Quality Management Branch Policy and Procedures for Compliance with Child Abuse Screening, Documenting and Reporting for Contractors Providers


Contractors/providers will be monitored to ensure compliance with screening for child abuse and reporting according to Chapter 261 of the Texas Family Code and the DSHS Child Abuse Screening, Documenting, and Reporting Policy for Contractors/Providers.

During site monitoring of contractors/providers by the Quality Management Branch the following procedures will be utilized to evaluate compliance.

1) The contractor's/provider's process used to ensure that staff are reporting according to Chapter 261 and the DSHS Child Abuse Screening, Documenting and Reporting Policy for Contractors/Providers will be reviewed as part of the Core Tool, Section I, B. Laws, Regulations, and Policies (Clinical), item # 2. To verify compliance with this item, monitors must review: a) that the contractor/provider adopted the DSHS Policy; b) the contractor's/provider's internal policy which details how the contractor/provider will determine, document and report instances of abuse, sexual or non-sexual for all clients who have never been married and are under the age of 17 in compliance with the Texas Family Code, Chapter 261 and the DSHS Policy; c) the contractor/provider followed their internal policy and the DSHS Policy; and d) the contractor/provider's documentation of staff training on child abuse reporting requirements and procedures.

2) All clinical/case management records of clients under 14 years of age who are pregnant or have a confirmed diagnosis of an STD acquired in a manner other than through perinatal transmission or transfusion will be reviewed for appropriate screening and reporting documentation as required in the clinic or site being visited during a site monitoring visit. The review of the records will involve reviewing that the Checklist for DSHS Monitoring was utilized; a report was made; and the report was made in the proper timeframes required by law. The records to be reviewed for compliance are only those for services provided. Results of the record reviews will be summarized on the Core Tool .

3) If during the record review process, noncompliance is identified, the staff person responsible will be notified and asked to make a report as required by law. The contractor/provider Director will be notified of the problem (or WIC Director for contractors that are WIC only contractors). Noncompliance will again be identified during the Exit Conference with the contractor/provider. One incidence constitutes noncompliance.

4) If it is found during routine record review of other records for services that a report should have been made as evidenced by the age of the client and evidence of sexual activity, the failure to appropriately screen and report will be identified as lack of compliance with the DSHS Policy; and the DSHS Quality Management Branch will identify the need for the contractor/provider to train staff. Failure to report will be brought to the attention of the staff person who should have made the report or the appropriate supervisor with a request to immediately report. This failure to report will also be discussed with the contractor/provider Director (or if a WIC only contractor, the WIC Director). Results of the record review will be summarized on the Core Tool.

5) The report sent to the contractor/provider will also indicate the number of records reviewed in each clinic that were found to be out of compliance. This report will be sent to the contractor/provider 4 to 6 weeks from the date of the review, which is the usual process for Site Monitoring Reports.

6) The contractor/provider will then be given 6 weeks to respond with written corrective actions to all findings. If the contractor/provider has other findings that warrant technical assistance, accelerated monitoring or probation, either regional or central office staff will make the necessary contacts. Records and/or policies will again be reviewed to ensure compliance with Chapter 261 and the DSHS Policy requirements. Only records created or amended since the last visit will be reviewed during subsequent monitoring. If any subsequent finding of noncompliance is identified during a subsequent monitoring or technical assistance visit, the contractor/provider will be referred for financial sanctioning.

7) If the contractor/provider does not provide corrective actions during the required time period, the contractor/provider will be sent a past due letter with a time period of 10 days to submit the corrective actions. If the corrective actions are not submitted during the time period given, failure to submit the corrective action is considered a subsequent finding of noncompliance and the contractor/provider will be referred for financial sanctioning due to noncompliance with Chapter 261 and the DSHS Policy.

8) If a contractor/provider is found to have minimal findings overall but did have findings of noncompliance with Chapter 261 and the DSHS Policy, an additional sanction (accelerated monitoring or probation) visit solely to review child abuse reporting will not be conducted. For agencies that receive technical assistance visits as a result of a quality assurance review, the agency will again be reviewed for compliance with child abuse reporting for the requirements with which the agency did not comply. In all cases, the corrective actions submitted by the contractor/provider will be reviewed to ensure that the issues have been addressed. Agencies who do not receive a sanction or technical assistance visit will be required to complete the DSHS Progress Report, Compliance with Child Abuse Reporting within 3 months after the corrective actions are begun (no later than 6 months from the initial visit). Failure to submit a Progress Report within the required time period or submission of a report that is not adequate, constitutes a subsequent finding of noncompliance with the DSHS Child Abuse Screening, Documenting, and Reporting Policy for Contractors/Providers and the contractor/provider will be referred for financial sanctions.

Last updated December 30, 2009