Report 2006-106 All Recommendation 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.

Agency Response*

"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."

  • Response Type†: Annual Follow Up
  • Response Date: December 2012

California State Auditor's Assessment of 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."


Agency Response*

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.

  • Response Type†: Annual Follow Up
  • Completion Date: September 2012
  • Response Date: September 2012

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #2 To: Health Services, Department of

To fill its authorized positions and manage its federal and state workloads, Health Services should consider working with the Department of Personnel Administration to adjust the salaries of its staff to make them more competitive with those of other state agencies seeking similarly qualified candidates. In addition, Health Services may want to consider hiring qualified candidates who are not registered nurses.

Agency Response*

CDPH has partially implemented this recommendation. CDPH partially agrees with BSAs recommendation to fill its authorized positions and manage its federal and state workloads, Health Services should consider working with the Department of Personnel Administration to adjust the salaries of its staff to make them more competitive with those of other state agencies seeking similarly qualified candidates. CDPH disagrees that In addition, Health Services may want to consider hiring qualified candidates who are not registered nurses.

In cooperation with the California Department of Human Recourses (CalHR), CDPH finalizing revisions to the job specifications for nurse surveyors, supervisors, and managers. CalHR anticipates that the revision package will be heard by the State Personnel Board in early 2013. If approved, the revisions will align the salaries of the surveyors, supervisors, and managers and establish continuity and a promotion path that will lead to better retention of staff.

Nurse staff provides critical clinical expertise needed in the surveying process to ensure the health and safety of the residents in regulated health facilities. Therefore, CDPH disagrees with the BSA recommendation to consider hiring qualified candidates who are not registered nurses.

  • Response Type†: Annual Follow Up
  • Response Date: December 2012

California State Auditor's Assessment of Status: Fully Implemented

We have noted that CDPH has worked with CalHR and has considered, but declined, to hire candidates other than registered nurses. CDPH has addressed the intent of our recommenadtion, and we consider this issue to be closed.


Agency Response*

CDPH has partnered with the Department of Personnel Administration (DPA) on the Health Facilities Evaluator reclassification project that aligns the pay structure of surveyors, supervisors, and managers to make them more competitive with other state agencies seeking similarly qualified candidates. The project has aggressive timelines and is moving towards completion. CDPH and DPA completed review of the reclassification package, which involved extensive field interviews and data/salary analysis in preparation for State Personnel Board (SPB) action in fall 2012. In preparation for SPB's action, CDPH and DPA are reaching out to labor relations to affirm the proposed changes affecting the bargaining units. If SPB approves the project in its entirety, we anticipate implementing the realignment of the pay structure in spring 2013.

  • Response Type†: Annual Follow Up
  • Completion Date: September 2012
  • Response Date: September 2012

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #3 To: Health Services, Department of

To proactively manage its complaint workload following the conclusion of the court order, Health Services should periodically evaluate the timeliness with which district offices initiate and complete complaint investigations. Based on this information, Health Services should identify strategies, such as temporarily lending its staff to address workload imbalances occurring among district offices.

Agency Response*

CDPH has fully implemented corrective action.

CDPH agrees with BSAs recommendation to proactively manage its complaint workload, Health Services should periodically evaluate the timeliness with which District Offices initiate and complete complaint investigations. Based on this information, Health Services should identify strategies, such as temporarily lending its staff to address workload imbalances occurring among District Offices.

CDPH has and continues to routinely conduct quality improvement studies and monitors initiation and completion of complaint investigations. Also, CDPH continues to send out weekly alerts to district offices regarding long-term care complaints that are approaching the statutory timeframe for initiation. CDPH routinely re-deploys surveyor staff to other district offices to help complete mandated survey workload.

In addition to these activities, this year CDPH has participated in a complaint policy workgroup with the Centers for Medicare and Medicaid (CMS) Regional IX Office and the 14 states that compose the CMS Western Consortia of state survey agencies. This workgroup seeks to identify the challenges that face the state surveying agencies in CMS Regions VIII, IX, and X. The workgroup has compiled statistics, on complaint intake and completion of investigations and has identified complaint investigations best practices among the Western Consortia states. The workgroup has prepared a white paper that it will present to the CMS Survey and Certification Director on October 5, 2011 during the annual Association of Health Facility Survey Agency Conference in Seattle. In addition, CMS selected CDPH Licensing and Certification (L&C) to participate in a separate project commissioned by CMS to identify barriers to complaint investigations and identify recommendations to streamline and improve the complaint investigation process. The CMS Western Consortia will request that its white paper be reviewed and folded into the CMS complaint project for consideration.

CDPH management directed district office managers during its monthly call meeting (September 21, 2011) to implement a policy for closing state entity reported incidents that mirrors direction included in the CMS State Operations Manual (SOM) 5070. This policy provides that events occurring more than 12 months prior to the intake date may not require the State Agency to conduct an investigation and that an on-site survey may not be required if there is sufficient evidence that the facility does not have continued noncompliance and the alleged event occurred before the last standard survey. District Office Managers will use the SOM instructions to determine which incidents do not need on-site investigations and close these events. Those events that are received prior to a survey will be reviewed as part of the off-site survey preparation for any upcoming recertification survey and any substantiated findings will be documented as part of the recertification survey. (2011-041, pp. 51-52)

  • Response Type†: Annual Follow Up
  • Response Date: January 2012

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #4 To: Health Services, Department of

To ensure that it fully complies with state law regarding communication with complainants, Health Services should reassess its current practice of delaying notification to complainants about investigation results until after it receives acceptable plans of correction from cited skilled nursing facilities. If Health Services continues to support this practice, it should seek authorization from the Legislature to adjust the timing of communications with complainants accordingly.

Agency Response*

Health Services has inserted additional guidance in its complaint investigation procedures to address our recommendation. Specifically, Health Services now requires its staff to notify complainants of the results of investigations within 10 days following the last day of the on-site inspection. Further, Health Services quality assurance process includes auditing complaint files to see if the letter was sent in a timely manner and included in the hard copy file. (2008-406, p. 10)

  • Response Type†: 6-Month
  • Response Date: October 2007

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #5 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 ensure that each complaint file includes a workload report (timesheet), an investigation report, and copies of both letters sent to complainants.

Agency Response*

Health Services has addressed two of the four bulleted recommendations by instituting a quality assurance process for its complaint investigations. Specifically, Health Services quality assurance process includes peer reviews to ensure that complainants receive timely notification at the initiation and conclusion of investigations. Further, this process includes reviewing the quality of the investigations performed, such as ensuring that its staff properly investigate complaints and issue citations that are adequately supported by the evidence. (2009-406, p. 17)

  • Response Type†: 1-Year
  • Response Date: July 2008

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #6 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 that investigation reports should be signed and approved prior to notifying skilled nursing facilities about the results of investigations.

Agency Response*

Health Services has addressed two of the four bulleted recommendations by instituting a quality assurance process for its complaint investigations. Specifically, Health Services quality assurance process includes peer reviews to ensure that complainants receive timely notification at the initiation and conclusion of investigations. Further, this process includes reviewing the quality of the investigations performed, such as ensuring that its staff properly investigate complaints and issue citations that are adequately supported by the evidence. (2009-406, p. 17)

  • Response Type†: 1-Year
  • Response Date: July 2008

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #7 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 attempt to obtain mailing addresses from all complainants that do not wish to remain anonymous.

Agency Response*

Since the bureaus audit findings were released, License & Certification (L&C) has conducted 5 separate monitoring studies to ensure that offices are following established complaint Policies & Procedures (P&P). The studies do not specifically review if mailing addresses for complainants are secured. However, in Sept. 2008, L&C conducted state wide trainings for all surveyors on the complaint P&P. This training included elements of the bureaus audit report and staff were instructed to attempt to secure mailing address for individuals who did not wish to remain anonymous. These studies do review attempts made by L&C to contact the complainant prior to starting the investigation. (2010-041, p. 50)

  • Response Type†: Annual Follow Up
  • Response Date: January 2011

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #8 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 ensure that staff correctly and consistently prioritize complaints and categorize the deficient practices of skilled nursing facilities.

Agency Response*

Health Services new quality assurance program includes reviewing randomly selected complaint investigations to ensure, among other things, that complaints are appropriately prioritized and that complaint dispositions are appropriate. (2008-406, p. 12)

  • Response Type†: 6-Month
  • Response Date: October 2007

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #9 To: Health Services, Department of

To ensure that it can provide the public access to complete and accurate information regarding skilled nursing facilities as the Legislature intended, Health Services should continue in its efforts to implement an Internet-based inquiry system and take steps to ensure that the data it plans to provide through the system are accurate.

Agency Response*

Health Services reports that it launched the Health Facilities Consumer Information System (HFCIS) on January 23, 2008. Our review of this system confirmed that users are able to find a variety of information on skilled nursing facilities, including locations and owners; the number of units or beds; and summary information on complaints, state-enforcement actions, and survey deficiencies. (2009-406, p. 18)

  • Response Type†: 1-Year
  • Response Date: April 2008

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #10 To: Health Services, Department of

To improve the accuracy of complaint data used to monitor its workload and staff performance, Health Services should develop strong application controls to ensure that its data are accurate, complete, and consistent. This process should include validating the data entered into key data fields, ensuring that key data fields are complete, and training staff to ensure consistent input into key data fields, such as the field designed to capture the date on which the investigation was completed.

Agency Response*

Health Services reports that it has developed standard performance measures for each district office. One of the performance measures requires, on a quarterly basis, random checks by the support staff supervisor to ensure the accuracy of data input as well as complaint files. Our review of Health Services quality assurance program confirmed that it evaluates whether the information noted in the complaint file agrees with its data system. Finally, Health Services reports that it has begun a recurring training program where it reminds staff of data input and accuracy procedures. (2009-406, p. 19)

  • Response Type†: 1-Year
  • Response Date: April 2008

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #11 To: Health Services, Department of

To reduce the predictability of its federal recertification surveys, Health Services should institute a practice of conducting surveys throughout the survey cycle, ensuring that each facility has a greater probability of being selected at any given time.

Agency Response*

Licensing and Certification (L&C) has met this recommendation through conducting Quarterly District Manager meetings to discuss both workload activities and the need to maintain an unpredictable survey schedule. Our unpredictable presence in skilled nursing facilities is enhanced by conducting off-hour surveys and through increased state licensing survey activities. (2010-041, p. 51)

  • Response Type†: Annual Follow Up
  • Response Date: January 2011

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #12 To: Health Services, Department of

To ensure that it can adequately justify the expenses it charges to the citation account, Health Services should take steps to gain assurance from temporary management companies that the funds they received were necessary. This should include reviewing the support behind temporary management companies e-mails requesting payments. In addition, Health Services should take steps to expand its pool of qualified temporary management companies to ensure that it has sufficient numbers of temporary management companies available and receives competitive prices. Finally, when Health Services charges general support items to the citation account, it should be able to document its rationale for determining the amounts charged.

Agency Response*

The Licensing and Certification (L&C) program implemented the recommendation through establishing and executing the attached procedures (Attachment 5, Procedures for Citation Penalty Accounts Expenditure Verification). These measures have ensured that general support items do not erroneously charge to the citation penalty account. L&C Administration Branch developed and disseminated Attachment 5 to L&C Administration staff to ensure proper documentation of charges against the citation penalty account per the bureaus recommendation. (2010-041, p. 52)

  • Response Type†: Annual Follow Up
  • Response Date: January 2011

California State Auditor's Assessment of Status: Fully Implemented


Recommendation #13 To: Health Services, Department of

Health Services should develop additional strategies, such as temporarily reallocating its staff from district offices that are less burdened by their workloads to those facing the highest workloads.

Agency Response*

Health Services reports that it has received a preliminary report on the employee classification study from its contractor, Cooperative Personnel Services. Health Services has reviewed this report and expects to submit its proposals to DPA in August 2008. In addition, Health Services reports that it has renegotiated, but not yet executed, a new contract with Los Angeles County. Health Services asserts that a provision of this new contract allows for the contractors staff to perform work outside of the county upon a written request from Health Services. (2009-406, p. 21)

  • Response Type†: 1-Year
  • Response Date: July 2008

California State Auditor's Assessment of Status: Fully Implemented

Subsequent to the original publication of this response, the state auditor considered this recommendation to be fully implemented.


All Recommendations in 2006-106

Response Type refers to the interval in which the auditee is providing the State Auditor with their status in implementing recommendations made in an audit report. Auditees must submit a response regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year or subsequent to one year.

*Agency responses received after June 2013 are posted verbatim.


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