4800, Risk Analysis

Revision 23-2; Effective June 26, 2023

A risk analysis is an objective report written by the Performance Management Unit (PMU) that contains:

  1. an analysis of an operation's compliance with CCR statutes, administrative rules and minimum standards;
  2. an identification of indicators associated with the potential of a higher risk of harm to the children in care at an operation; and
  3. recommendations regarding monitoring or enforcement actions with the operation, based on the risk identified.

Human Resources Code (HRC) Section 42.0211

A risk analysis supplements the assessment of risk at an operation, but it does not replace CCR’s responsibility to assess risk before and after each inspection, investigation, assessment or significant change that occurs at an operation.

Additional information on the Risk Analysis process can be found on the CCR PMU SharePoint site.

4810 Risk Analysis Review Period

Revision 23-2; Effective June 26, 2023

Procedure

PMU identifies an operation for a risk analysis based on the operation’s two-year compliance history; however, the assigned PMU risk analyst completes the risk analysis by assessing the operation's compliance history over the last five years. The five-year time frame is determined as follows:

If …then …
the operation has had a permit for five or more years when the PMU initiates the risk analysis, and the PMU has not previously completed a risk analysis on the operation …the review period begins five years prior to the date when the PMU initiates the risk analysis.
the operation has had a permit for less than five years when the PMU initiates the risk analysis …the review period begins on the date when CCR issued the initial permit.
the PMU previously completed a risk analysis on the operation within the last five years, and PMU is no longer tracking the operation through the risk review process …the PMU completes a new risk analysis by analyzing only the operation's compliance history since the most recent risk analysis was completed.

4811 Identifying an Operation for a Risk Analysis

Revision 23-2; Effective June 26, 2023

PMU identifies operations for a risk analysis monthly, based on rates of non-compliance in high-risk areas over the preceding two years as compared to other operations: 

  • of similar type and size;
  • located in the same region; and 
  • which have been in operation for a similar length of time.

High-risk areas include:

  • deficiencies by weight of the standard;
  • reason to believe (RTB) findings;
  • RTB findings resulting from a child fatality;
  • enforcement actions previously imposed;
  • serious injuries; and
  • day care director or residential care licensed administrator vacancies reported.

Operations not operating, currently on probation, placed on heightened monitoring, or pending adverse action are exempt from being the subject of a risk analysis.

Procedure

PMU assigns the risk analysis by the 15th day of the month that an operation is identified for a risk analysis. The risk analysis is completed by the 15th day of the following month. For example, a risk analysis assigned between Jan. 1-15 is due to be completed by Feb. 15.

When an operation is identified for a risk analysis, PMU sends an email notification to the administrative assistant (if the operation is a listed family home), inspector, supervisor, program administrator and regional director assigned to the operation. This notification contains: 

  • information about the operation; and 
  • the assigned PMU risk analyst.

If regional CCR staff receive a risk analysis notification for an operation that is actively being considered for probation or adverse action, then regional CCR staff notify the assigned risk analyst via email within two days of being notified of the risk analysis assignment.

4812 CCR Staff Responsibilities after an Operation is Identified for a Risk Analysis

Revision 23-2; Effective June 26, 2023

Procedure

CCR staff complete the following tasks after the PMU identifies an operation for a risk analysis:

TaskWho is ResponsibleWhen Task is Completed

Review the operation's compliance history and all documentation in the operation’s CLASS record within the designated review period (includes reviewing abuse and neglect investigations completed by DFPS). 

See:

4811 Risk Analysis Review Period

PMU Risk AnalystUpon being assigned a risk analysis to complete.

Review any enforcement actions imposed on the operation within the designated review period.

See: 

4811 Risk Analysis Review Period

PMU Risk AnalystUpon being assigned a risk analysis to complete.
Analyze the information reviewed and recommend a monitoring or enforcement action in accordance with relevant administrative rules and CCR policy.PMU Risk AnalystAfter conducting a review of the operation’s history and record.
Draft a written report which summarizes the information reviewed and analyzed.PMU Risk AnalystBy the 15th day of the following month.
Document a summary of the risk analysis on the operation’s CLASS Chronology page.PMU Risk AnalystBy the 15th day of the following month.
Upload a copy of the written report to the operation’s record in CLASS.PMU Risk AnalystBy the 15th day of the following month.

Send the completed written report to the following regional CCR staff assigned to the operation, via email:

  • administrative assistant (listed family homes only)
  • inspector
  • supervisor
  • program administrator
  • regional director
  • director of regional operations
  • deputy associate commissioner for regional operations
  • deputy associate commissioner for quality and compliance
PMU Risk AnalystBy the 15th day of the following month.
Review the written report.Regional CCR staffUpon receiving the written report.
Determine whether to implement all, some or none of the recommendations.Regional CCR staffUpon receiving the written report.

4820 Risk Review Overview

Revision 23-2; Effective June 26, 2023

A risk review is an objective report written by the PMU that contains:  

  • a high-level overview of:  
    • the most recent risk analysis completed on the operation; or 
    • the most recent probation imposed on the operation; 
  • a summary of the operation's compliance history; and   
  • an assessment of this information to evaluate the impact of an action taken against an operation.  

A PMU risk analyst completes a risk review for an open operation: 

  • with a completed risk analysis on file;  
  • that is placed on probation; or 
  • that the director of PMU determines requires a review. 

Procedure

A risk analyst completes a risk review every six months after the completion date of the risk analysis, the probation actual begin date, or the date determined by the director of PMU. A risk review is completed every six months until: 

  • three risk reviews have been completed (even if a probation period has ended); or  
  • the operation is closed in CLASS. 

After each risk review is complete, the risk analyst sends a written copy of the results to the following regional CCR staff assigned to the operation, via email:  

  • administrative assistant (listed family homes only); 
  • inspector;  
  • supervisor;  
  • program administrator;  
  • regional director; 
  • director of regional operations;  
  • deputy associate commissioner for regional operations; and 
  • deputy associate commissioner for quality and compliance. 

The PMU risk analyst also uploads a copy of the risk review to the operation's record in CLASS.