Report 2012-107 Recommendation 17 Responses

Report 2012-107: Developmental Centers: Poor-Quality Investigations, Outdated Policies, Leadership and Staffing Problems, and Untimely Licensing Reviews Put Residents at Risk (Release Date: July 2013)

Recommendation #17 To: Public Health, Department of

To ensure that investigations are conducted on a timely basis across priority levels, Public Health should develop and implement target time frames for the priority levels that lack them. Public Health should ensure that the timelines are being met and, if not, explore new ways to increase efficiency and manage its workload, thereby facilitating timely investigations.

Annual Follow-Up Agency Response From August 2016

Public Health has developed and implemented policies and procedures with targeted time frames to ensure investigations are conducted timely across priority levels that lack them.

Additionally, Public Health developed complaint teams at each Public Health District Office to ensure complaint time frames are being met, increase efficiencies, and manage complaint workload.

  • Completion Date: August 2016

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

Based on information it provided to us, Public Health has updated its policy and procedure manual and has demonstrated a high level of compliance in meeting those targets. Specifically, the department updated its Licensing and Certification Policy and Procedure manual to include target time frames for applicable priority levels that lacked them. Further, for fiscal year 2015-16, Public Health initiated 97 percent of both immediate jeopardy complaints and non-immediate jeopardy complaints within the target time frame of 24 hours and 10 days respectively. In addition, the metrics show that in the same time period, Public Health initiated 94 percent of immediate jeopardy self-reported incidents within the target time frame of 24 hours.

Further, the department established complaint teams to, among other things, ensure complaint time frames are being met. Complaint teams are established in district offices that fail to complete 95 percent of their investigations within the required time frames. The policies also state that complaint team supervisors are responsible for reviewing complaint files and triaging complaints in the tracking system. Moreover, Supervisors are required to conduct weekly group and individual meetings that discuss the status of all open complaints and the entire team's workload and updates to help manage complaint workloads.


Annual Follow-Up Agency Response From October 2015

CDPH disagrees that it should develop and implement target timeframes for the priority levels that lack them. The Centers for Medicare and Medicaid Services (CMS) provides prioritization guidance on these lower level complaints and facility reported incidents.

Per CMS, these include allegations which "may cause harm that is of limited consequences and does not significantly impair the individual's mental, physical, and/or psychosocial status or function." CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

An integral part of prioritizing complaints and facility-reported incidents is making a clinical judgment of their severity. CDPH nurse surveyors and supervisors, using assessment skills learned in federal and state training and survey experience, triage and prioritize complaints and facility-reported incidents based on the information gathered during the intake, their understanding of the potential impact to the client/resident, their knowledge of the facility, and the significance of the possible regulatory violation.

CDPH uses the CMS process and database to track complaints and facility-reported incidents. This database requires a target initiation date for each intake. Although CDPH and CMS policies do not have a prescribed target initiation date for some low priority levels, CDPH generally assigns an initiation date of 45 days. CMS conducts performance reviews of our investigations, which includes reviewing whether we initiated an investigation within the timeframe assigned during the intake. CDPH believes this process is sufficient to assign and monitor timelines

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


1-Year Agency Response

"CDPH disagrees that it should develop and implement target timeframes for the priority levels that lack them. The Centers for Medicare and Medicaid Services (CMS) provides prioritization guidance on these lower level complaints and facility reported incidents.

Per CMS, these include allegations which "may cause harm that is of limited consequences and does not significantly impair the individual's mental, physical, and/or psychosocial status or function." CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

An integral part of prioritizing complaints and facility-reported incidents is making a clinical judgment of their severity. CDPH nurse surveyors and supervisors, using assessment skills learned in federal and state training and survey experience, triage and prioritize complaints and facility-reported incidents based on the information gathered during the intake, their understanding of the potential impact to the client/resident, their knowledge of the facility, and the significance of the possible regulatory violation.

CDPH uses the CMS process and database to track complaints and facility-reported incidents. This database requires a target initiation date for each intake. Although CDPH and CMS policies do not have a prescribed target initiation date for some low priority levels, CDPH generally assigns an initiation date of 45 days. CMS conducts performance reviews of our investigations, which includes reviewing whether we initiated an investigation within the timeframe assigned during the intake. CDPH believes this process is sufficient to assign and monitor timelines."

  • Response Date: October 2014

California State Auditor's Assessment of 1-Year Status: Will Not Implement

Public Health correctly quotes a portion of the Centers for Medicare and Medicaid Services (CMS) guidance but neglects to address CMS guidance indicating that prevention is one of the objectives of the complaint and incident management system. As we discuss on page 66 of our audit report, federal guidance explains that the investigation of these events, even ones that are designated as less serious, is designed to identify and correct less serious issues to prevent them from becoming more serious problems. By not addressing lengthy delays in investigations—like some of the delays shown in Figure 7 on page 65 of our audit report—Public Health appears to be missing opportunities to prevent in a timely manner the potential escalation of problems within the developmental centers. In addition, although we understand that clinical judgment is essential in the process of prioritizing complaints and facility reported incidents, we do not believe that this specialized expertise negates the need for accountability within Public Health. Thus, we stand by our recommendation that Public Health establish target time frames across priority levels.


6-Month Agency Response

As stated in our 60-day response:

CDPH disagrees that it should develop and implement target timeframes for the priority levels that lack them. The Centers for Medicare and Medicaid Services (CMS) provides prioritization guidance on these lower level complaints and facility reported incidents.

Per CMS, these include allegations which may cause harm that is of limited consequences and does not significantly impair the individuals mental, physical, and/or psychosocial status or function. CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

An integral part of prioritizing complaints and facility-reported incidents is making a clinical judgment of their severity. CDPH nurse surveyors and supervisors, using assessment skills learned in federal and state training and survey experience, triage and prioritize complaints and facility-reported incidents based on the information gathered during the intake, their understanding of the potential impact to the client/resident, their knowledge of the facility, and the significance of the possible regulatory violation.

CDPH uses the CMS process and database to track complaints and facility-reported incidents. This database requires a target initiation date for each intake. Although CDPH and CMS policies do not have a prescribed target initiation date for some low priority levels, CDPH generally assigns an initiation date of 45 days. CMS conducts performance reviews of our investigations, which includes reviewing whether we initiated an investigation within the timeframe assigned during the intake. CDPH believes this process is sufficient to assign and monitor timelines.

  • Response Date: January 2014

California State Auditor's Assessment of 6-Month Status: Will Not Implement


60-Day Agency Response

CDPH disagrees that it should develop and implement target timeframes for the priority levels that lack them. The Centers for Medicare and Medicaid Services (CMS) provides prioritization guidance on these lower level complaints and facility reported incidents.

Per CMS, these include allegations which "may cause harm that is of limited consequences and does not significantly impair the individual's mental, physical, and/or psychosocial status or function." CDPH does have a policy to initiate immediate jeopardy complaints and facility reports within 24 hours and non-immediate jeopardy high complaints and facility reports within 10 days.

An integral part of prioritizing complaints and facility-reported incidents is making a clinical judgment of their severity. CDPH nurse surveyors and supervisors, using assessment skills learned in federal and state training and survey experience, triage and prioritize complaints and facility-reported incidents based on the information gathered during the intake, their understanding of the potential impact to the client/resident, their knowledge of the facility, and the significance of the possible regulatory violation.

CDPH uses the CMS process and database to track complaints and facility-reported incidents. This database requires a target initiation date for each intake. Although CDPH and CMS policies do not have a prescribed target initiation date for some low priority levels, CDPH generally assigns an initiation date of 45 days. CMS conducts performance reviews of our investigations, which includes reviewing whether we initiated an investigation within the timeframe assigned during the intake. CDPH believes this process is sufficient to assign and monitor timelines.

  • Response Date: August 2013

California State Auditor's Assessment of 60-Day Status: Will Not Implement

By not implementing our recommendation, CDPH does not have a clear measure to assess the timeliness of its reviews.


All Recommendations in 2012-107

Agency responses received are posted verbatim.


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