Current through Vol. 42, No. 1, September 16, 2024
(a)
Non-compliance documentation
. Licensing staff
clearly and concisely documents non-compliance areas on the monitoring
checklist and summary, including operator discussion.
(1) A plan of correction, including a
specific agreed-on time period for non-compliance correction is documented on
the monitoring summary. Each non-compliance or documentation indicates a plan
of correction will be submitted by the executive or program director. When a
previous non-compliance was not corrected by the agreed-on time period, the
non-compliance is documented again with a shorter plan of correction
date.
(2) Immediate correction is
required when the non-compliance directly impacts children's health, safety, or
well-being.
(3) Licensing staff
requests the operator's signature on the monitoring summary, explaining the
signature indicates acknowledgment of recorded information.
(4) When the operator or individual in charge
refuses to sign, the refusal is documented on the monitoring summary.
(5) The operator is provided a monitoring
summary copy.
(6) Timeframes for
filing a grievance regarding non-compliance with requirements are provided on
the monitoring summary. Refer to grievance procedures, per Oklahoma
Administrative Code (OAC)
340:110-1-54.
(b)
Referrals to fire and
health officials. When non-compliance regarding fire or health
requirements places children at risk of harm or remains uncorrected, Licensing
staff requests an inspection by a fire, health, or Oklahoma Department of
Environmental Quality official.
(c)
Repeated and serious non-compliance.
(1) Repeated non-compliance is three or more
documented incidents of non-compliance with the same requirement within the
last 12 months.
(2) Serious
non-compliance is non-compliance with Licensing requirements exposing children
to conditions presenting an imminent risk of harm based on the child's age, the
amount of time the program or agency was out of compliance, and the program or
agency efforts to mitigate the risk. Serious non-compliance is identified
through Licensing observations, and/or confirmed complaint investigations.
Failure to comply with licensing requirements that may be considered as serious
non-compliance include:
(A) when applicable,
staff-child ratio;
(B) child
supervision;
(C) infant sleep
environments;
(D) prohibited
disciplinary actions;
(E) licensed
capacity;
(F)
transportation;
(G) water
activities;
(H) pools and other
water hazards;
(I) multiple
hazards;
(J) weapons;
(K) failure to report child abuse or human
trafficking;
(L) knowingly
permitting access to children by individuals identified as restricted or
Restricted Registry registrants;
(M) failure to obtain background
investigations or Restricted Registry searches;
(N) medication administration;
(O) room temperatures;
(P) heat sources and/or loss of any utility
service;
(Q) cardio-pulmonary
resuscitation and first aid training; or
(R) required behavior management
training.
(d)
Case management responses to non-compliant facilities. One or more
responses in this subsection are used when there is repeated or serious
non-compliance.
(1)
Technical
assistance. Licensing staff offers technical assistance, including
referrals to consultants or professional development resources, assisting the
operator in meeting and maintaining Licensing requirements.
(2)
Follow-up phone call to the
program. Phone calls are documented on Form 07LC080E, Licensing Services
Supplemental Information, and a copy provided to the program.
(3)
Non-compliance letter. A
non-compliance letter may be written to the operator. Licensing staff provides
a monitoring summary copy with the non-compliance letter to the governing board
or owner, when applicable.
(4)
Return monitoring visit. A return monitoring visit may be
conducted when there is repeated or serious non-compliance with Licensing
requirements or when non-compliance places children at imminent risk of harm.
When the non-compliance is associated with a specific time of day, such as
understaffing after school or a lack of early morning supervision, the return
monitoring visit is conducted at the approximate time.
(5)
Use of witnesses. A witness
may accompany Licensing staff when the program had repeated or serious
non-compliance or considered for request for license denial or license
revocation. The witness may be an Oklahoma Department of Human Services
employee, a representative from the fire or health department, or law
enforcement. The witness signs the monitoring summary.
(6)
Increased monitoring visits.
Licensing staff may increase monitoring frequency plans when there was repeated
or serious non-compliance or when the need for additional technical assistance
is indicated.
(7)
Notice to
comply. Licensing staff provides the operator with Form 07LC037E, Notice
to Comply, and the operator documents the plan of correction. Immediate
correction may be required when the non-compliance places children's health,
safety, or well-being at risk.
(A) When the
plan submitted is unacceptable, Licensing staff negotiates a revised plan and
requests submission within 10-calendar days.
(B) When Form 07LC037E, Notice to Comply, is
not submitted within the specified time period, Licensing staff contacts the
operator and documents the conversation.
(C) When non-compliances continue to place
children at risk, Licensing staff provides a letter stating non-compliances
and/or continued failure to correct non-compliances may result in request for
license denial, license revocation, filing of an injunction, or issuance of an
Emergency Order.
(8)
Office conference. Licensing staff may schedule an office
conference with the program owner or operator. The programs manager is present
at the office conference. Program status, non-compliance areas, and progress
toward meeting the plan(s) of correction are reviewed and technical assistance
is offered. The office conference is documented on Form 07LC080E, Licensing
Services Supplemental Information and signed by Licensing staff, the operator,
and witnesses. This documentation includes a list of individuals present,
conference purpose, and re-verification of ownership documentation. Form
07LC037E, Notice to Comply, is completed when one addressing these issues was
not previously completed.
(9)
Consent agreement. Child Care Services (CCS) and the program owner
may enter into a consent agreement when the program owner agrees to specific
conditions in lieu of request for license denial or license revocation, per OAC
340:110-1-52.
(10)
Revocation or denial.
Licensing staff may recommend the request for license be denied or license
revoked when repeated or serious non-compliance with requirements was observed
and documented or the program failed to adequately protect children, per OAC
340:110-1-52.
(11)
Voluntary cease care. With
CCS State Office approval, the owner is asked to voluntarily cease caring for
children or child-placing activity. The programs manager is notified of every
situation involving a request for voluntary cease care or child-placing
activity.
(12)
Voluntary
closure. With CCS State Office approval, the owner is asked to
voluntarily close the program.
(e)
Case management responses when
children are at risk. When Licensing staff documents non-compliance with
requirements or is investigating a complaint that children may be at imminent
risk of harm, options to consider with the operator and the programs manager
are outlined in this subsection.
(1) The
operator is asked to immediately correct the non-compliance; such as, the
personnel will not be present or work alone with children at the program
pending the outcome of an investigation.
(2) With CCS State Office approval, the owner
is asked to voluntarily cease care until the non-compliance is corrected or the
investigation is complete.
(3) With
CCS State Office approval, the owner is asked to voluntarily close the
program.
(4) When immediate action
is needed to protect children, Licensing staff requests an Emergency Order, per
OAC 340:110-1.52.
(5) CCS and the
owner may enter into a consent agreement when the program owner agrees to
specific conditions in lieu of request for license denial or license
revocation, per OAC
340:110-1-52.
(6) Licensing staff may recommend the request
for license be denied or license be revoked when repeated or serious
non-compliance with requirements was observed and documented or the program
failed to adequately protect children, per OAC
340:110-1-52.
(7) An injunction may be requested when the
residential program or child-placing agency is:
(A) unlicensed;
(B) on request for license status;
(C) licensed;
(D) violating an Emergency Order;
(E) operating during an appeal following
request for license denial or license revocation and children are at risk of
harm; or
(F) violating the notice
to cease and desist care following request for license denial or license
revocation.
(f)
Notification to programs manager
when children are at risk. When during a monitoring visit Licensing
staff is concerned the children's health, safety, or well-being is at imminent
risk, the programs manager or CCS State Office staff is contacted
immediately.
(g)
Alternative
method of compliance. CCS may approve an alternative method of
compliance to a minimum Licensing requirement. An alternative method of
compliance may be authorized when Licensing determines the alternative method
of compliance offers equal protection of children's health, safety, or
well-being, meets the requirement's basic intent for the requested alternative
compliance, and does not violate statutory requirements.
(1) An applicant or licensee submits a
written request with supporting documentation on Form 07LC061E, Alternative
Compliance Request, to Licensing staff. A separate alternative method of
compliance request is submitted for each requirement identified.
(2) Licensing staff completes Form 07LC105E,
Alternative Compliance Referral, and submits all documentation to the statewide
licensing coordinator or designee.
(3) Approval of an alternative method of
compliance does not set a precedent, and is independently evaluated on the
merits of each request.
(4) The
program's compliance record is considered when determining approval.
(5) An alternative method of compliance is
not authorized for requirements affecting children's health and safety, such as
exceeding licensed capacity of a residential program, staff-child ratios, fire
safety, or behavior and guidance.
(6) Form 07LC075E, Notice of Alternative
Compliance, stating the nature of the exception, is posted with the
license.
Added at 20 Ok Reg 1274, eff 6-1-03; Amended at 22 Ok
Reg 1304, eff 6-1-05; Amended at 24 Ok Reg 1351, eff 7-1-07; Amended at 25 Ok
Reg 1962, eff 7-1-08; Amended at 26 Ok Reg 415, eff 11-20-08 (emergency);
Amended at 26 Ok Reg 2239, eff 7-1-09; Amended at 28 Ok Reg 1669, eff 7-1-11;
Amended at 29 Ok Reg 1229, eff 7-1-12; Amended at 30 Ok Reg 1385, eff
7-1-13
