Report 2014-111 Recommendation 12 Responses

Report 2014-111: California Department of Public Health: It Has Not Effectively Managed Investigations of Complaints Related to Long-Term Health Care Facilities (Release Date: October 2014)

Recommendation #12 To: Public Health, Department of

To ensure that its district offices properly investigate complaints and ERIs, Public Health should make certain that all district offices follow procedures requiring supervisory review and approval of complaint and ERI investigations. If the district offices do not have a sufficient number of supervisors to review investigations they did not conduct, Public Health should arrange to assist the districts until such time that they do have a sufficient number of supervisors.

Annual Follow-Up Agency Response From September 2019

The previous method for monthly metrics was for districts to self-report its data on review and approval of complaints and Entity Reported Incidents (ERI) investigations. The current method is that each district submits its data to CHCQ. Staff analyze the metrics and notify the respective branch chief of the results. The branch chief discusses any deficiencies with the district manager and together they create an action plan for meeting the threshold.CHCQ's training section recorded and dispersed a training covering FRI/Complaints. All Health Facilities Evaluator Nurses (HFENs)were required to complete this training. CHCQ tracked the training through its training platform. The link for the training is as follows:

https://www.proprofs.com/training/course/?title=untitled-course_5c90035f66e0d_213638

To ensure procedural consistency, in January 2019 the CHCQ training unit presented at a District Administrator / District Manager meeting a PPT of data collected from January-September 2018 on state and federal complaint/incident survey review criteria. Any criterion that do not score an 85% compliance rate or greater have an associated action plan. CHCQ leadership approves an action plan and it, along with related findings, is sent to all district offices and branch chiefs. At the time of the April meeting, only one criterion was below the 85% threshold:

Federal Criteria 1: Was a sufficient sample chosen to evaluate the complaint/incident

Investigation mirroring the time and conditions of the incident: 72% of sample reviews met this criterion.

Action Plan: This component was addressed in the training and SEQIS is reviewing how the question regarding this data is worded to ensure we are getting an accurate response from the offices. All other criteria was met. Staff in CHCQ are monitoring the districts' compliance with all criteria and threshold levels, and reporting any deficiencies to the branch chief overseeing the respective district(s).

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

Public Health provided documentation showing that it is ensuring districts are requiring supervisory review and approval of its investigations, as we recommended. Specifically, it provided an example of a district's survey tool that, among other items, measures the frequency that a district's complaint and facility related incident (FRI) investigations have supervisory review and approval. The survey tool indicates that districts scoring less than 85 percent on any of its metrics must include an action plan to remedy issues identified. Public Health also provided an example of its summary metrics report, incorporating results for all of its district offices.

Annual Follow-Up Agency Response From November 2018

California Department of Public Health (CDPH) continues to work diligently to reduce the vacancy rate for Health Facilities Evaluator II (HFE II) Supervisors, who are important to the complaint and Entity Reported Incidents (ERI) (now called Facility Reported Incidents [FRI]) review process. As of September 30, 2018, 94 out of 102 HFE II positions were filled for a vacancy rate of 7.9%, as compared to September 2017 where 88 out of 103 HFE II positons were filled for a vacancy rate of 14.6%.

CDPH initiated a monthly review of complaints and FRIs for compliance with policies and procedure in July 2017. The protocol describes in detail the monthly reporting process. The summary report reflects the data obtained from district office surveys. A total of 896 complaints and/or FRI samples were reviewed from all district offices. The report captures information from July 2017 through March 2018; results for April, May and June 2018 are pending. Page three of the summary document shows 83% compliance with sending a supervisory peer-reviewed complaint/FRI. The second chart shows 68% compliance with sending one complaint/FRI for sample review. This number will increase proportionately, as the HFE II supervisor vacancy rate decreases. The data collected in this project was presented to district office management and CHCQ leadership groups on June 20, 2018.

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

Public Health provided documentation showing that it has a process for reviewing the investigations of complaints and FRIs completed by district offices, and that it has generally made progress in hiring additional supervisors for its district offices. Public Health's response and the documentation provided shows that not all districts have met Public Health's internal goal of supervisors reviewing a minimum of 85 percent of district office investigations. In follow up discussion regarding its response, Public Health indicated that branch chiefs and other staff meet with district offices that are not meeting this goal, and that they create an action plan to assist the district get back to at least the minimum goal. However, Public Health did not provide documentation of those action plans.

Annual Follow-Up Agency Response From December 2017

Public Health redirects resources to district offices that demonstrate a need for support and an ability to hire health facilities evaluator supervisors. Public Health continues to reinforce the supervisor's role in reviewing and approving investigation findings. A standardized report template specifically identifies all complaint types and volume and allows each branch chief to discuss workload priorities and policy and procedure compliance to ensure supervisors are available to review and approve the documents. District offices have multiple supervisors to provide review of complaints and ERIs. The supervisor position vacancies are declining; as of September 30, 2017, 16 of 110 positions are vacant (15% vacancy rate); the functional vacancy rate is approximately one supervisor vacancy per district office. Public Health collaborated with the Human Resources Branch to increase the frequency of the supervisor's eligibility exam processing so that Public Health can quickly promote eligible candidates who are ready for a supervisor position. The exams dates are listed on the department's website.

Public Health continues to conduct periodic reviews of ERIs and complaints for quality and adherence to policy. In September and November 2016, the Quality Improvement (QI) team conducted the Abbreviated Survey Review project. We selected 19 abbreviated surveys for review, and found all 19 to comply with state and federal case closure requirements.

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

Public Health has not made certain that all district offices follow procedures requiring supervisory review and approval of complaint and ERI investigations. Although Public Health's response states that it continues to conduct periodic reviews, it only demonstrated reviews of compliance in the fall of 2016. Further, based on the documentation provided from those compliance reviews, Public Health reviewed only one sample at each district and therefore we do not believe this is a sufficient review for the basis of its conclusion that it has fully implemented this recommendation to make certain that district offices follow procedures requiring supervisory review and approval of complaint and ERI investigations.

Annual Follow-Up Agency Response From November 2016

Public Health has filled most of the Health Facilities Evaluator Nurse supervisor positions. District offices are 81% staffed and recruiting and hiring is ongoing.

On August 4, 2016, Public Health released updated policy and procedures for the Abbreviated Standard Survey (federal complaint process) in Skilled Nursing/Nursing Facilities. These policy and procedures provide specific guidance to all district offices on timelines, investigation, documentation, and completion using best practices for consistent and efficient processing of entity-reported incident. These policies include quality measures for continuing monitoring and evaluating performance according to these policy and procedure.

Licensing and Certification's district office supervisors received training on these updated policy and procedures between January-July 2016.

This topic was also discussed at an all-state District Administrator/District Manager meeting in August 2016, which reinforced the role of the supervisor in triage and review of prioritization as well as the quality of the process for timely completion.

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

1-Year Agency Response

CDPH continues to remind supervisors of their review obligations, most recently in the District Administrator/District Manager Academy in August 2015. We are developing a sign-off sheet to document supervisory review as part of the complaint investigation documentation. By January 31, 2016, we will prepare a District Office Memo communicating this new procedure.

The 2015-16 Budget Act increased CDPH's funding for 240 positions and $14.85 million for LA County to conduct L&C work. The new positions included 24 new supervisors. CDPH has scheduled new supervisor academies for January, March, and June 2016 for the newly hired supervisors to assist with their orientation and staff development.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate prioritization level, timely onsite visit, and investigations. These reviews are currently conducted for LA County District offices. After April 2015, the review will expand to the other district offices ensuring all district offices are reviewed each quarter.

The Governor's 2015-16 Budget, updated at the May Revision, includes a request for funding for 237 state positions, including 24 new supervisors, to conduct L&C state and federal work.

In addition, CDPH is developing and implementing plans to assist district offices that have vacancies of supervisors by redirecting work to neighboring offices.

California State Auditor's Assessment of 6-Month Status: Pending

Public Health has not yet provided documentation of the actions noted in its response.

60-Day Agency Response

On October 28, 2014, CDPH issued a reminder to all district office managers during the face-to-face District Administrator/District Manager meeting about the importance to investigate properly complaints and ERIs. Additionally, it included a web link to the most current complaint policies and procedures, which include supervisory review.

CDPH has developed criteria for reviewing complaint and ERI prioritization and quality of investigations. Beginning May 2014, CDPH has used these criteria to conduct monthly reviews of a sample of complaint and ERI investigations in LA County. CDPH prepares a quarterly report of these reviews. These reviews will continue in LA County until April 2015.

By April 2015, CDPH will add criteria for reviewing plans of correction and supervisory review to the LA County monthly reviews. By October 2015, CDPH will use the criteria to monthly review a sample of the investigations in district offices statewide.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2014-111

Agency responses received are posted verbatim.