Report 2007-114 Recommendation 1 Responses

Report 2007-114: Low-Level Radioactive Waste: The State Has Limited Information That Hampers Its Ability to Assess the Need for a Disposal Facility and Must Improve Its Oversight to Better Protect the Public (Release Date: June 2008)

Recommendation #1 To: Public Health, Department of

To ensure that the branch uses sufficiently reliable data from its future data system to manage its inspection workload, the department should develop and maintain adequate documentation related to data storage, retrieval, and maintenance.

Agency Response*

RHB has implemented the following systems to store, retrieve, & maintain reliable data that enable RHB to manage the inspection workload: Certification/Registration- Health Application Licensing (HAL). RHB has implemented several procedures to minimize data integrity issues with HAL. First, CSA had discovered that records appeared to be in open status but were actually no longer eligible for renewal. All X-ray Technician Limited Permits (prefix RHP) & all Supervisor & Operator Certificates/Permits with expiration dates prior to January 1, 2007 were administratively revoked in HAL. These records now reflect the following: Primary Status Code 9 & Renewal Process Code V. The status code "9V" indicates that the certificate/permit has been administratively revoked & not eligible for reinstatement. Secondly, in order to help ensure that HAL data is accurately reflected, HAL procedures were implemented to help ensure that HAL data was correctly & accurately input. For example, The Request for Information procedure formally puts into place a process for staff to change, delete or add data into HAL. The Staff Access procedure formally puts into place the process of allowing a staff member to access HAL with read/write privileges. Only properly trained & experienced staff are given these rights. Finally, the Change Request Procedure formally puts into place the process of requesting ITSD to perform a business operational programming change in HAL. The ICE X-ray section has also implemented two new procedures to ensure that inspections are performed within their allotted time. The MQSA procedure requires the CAMIS data base be cross checked against the FDA's data base. The inspection dates are verified & validated that they match. Also, the ICE X-ray internal access data base where inspection data is recorded & stored, such as the last inspection date, is cross checked against the HAL last inspection date to verify that they match.

  • Response Type†: Annual Follow Up
  • Completion Date: April 2015
  • Response Date: August 2015

California State Auditor's Assessment of Status: Resolved


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*

RHB has implemented the following systems to store, retrieve, and maintain reliable data that enable RHB to manage the inspection workload:

The RHB X-Ray Inspection, Compliance, and Enforcement (ICE) program instituted a method to crosscheck federal Mammography Quality Standards Act inspection due and overdue dates with the federal database maintained by the U.S. Food and Drug Administration. The first crosscheck of all dates is performed by the analyst who performs all data entry for ICE Inspection. This single point of entry minimizes the opportunity for error. The two reports are checked by the Senior Health Physicist who manages the routine contract management functions. In addition, X-Ray ICE tracks the non-mammographic state inspection workload information independently from the Health Applications Licensing (HAL) database and performs cross checks of the X-Ray inspection database with HAL data to identify missing or erroneous data.

  • Response Type†: Annual Follow Up
  • Completion Date: January 2011
  • Response Date: October 2013

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

The department asserts that it has developed controls to improve the quality of the data in its computer systems. However, the department did not provide evidence of this control actually being used in practice.

  • Auditee did not substantiate its claim of full implementation

Agency Response*

The California Department of Public Health (CDPH) agrees with the Bureau of State Audits; CDPH Radiologic Health Branch (RHB) will make functional system modifications to address data reliability and quality concerns with existing systems. CDPH has continued to take specific quality control steps on the existing data in the Health Application Licensing (HAL) system to identify and subsequently correct any anomalies. The status of RHB's implementation of this recommendation is noted below.

1) a. To assist in decisions on managing data reliability and quality

i. Completed; does not require status update.

ii. Completed; does not require status update.

iii. Completed; does not require status update.

iv. Change Request (CR) in progress include the following:

1. Implementing delinquent billing for licentiates

a. Completed April 2011

2. Implementing delinquent billing for nuclear medicine

a. Completed April 2011

3. Correcting fee cap issue on facility renewals

a. Corrected November 2010

4. Correcting association issues with specific license types

a. RHB has determined that the workload associated with correcting technologist association issues requires a review of approximately 19,000 hard copy files to determine what licensing database updates are needed. Therefore, RHB will submit a request for information to the CDPH Information Technology Services Division to determine a process to administratively inactivate technologists. The estimated date of completion is December 31, 2013.

5. Inactivating expired certificate records

a. RHB has submitted CRs to administratively inactivate certificate records for licentiates and limited permit technicians. The estimated date of completion is December 31, 2012.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: 2013
  • Response Date: September 2012

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


All Recommendations in 2007-114

†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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