Report 2006-106 Recommendation 1 Responses

Report 2006-106: Department of Health Services: Its Licensing and Certification Division Is Struggling to Meet State and Federal Oversight Requirements for Skilled Nursing Facilities (Release Date: April 2007)

Recommendation #1 To: Health Services, Department of

To ensure that district offices consistently investigate complaints and include all relevant documentation in the complaint files, Health Services should clarify its policies and procedures, provide training as necessary, and periodically monitor district office performance to ensure compliance. At a minimum, Health Services should clarify its 45 working-day policy for closing complaints by establishing target timeframes for facility evaluators, supervisors, and support staff to complete key stages in the complaint process.

Annual Follow-Up Agency Response From December 2012

"As stated in previous correspondence to BSA, CDPH disagrees with the recommendation to ensure that district offices consistently investigate complaints and include all relevant documentation in the complaint files, Health Services should clarify its policies and procedures, provide training as necessary, and periodically monitor district office performance to ensure compliance. At a minimum, Health Services should clarify its 45 working day policy for closing complaints by establishing target timeframes for facility evaluators, and support staff to complete key stages in the complaint process. Specifically, CDPH disagrees with the recommendation to establish target timeframes to complete complaint investigations.

In 2009, the L&C complaint policy underwent revision to clarify and more clearly establish when a complaint was completed and when it should be closed. The new Policy and Procedure (P&P) considers a complaint closed when the supervisor has approved the findings and written a report of the investigation. This is the date L&C uses to notify the complainant within 10 days of the outcome of the investigation. Although the P&P no longer references closing a complaint within 45 days of receipt, L&C continues to work diligently to resolve these investigations as timely as possible and monitors closure rates."

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

After initially indicating that it had fully implemented our recommendation, CDPH changed its position In December 2012, stating that it would not establish target time frames for its staff to complete the incremental steps required to complete an investigation. We stand behind our recommendation. As we state on page 24 of the audit report, "Without timelines for individual steps in the complaint investigation process linked to the parties responsible for performing them, the department cannot be sure its objectives are being met and will have difficulty holding staff accountable for the timely completion of their work."


Annual Follow-Up Agency Response From September 2012

Effective May 1, 2012, the California Department of Public Health, Licensing and Certification Division (L&C), adopted a policy to align its complaint investigation process with the Centers for Medicare and Medicaid Services. L&C developed policies and procedures using the federal complaint investigation process and provided training to all staff including managers, supervisors, surveyors, and administrative support staff. During the training phase, all District Offices received directions and guidance on how to carry out the federal complaint investigation process and the timeframes for completing investigations. The federal complaint investigation process that L&C adopted sets the standard for all complaints to be investigated and closed within 60 days from when the investigation was initiated. L&C established a monitoring and evaluation system that ensures collective accountability among L&C staff from the field to headquarters in implementing the process and a more timely completion of the investigation.

  • Completion Date: September 2012

California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented


All Recommendations in 2006-106

Agency responses received after June 2013 are posted verbatim.


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