing's jurisdiction.
  • For example:
    • Licensing staff may not endorse an operation's personnel policy on sexual harassment; and
    • Licensing staff do not review CPS policies related to family based services.
  • Communicate clearly to the operation that Licensing cannot endorse therapeutic techniques or programming. Licensing assesses therapeutic techniques or programming only to the extent that they directly relate to compliance with minimum standard rules.

When an Operation Requests Licensing to Review Its Policy

If an operation requests a policy review, Licensing staff use the following language to inform the operation in writing about whether its policy violates law or minimum standard rules:

Licensing received a request to review your operation's policy or policies on (insert date). Licensing reviewed the policy/policies for compliance with law and minimum standard rules. Licensing cannot otherwise review a policy or assess a clinical or therapeutic technique used by your operation. If Licensing determines that an operation's policies comply with minimum standard rules, this does not imply endorsement of any clinical or therapeutic technique noted within the policies.

The policy or policies you submitted (do or do not) comply with Licensing rules and law.

If the policy or policies do not comply with Licensing rules, Licensing staff include the rationale. For example:

The discipline policy you submitted includes use of corporal punishment. Corporal punishment is prohibited by 26 Texas Administrative Code §748.2303.