Report 2014-111 Recommendation 2 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 #2 To: Public Health, Department of

To protect the health, safety, and well-being of residents in long-term health care facilities, Public Health should improve its oversight of complaint processing. Specifically, by January 1, 2015, Public Health should improve the accuracy of information in the spreadsheet that PCB uses to track the status of complaints against individuals and review the reports of open complaints to ensure that all complaints are addressed promptly.

Annual Follow-Up Agency Response From September 2016

The Professional Certification Branch (PCB) modified the data collection process to improve tracking of timeliness of open investigations and continues to use the data to monitor timeliness of open investigations. PCB also upgraded an entry-level position to an analytical position to analyze the data entered and retrieved from the spreadsheet and to reconcile data from the spreadsheet with the database and reports. This analyst is distinct from staff that enters the data. In addition, the number of people authorized to enter data was reduced; training regarding the relationship of data to produced reports and database and need for accuracy was provided; a full journey level analyst was hired to provide administrative assistance and the Intake Manager now provides oversight of data contained on spreadsheet and randomly audits entries monthly to promote accuracy. Furthermore, reports were created to better monitor aging and quarterly reports are published on internet to identify volume, timeliness, and existing workload. Public Health to provide documentation to substantiate that this is fully implemented.

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

1-Year Agency Response

PCB modified data collection process to improve tracking of timeliness of open investigations and continues to use the data to monitor timeliness of open investigations. PCB modified data collection by adding columns in the spreadsheet to include: Appeal, Drop Down Menu allows a Yes or No response to indicate an appeal was received from subject of the complaint, Appeal Status, Depicts final status of appeal and whether proposed decision was altered by Dept. (Altered, Denied, Granted, Settled, or Withdrawn), Final Decision Outcome, Reflects outcome (action) listed in Final Decision issued by Dept. following the hearing, Final Decision Date, Identifies the date of the Final Decision issued by Dept. following the hearing, Type of Finding (A/N/M, 1AN, 2AM, 3NM, 4ANM). For those investigations that result in a Finding being included on the State Nurse Aide Registry, this field identifies type of finding (abuse [A], neglect [N], misappropriation [M], or a combination of findings). Columns were added to identify type of finding included on the State Nurse Aide Registry and information related to the receipt and outcome of a request for an appeal. PCB upgraded an entry-level position to an analytical position to analyze the data entered and retrieved from the spreadsheet and to reconcile data from the spreadsheet with the database and reports. This analyst is distinct from staff that enters the data. In addition, the number of people authorized to enter data was reduced; training regarding the relationship of data to produced reports and database and need for accuracy was provided; full journey level analyst was hired to provide administrative assistance and the Intake Manager now provides oversight of data contained on spreadsheet and randomly audits entries monthly to promote accuracy. Furthermore, reports were created to better monitor aging and quarterly reports are published on internet to identify volume, timeliness, and existing workload.

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

Public Health did not provide documentation to substantiate its claim that the recommendation is fully implemented. Specifically, it did not provide any documentation to demonstrate that it provided training to staff to emphasize the need for accuracy of the data. Public Health also did not provide documentation to demonstrate its claim that the intake manager now provides oversight of data contained in its tracking spreadsheet and randomly audits entries monthly to promote accuracy.

6-Month Agency Response

PCB modified its data collection process to improve tracking & monitoring of the timeliness of open

investigations.

PCB modified the data collection by adding additional columns in the spreadsheet to include:

- Appeal

o Drop Down Menu allows a Yes or No response to indicate an appeal was received from the subject of the complaint

- Appeal Status

o Depicts the final status of the appeal & whether the proposed decision was altered by the Department (Alternated, Denied, Granted, Settled, or Withdrawn)

- Final Decision Outcome

o Reflects outcome (action) listed in Final Decision issued by the Department following the hearing

- Final Decision Date

o Identifies the date of the Final Decision issued by the Department following the hearing

- Type of Finding (A/N/M, 1AN, 2AM, 3NM, 4ANM)

o For those investigations that result in a Finding being included on the State Nurse Aide

Registry, this field identifies the type of finding (abuse [A] neglect [N] misappropriation [M] or a combination of findings)

Columns were added to identify the type of finding included on the State Nurse Aide Registry & information related to the receipt & outcome of a request for an appeal. PCB upgraded an entry level position to an analytical position to perform an analysis of the data entered & retrieved from the spreadsheet & to reconcile the data from the spreadsheet with the information found in the database & reports. In addition, the number of people authorized to enter data was reduced; training regarding the relationship of the data to the produced reports & database & need for accuracy was provided; the full journey level analyst hired to provide administrative assistance & the Intake Manager provide oversight of the data contained on the spreadsheet & randomly audit entries on a monthly to promote accuracy. Furthermore, reports were created to better monitor aging & quarterly reports are published on the internet to identify volume timeliness & existing workload.

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

Health Care Services' PCB indicated it has modified its process for tracking and monitoring data for its open investigations and creates reports of aging complaints. These reports are published on its website. However, Health Care Services has not yet provided documentation to support that it has improved the accuracy of its tracking spreadsheet.

60-Day Agency Response

PCB has modified its data collection process to improve tracking of the timeliness of the open investigations. Additionally, PCB clearly defined the data elements that are collected and recorded in the tracking spreadsheet and restricted edit permissions. On August 26, September 19, and November 13, 2014, PCB issued emails to all Investigations Section staff to with instructions for improving and monitoring monthly the accuracy of the data in the master spreadsheet.

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

All Recommendations in 2014-111

Agency responses received are posted verbatim.