Report 2007-040 Recommendation 5 Responses

Report 2007-040: Department of Public Health: Laboratory Field Services' Lack of Clinical Laboratory Oversight Places the Public at Risk (Release Date: September 2008)

Recommendation #5 To: Public Health, Department of

This recommendation has been superseded by a recommendation from a subsequent report. See 2015-507 #4.

To strengthen its complaints process, Laboratory Services should identify necessary controls and incorporate them into its complaints policies. The necessary controls include, but are not limited to, receiving, logging, tracking, and prioritizing complaints, as well as ensuring that substantiated allegations are corrected. In addition, Laboratory Services should develop and implement corresponding procedures for each control. Further, Laboratory Services should establish procedures to ensure that it promptly forwards complaints for which it lacks jurisdiction to the entity having jurisdiction.

Agency Response*

Laboratory Field Services (LFS) revised its complaint policies and procedures; increased staffing dedicated to focusing on complaints by three full-time staff, and enhanced its complaint database. Changes made to the complaint database include documenting the rationale for not investigating a complaint, and when to perform follow-up investigations to verify corrective action has been completed. In addition, the database now has a reporting function that provides "due dates" of complaint investigations, which staff review to ensure that the appropriate timeframes are being met.

LFS staff was trained on the new complaint policy and procedures on August 18, 2016.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: June 2018
  • Response Date: September 2016

California State Auditor's Assessment of Status: See 2015-507 #4 for the most current assessment


Agency Response*

The status of this recommendation is unchanged.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: 9/2015
  • Response Date: October 2014

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

In March 2009, Laboratory Field Services (LFS) developed a master complaint register that tracks the following for each complaint: the facility or professional identified by the complaint, the sequential case number, date opened, date closed, acuity/priority, acknowledgement of receipt, disposition (letter to facility/professional, referral to outside agency or internal section). LFS uses the complaint register to track complaint investigation or referral to the appropriate agency.

LFS has developed policies and procedures for receiving, processing, and following up on complaints.

Full implementation of these policies and procedures is pending sufficient staffing. LFS continues to identify new Examiner candidates and recruit to fill the remaining 11 vacant Examiner positions. Because Examiner salaries are 30-50 percent lower than those for comparable positions in the private sector, LFS continues to work with CDPH Human Resources Branch to implement a recruitment and retention bonus by fall 2014. LFS is also working with CalHR to remove the requirement for supervisory experience for entry level Examiners to allow more scientists to qualify for the Examiner series. We anticipate completion of this change by June 30, 2015.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: June 30, 2015
  • Response Date: October 2013

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

In March 2009, LFS developed a master complaint register that tracks the following for each complaint: the facility or professional identified by the complaint, the sequential case number, date opened, date closed, acuity/priority, acknowledgement of receipt, disposition (letter to facility/professional, referral to outside agency or internal section). LFS uses the complaint register to track complaint investigation or referral to the appropriate agency.

LFS has developed policies and procedures for receiving, processing, and following up on complaints (attached).

In March 2009, LFS developed a master complaint register that tracks the following for each complaint: the facility or professional identified by the complaint, the sequential case number, date opened, date closed, acuity/priority, acknowledgement of receipt, disposition (letter to facility/professional, referral to outside agency or internal section). LFS uses the complaint register to track complaint investigation or referral to the appropriate agency.

LFS has developed policies and procedures for receiving, processing, and following up on complaints (attached).

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: June 2015
  • Response Date: October 2012

California State Auditor's Assessment of Status: Not Fully Implemented


All Recommendations in 2007-040

†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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