7400, Corrective Action

September 2019

Corrective actions are enforcement actions Licensing initiates to ensure the safety of children in care of an operation that refuses to or is not eligible to participate in a voluntary plan of action, and adverse action is not necessary to mitigate risk. Corrective actions include the following:

• evaluation (imposed before September 1, 2019); and
• probation.

The time frame for evaluation is six months, and the time frame for probation is twelve months.

Provisional Clause Regarding Evaluation

Licensing does not impose an evaluation on an operation after August 31, 2019.

For an operation that begun evaluation before September 1, 2019, Licensing will continue to monitor the operation during the evaluation period according to the policies and procedures in this section.

Texas Human Resources Code §42.071(c)

26 TAC §§745.8603; 745.8607; 745.8611; 745.8633(c) and 745.8637

7410 Criteria for Imposing Corrective Action

7411 Criteria for Imposing Evaluation

September 2019

Licensing may not impose an evaluation on an operation after August 31, 2019.

Texas Human Resources Code §42.071(c)

7412 Criteria for Imposing Probation

September 2019

Licensing imposes probation on an operation when determining that the operation has repeatedly demonstrated the inability to make necessary corrections to address risk. Specifically, Licensing may impose probation on an operation if a circumstance described in 7110 Circumstances That May Call for Enforcement Action exists and upon determining that:

1. the operation does not qualify for a less restrictive enforcement action;
2. the operation has not demonstrated the ability to make the necessary changes to address risk, but expresses a willingness to comply and make corrections;
3. the operation will be able to mitigate risk by complying with the conditions identified in the plan in addition to minimum standards; and
4. a more restrictive enforcement action is not necessary to reduce risk.

See Appendix 7000-1: Factors to Consider for Enforcement Actions

Texas Human Resources Code §42.071(c)

26 TAC §§745.8601; 745.8605; 745.8607; and 745.8637 

7420 Staffing a Corrective Action

September 2019

The inspector must obtain supervisory approval before imposing probation on the operation.

Procedure

Following a deficiency or other triggering event, the inspector discusses the reason for recommending probation with the supervisor and the program administrator or district director.

Upon receiving supervisory approval to impose probation, the inspector documents the plan and conditions in CLASS.

7421 Documenting the Corrective Action and Creating the Corrective Action Letter in CLASS

September 2019

Procedure

Before Licensing staff meet with the operation, Licensing staff document the probation on the Provider Corrective Action Plan page in CLASS as follows:

See 7422 Meeting with an Operation About a Corrective Action

7421.1 Considering the Conditions for a Corrective Action

August 2021

Probation involves imposing conditions that go beyond minimum standards and basic permit requirements to help the operation improve compliance and reduce risk at the operation.

26 TAC §§745.8631(1),(2) and 745.8643

Procedure

The inspector, in consultation with the supervisor, develops conditions that:

• directly relate to the specific deficiencies which resulted in the action; and
• are designed to correct the deficiencies, reduce risk to children and ensure that the operation can come into and maintain compliance with the minimum standards, administrative rules and statutes.

Certain conditions are always included when an operation is placed on probation. These conditions are automatically included in the Corrective Action Letter and specify that the operation must:

• comply with all of the conditions in the corrective action plan and correct the minimum standards that were deficient;
• post the enclosed probation notice in a prominent place near all public entrances of the operation (if a CPA is on probation, foster homes verified by the CPA do not have to post the notice); and
• establish and maintain compliance with all CCR statutes, rules and minimum standards.

The inspector discusses the conditions with the operation at the meeting to discuss the corrective action. See 7422 Meeting with an Operation About a Corrective Action.

When an operation is on corrective action, CCR may amend conditions if it is determined the conditions do not protect children or improve the status of the compliance. See 7428.2 Modifying or Ending a Corrective Action When Compliance Has Not Been Established.

CCR staff may add a condition to the permit for the duration of the corrective action if the operation’s compliance history supports that such a condition is warranted. CCR staff may not add permanent conditions or restrictions to the permit as part of the corrective action. If CCR wants to impose permanent conditions or restrictions on the permit, CCR may impose an adverse amendment.

See:

3810 Circumstances That May Require Amending the Permit
7622 Criteria for Imposing an Adverse Amendment

7421.2 Documenting Supervisory Approval of a Corrective Action

March 2017

Procedure

Once Licensing staff have determined the conditions for the corrective action, the Licensing supervisor must review and approve the plan and conditions. The supervisor must document this approval by completing the following fields in the Supervisory Decision and Provider Acknowledgement box on the Provider Corrective Action Plan page in CLASS:

• Supervisory Decision Date;
• Supervisory Decision; and
• Reason for Decision.

7421.3 Creating the Corrective Action Letter

August 2021

Procedure

CCR staff prepare a draft Corrective Action Letter (Form 2885), on the Provider Corrective Action Plan page in the CLASS.

In the letter, CCR staff specify:

1. the basis for the corrective action;
2. information about the corrective action;
3. the deficiencies cited during the inspections and investigations that are the basis for the corrective action; and
4. the conditions imposed to correct them.

The inspector does not enter the following conditions into the Provider Corrective Action Plan page because the CLASS system automatically includes them in Form 2885:

• That the operation must comply with all of the conditions in the corrective action plan and correct the minimum standards that were deficient;
• That the operation must post the enclosed probation notice in a prominent place near all public entrances of the operation (if a CPA is on probation, foster homes verified by the CPA do not have to post the notice); and
• That the operation must establish and maintain compliance with all CCR statutes, rules and minimum standards.

7422 Meeting with an Operation About a Corrective Action

September 2019

Licensing staff schedule a meeting, in person or via telephone, with the operation’s permit holder, designee, director or administrator to:

1. notify the operation about the probation;
2. explain the reasons for the probation;
3. discuss the conditions being imposed; and
4. answer any questions the operation’s staff may have.

The meeting must take place at least 15 days before the probation period is scheduled to begin, to ensure that the operation has opportunity to request an administrative review.

Texas Human Resources Code §42.071(c)
26 TAC §745.8609

Procedure

During the meeting, Licensing staff provide the operation a copy of the Corrective Action Letter. If the meeting is conducted by phone, the inspector ensures that the permit holder receives copy of the plan before the phone conference.

7422.1 Required Participants When Meeting with an Operation About a Corrective Action

September 2019

Procedure

The inspector and the inspector’s supervisor must attend when meeting with an operation to discuss a probation period.

Directors and program administrators participate in the meeting if circumstances exist to warrant their involvement.

7422.2 Topics Covered When Meeting with an Operation About a Corrective Action

September 2019

Procedure

During the meeting held with an operation to discuss a probation period, the inspector discusses:

1. the reason for the probation period, including the operation’s history of compliance with statutes, administrative rules, minimum standards and restrictions or conditions on the permit;
2. the conditions of probation that the operation must meet to comply with the action;
3. how Licensing follows up on the implementation of the action;
4. projected begin and end dates of the action; and
5. the possible consequences, including adverse action, if the correction is not made, the violation is repeated, and/or the conditions are not met.

26 TAC §§745.8631; 745.8639 and 745.8643

7422.3 Finalizing the Corrective Action Letter

September 2019

Procedure

At the end of a meeting held with an operation to discuss a probation period, the inspector gives the finalized Corrective Action Letter (CLASS Form 2885) to the operation’s representatives.

If more time is needed to finalize the letter, the inspector sends the final letter to the operation by certified and regular mail within five days after the meeting.

Licensing staff documents the date the Corrective Action Letter (CLASS Form 2885) was delivered or mailed to the operation in CLASS in the Acknowledgement Date field on the Provider Corrective Action Plan page.

7422.4 Documenting the Corrective Action Plan Meeting

March 2017

Procedure

The inspector documents the following, in CLASS, by selecting the Corrective/Adverse Action category when entering data in the Chronology:

• The meeting’s attendees;
• If conditions were amended as a result of the meeting; and
• Any technical assistance provided.

7423 Requesting or Waiving the Right to an Administrative Review of a Corrective Action

Revision 23-3; Effective Sept. 22, 2023

If an operation disagrees with the action or any of the conditions imposed as a part of the evaluation (imposed before Sept. 1, 2019) or probation, the operation may request an administrative review within 15 days of receiving the finalized Corrective Action Letter.

The operation waives the right to request an administrative review of the evaluation or probation if:

• The operation does not submit a request for an administrative review within the 15 days; or
• The operation waives the administrative review, in writing, within the 15 days.

See 5600 Administrative Reviews

7424 Starting a Corrective Action

Revision 23-3; Effective Sept. 22, 2023

A corrective action does not start until:

• the operation waives the right to an administrative review; or
• the person who conducted the administrative review upholds the corrective action.

If the operation waives the administrative review, in writing, before the 15 days to request the administrative review expire, Licensing may begin the action sooner the planned start date. 

Procedure

After the administrative review for the corrective action is waived or upheld, the inspector:

• enters the Actual Begin Date field on the Provider Corrective Action page in CLASS; and
• notifies the operation of the Actual Begin Date.

The Actual Begin Date cannot be earlier than the date the operation waives the right to administrative review or the date the administrative review is upheld. See 5616.11 Determining Whether a Request for an Administrative Review Meets the Due Date.

7425 Inspecting an Operation During a Corrective Action

September 2019

Procedure

During an evaluation (imposed before September 1, 2019) or probation, Licensing staff conduct a monitoring inspection at all of the following times, unless there is good cause not to inspect within these times (such as when Licensing is conducting an investigation):

• At least once within 21 days after the corrective action period begins; and
• At least once per month during the duration of the corrective action period.

If there is good cause not to inspect within these times, the inspector requests approval from the supervisor and documents the reason for the variation in a Chronology in CLASS.

During each monitoring inspection, the inspector:

1. Evaluates the operation’s compliance with:
   • the conditions imposed by the corrective action plan;
   • at least one subchapter associated with the minimum standards listed in the Basis for Corrective Action section of the Provider Corrective Action Plan page in CLASS; and
   • at least one additional subchapter of the minimum standards to ensure overall compliance with the minimum standards;
2. Documents that the corrective action conditions were evaluated during the inspection in the Narrative field on CLASS Form 2936; and
3. Completes all other tasks required during a monitoring inspection (See 4126 Monitoring Inspections).

If the operation is in violation of any condition or minimum standard, administrative rule, or statute associated with the action, the inspector:

1. cites the operation;
2. provides technical assistance in the area where the operation is deficient; and
3. reviews the conditions related to the deficiencies with the permit holder or designee at the time of the inspection.

Before the end of the corrective action, Licensing staff evaluate the operation’s compliance with the entire subchapter associated with each minimum standard listed in the Basis for Corrective Action section of the Provider Corrective Action Plan page in CLASS.

7426 Conducting Surveillance During Corrective Action

March 2017

An inspector or supervisor may determine that surveillance is necessary to evaluate whether a program or caregiver is complying with minimum standards or conditions outlined in the corrective action plan. Valid reasons for surveillance include, but are not limited to determining whether an operation is:

1. complying with transportation requirements;
2. providing adequate supervision during outdoor activities; or
3. providing care to more children than the permit allows.

Procedure

An inspector must receive supervisory approval to conduct surveillance. Upon receiving the necessary approval, the inspector may conduct surveillance at the location of the operation or at other locations where children in care are transported by the operation. The inspector should take photographs or video recordings, as necessary, during the course of the surveillance to support violations or a lack of violations. See 1400 State-Issued Equipment, Photographs, Video, Audio and Digital Files.

All decisions regarding surveillance and all information obtained from conducting surveillance must be documented as a Chronology in CLASS.

7427 Staffings During Corrective Action

September 2019

During corrective action, the Licensing inspector meets with the Licensing supervisor to review the operation’s compliance with minimum standards, administrative rules, and statutes, and the conditions of the corrective action. These meetings take place at least:

• twice if the corrective action is evaluation (imposed before September 1, 2019); and
• four times if the corrective action is probation.

Procedure

During each staffing, the Licensing inspector and supervisor:

• review the operation’s progress on the corrective action, including the operation’s overall compliance with the minimum standards, administrative rules, and statutes, and the conditions of the corrective action;
• discuss whether the corrective action plan and conditions remain appropriate, including whether additional inspections are needed or a more serious enforcement action would be more appropriate; and
• whether the corrective action has been successful.

Before ending a corrective action, the inspector must staff the decision with a supervisor and receive the supervisor’s approval to end the corrective action.

The staffing and any recommendations are documented as a Corrective/Adverse Action Chronology in CLASS.

26 TAC §745.8631

See 4152 Reviewing Restrictions, Conditions, Waivers, and Variances.

7428 Ending Corrective Action

September 2019

Licensing may not extend a corrective action, but may end a corrective action early with supervisory approval if the Licensing inspector determines:

• that the operation has reduced risk and come into and maintained compliance with minimum standards, administrative rules, and statutes; or
• the operation’s compliance does not improve and a more restrictive enforcement action is necessary.

See:

7427 Staffings During Corrective Action
7428.1 Ending a Corrective Action When Compliance Has Been Established
7428.2 Modifying or Ending a Corrective Action When Compliance Has Not Been Established
26 TAC §§745.8611(b) and 745.8643

7428.1 Ending a Corrective Action When Compliance Has Been Established

September 2019

Procedure

If the operation has come into and maintained compliance with minimum standards associated with the corrective action and all other minimum standards, administrative rules, and statutes, the inspector sends a letter on HHSC letterhead to the operation stating that:

• compliance with the minimum standard rules, the law, and conditions has been established;
• the corrective action period has ended; and
• compliance with the minimum standards, administrative rules, and statutes, and any restrictions or conditions on the permit must be maintained.

On the Provider Corrective Action Plan page in CLASS the inspector:

• selects the appropriate selection from the Result of Corrective Action drop-down menu; and
• enters the end date in the Actual End Date field.

Licensing staff follow this process whether the plan ends early or on time.

See 7427 Staffings During Corrective Action

7428.2 Modifying or Ending a Corrective Action When Compliance Has Not Been Established

September 2019

Procedure

During the course of the corrective action, if the operation’s compliance with minimum standards, administrative rules, the law, and conditions of the corrective action plan have NOT improved sufficiently to reduce risk at the operation, Licensing staff:

1. reevaluates the plan to determine the appropriateness of the terms and conditions and:
   • recommends an amendment to the conditions and/or increased inspections if the term of the corrective action is not expiring within the next 45 days; or
   • imposes a more restrictive enforcement action, including adverse action; and
2. notifies the operation, in writing, that compliance has not been met and Licensing is proceeding with the decided upon action.

If ending the plan, the inspector also completes the following fields on the Provider Corrective Action Plan page in CLASS as shown below. The inspector:

• selects the appropriate selection from the Result of Corrective Action drop-down menu; and
• enters the end date in the Actual End Date field.

See 7427 Staffings During Corrective Action

7428.3 Following Up After Ending a Corrective Action

September 2019

Procedure

Within six months of the date a corrective action ends, the inspector conducts a monitoring inspection to ensure the operation is in compliance with minimum standards and rules.