Department of Early Education and Care - Finding 1

The Department of Early Education and Care Did Not Conduct Licensing Visits to Residential Programs Within Required Timeframes.

Overview

During the audit period, the Department of Early Education and Care (EEC) did not conduct licensing visits to residential programs within required timeframes. Specifically, EEC did not conduct these visits within required timeframes for 18 (45%) of the 40 residential programs in our sample, resulting in a compliance rate of only 55%. The breakdown of program visit exceptions are as follows:¹⁷

• Of these 18 residential programs, 10 (56%) had one late visit during the audit period.
• Of these 18 residential programs, 7 (39%) had only one of the two visits that were required during the audit period.
• Of these 18 residential programs, 1 (6%) had no visits during the audit period.

EEC cannot ensure that its residential programs operate within safe and healthy environments if it does not complete licensing visits within the required timeframes.

Authoritative Guidance

EEC’s Differential Licensing Residential Handbook states,

The year after the issuance of the [program’s or] provider’s first full two-year license, the [program or] provider will be eligible for a Monitoring Visit. The Monitoring Visit will be conducted annually approximately 12 months after the Full Licensing Review Visit, within a four-month window (two months before or after the date). . . .

Following a [program’s or] provider’s first Monitoring Visit, a Licensor will conduct an Enhanced Monitoring Visit. The Enhanced Monitoring Visit will be conducted approximately 12 months after the Monitoring Visit, within a four-month window (four months prior to the renewal date). . . .

Approximately 12 months after the Enhanced Monitoring Visit, within a four-month window (two months before or after the date), a [program or] provider will again be due for another Monitoring Visit. . . .

Following the second Monitoring Visit, the licensing cycle will restart for the [program or] provider. The next visit (approximately 12 months after the Monitoring Visit) will thus be a Full Licensing Review Visit, where all licensing regulations are inspected by a Licensor and the [program’s or] provider’s license may be renewed for another two years.

Reasons for Late/Missing Visits

EEC told us that the policies and annual due dates for residential licensing visits are self-imposed by the agency and are not required by federal or state law. EEC told us that it paused annual visits during the COVID-19 pandemic, up until June 15, 2021; however, EEC did not provide a reason why it did not follow its policies for residential licensing visits during the rest of the audit period.

Recommendations

1. EEC should conduct all licensing visits to residential programs within required timeframes.
2. EEC should follow its self-imposed policies for the timelines of residential licensing visits.

Auditee’s Response

EEC recognizes the importance of regular monitoring visits to residential programs. EEC applies the differential licensing lifecycle to residential programs. EEC’s Differential Licensing Residential Handbook (VII)(b) states that:

The year after the issuance of the provider’s first full two-year license, the provider will be eligible for a Monitoring Visit. The Monitoring Visit will be conducted annually approximately 12 months after the Full Licensing Review Visit, within a four-month window (two months before or after the date).

EEC tracks these deadlines in the Licensing Education Analytic Database (LEAD) system, which automatically generates an internal “deadline” for annual monitoring visits. This date is an internal benchmark and is not dictated by any statute or regulation. In practice, residential program visits are regularly conducted by EEC staff for many reasons including, but not limited to, a new license application site visit, a new program site visit where existing programs already exist, a license renewal, an investigation, focused monitoring, or technical assistance. These visits are tracked separately in the LEAD system and are not automatically marked as satisfying the “licensing visit” deadline.

Prior to the COVID-19 pandemic, annual monitoring visits were conducted by EEC at residential programs. During the audit period, annual visits were suspended or delayed due to the COVID-19 State of Emergency declared by then-Governor Baker from March 10, 2020, through June 15, 2021. After that time, annual visits resumed and were brought back into alignment with the differential licensing lifecycle. Annual visits are currently being conducted in accordance with EEC’s Differential Licensing Residential Handbook.

Auditor’s Reply

EEC states that the deadlines tracked in the Licensing Education Analytic Database (LEAD) system are internal benchmarks not dictated by statute or regulation. We believe EEC’s dismissal of its own policies as “internal benchmarks” is problematic. Agency policies are typically developed over a period of time, using a process that considers multiple elements, including, in this case, child safety. Disregarding these policies implies a disregard for the factors that led to their development. By failing to follow its established policies without any justification for overruling them, EEC is not fulfilling its oversight duties, which may have a negative impact on children in residential programs.

EEC states that various types of visits—such as new license application site visits, license renewals, investigations, focused monitoring, or technical assistance—are tracked separately and not automatically marked as satisfying the “licensing visit” deadline in LEAD. However, the purpose of this audit objective was to determine whether EEC conducted the required licensing visits within the established timeframes. The occurrence of other types of visits does not substitute for the mandated licensing visits, which are critical for comprehensive compliance assessments.

Regarding the suspension or delay of annual visits due to the COVID-19 state of emergency from March 10, 2020, through June 15, 2021, we understand that this period posed challenges. However, the majority of the audit period occurred after the state of emergency was lifted. Additionally, all of the exceptions occurred after the state of emergency ended, so EEC did not conduct all required licensing visits within the prescribed timeframes during the remainder of the audit period. EEC did not provide any reason for not following its policies for residential licensing visits after June 15, 2021.

17.    The percentages in the breakdown do not add to 100% due to rounding.

Date published:	November 25, 2024