Report 2014-111 Recommendation 3 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 #3 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 May 1, 2015, Public Health should establish a specific time frame for completing facility-related complaint investigations and ERI investigations and inform staff of the expectation that they will meet the time frame. Public Health should also require district offices to provide adequate, documented justification whenever they fail to meet this time frame.

Annual Follow-Up Agency Response From October 2020

The California Department of Public Health (CDPH) follows the complaint investigation timeframe established by Senate Bill 75, Statutes of 2015. Compliance with the requirement to complete all long-term care complaint investigations within 60 days of receipt can be monitored at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/FieldOperationsComplaints_ERIs.aspx.

CDPH is working hard to investigate all FRIs; however, we disagree with the recommendation to establish timelines for ERI investigations. CDPH is implementing strategies to eliminate backlogged complaints and ERIs with the goal of investigating and closing the backlogged cases by the end of 2021. Federal requirements on initiating and completing entity-reported incident investigations vary, based on facility type and how the intake is prioritized. CDPH continues to work on the timeliness of these investigations through enhanced monitoring of workload activities, public reporting of workload performance, and improved district office implementation.

In response to the open complaints against individuals, there are no state or federal requirements to complete investigations about certified individuals within specified timelines. The Professional Certification Branch (PCB) within the CDPH continues to closely monitor the investigations performance metrics. PCB has investigation policies and procedures and PCB posts their performance metrics on CDPH's website on a quarterly basis.

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

Annual Follow-Up Agency Response From November 2018

The California Department of Public Health (CDPH) follows the complaint investigation timeframe established by Senate Bill 75, Statutes of 2015. Compliance with the requirement to complete all long-term care complaint investigations and all long-term care entity-reported incidents within 90 days of receipt can be monitored at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/FieldOperationsComplaints_ERIs.aspx.

CDPH disagrees with the recommendation to establish licensure timelines for ERI investigations. Federal requirements on initiating and completing entity-reported incident investigations vary, based on facility type and how the intake is prioritized. CDPH continues to work on the timeliness of these investigations through enhanced monitoring of workload activities, public reporting of workload performance, and improved district office implementation.

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

We assessed the status of this recommendation as partially implemented because Public Health revised its complaint investigation policies and procedures to reflect the revised time frames specified in SB 75, statutes of 2015. However, SB 75 does not require such time frames for ERI investigations and Public Health does not agree with our recommendation to establish time frames for ERI investigations. Public Health's website shows that during fiscal year 2017-18, it completed 28 percent of ERI investigations within 90 days and 43 percent within 180 days. Its website also shows that of the 10,705 ERI investigations that were open during the quarter ending June 30, 2018, more than 6,000 ERI investigations had remained open for more than 180 days. As we state on page 32 of our report, we believe that Public Health's lack of accountability has contributed to its district offices' failure to complete investigations within reasonable time.

Annual Follow-Up Agency Response From December 2017

Public Health policies for complaint investigations aligned with Senate Bill 75, Statutes of 2015. As of July 2017, Public Health is 93% compliant with the requirement to complete all immediate jeopardy long-term care complaint investigations within 90 days of receipt (see https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/FieldOperationsComplaints_ERIs.aspx).

As part of process improvement and performance management efforts in this area, in August 2016, Public Health issued policy and procedure 100.3.75 regarding the requirements for complaint investigations and the formation of complaint teams (Complaint Team PP, attached). The complaint team at each district office comprises Health Facilities Evaluator Nurses who investigate complaint uninterrupted from start to finish.

As noted in our initial response Public Health CDPH disagrees with the recommendation to establish timelines for ERI investigations. CDPH continues to work on the timeliness of these investigations through enhanced monitoring of workload activities, public reporting of workload performance, and improved district office implementation.

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

We assessed this recommendation as partially implemented because Public Health said it disagrees with part of the recommendation regarding establishing timelines for ERI investigations. As we state on page 32 of our report, we believe that Public Health's lack of accountability has contributed to its district offices' failure to complete investigations within reasonable time.

Annual Follow-Up Agency Response From September 2016

Public Health 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. Public Health holds District Administration and District Managers monthly meetings to inform staff of the policies and procedures and expectation that they will meet the time frame.

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

Although Public Health has revised its policies and procedures to reflect the new timelines required by Senate Bill 75, Statutes of 2015, for facility-related complaint investigations, it did not provide documentation to demonstrate that it has established time frames for ERI investigations. When we followed-up, Public Health staff acknowledged that it has not established time frames for ERI investigations.

1-Year Agency Response

On June 24, 2015, SB 75 chaptered, which created complaint investigation completion timeframes that will be implemented on a phased in basis over the next few years. Specifically SB 75 requires:

- L&C to complete long-term care (LTC) IJ level complaint investigations that are received on or after July 1, 2016 within 90 days of receipt.

- All other LTC complaints received between July 1, 2017 and July 1, 2018, must be completed within 90 days of receipt.

- After July 1, 2018 complaint investigations must be completed within 60 days of receipt.

- These time periods may be extended up to an additional 60 days if the investigation cannot be completed due to extenuating circumstances.

- Any citation issued must be completed within 30 days of the investigation.

- CDPH to annually report data on department's compliance with the complaint investigation completion timelines beginning in 2018-2019.

- If CDPH does not meet the timeframes we must document the extenuating circumstances explaining why and provide written notice to the facility and the complainant, if any, of the basis for the extenuating circumstances and the anticipated completion date.

CDPH is revising its complaint investigation policies and procedures to reflect the revised timeframes. The revision will be published by the end of 2015.

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

We assessed the status of this recommendation as partially implemented because Public Health states that it is revising its complaint investigation policies and procedures to reflect the revised time frames specified in SB 75, statutes of 2015. Additionally, we followed up with Public Health to clarify why it indicated the status of this recommendation as "will not implement." Public Health indicated although SB 75 establishes time frames for completing investigations of complaints against facilities, ERIs were not part of SB 75 and Public Health does not plan to establish time frames for ERIs. As we state on page 32 of our report, we believe that Public Health's lack of accountability has contributed to its district offices' failure to complete investigations within reasonable time.

6-Month Agency Response

On May 8, 2015, CDPH posted district office-specific data to the stakeholder website page. CDPH Branch Chiefs use this district office-specific data with the district office managers to manage performance.

www.cdph.ca.gov/programs/Pages/CHCQPerformanceMetrics

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

Public Health does not provide any reason for why it will not implement our recommendation to establish a specific time frame for completing facility-related complaints and entity-reported incident (ERI) investigations. As we state on page 32 of the report, we believe that Public Health's lack of accountability has contributed to its district offices' failure to complete investigations within reasonable time. Public Health's response indicates that in May 2015 it posted district office-specific data to the website and that branch chiefs use this data with district office managers to manage performance. However, without first defining specific time frames that it considers to be timely, it is unclear how district office managers will manage performance and effectively ensure that staff promptly complete all investigations.

60-Day Agency Response

CDPH is committed to respond to facility-related complaints and ERIs in a timely manner. Rather than establish specific time frames for investigations at this point. CDPH has developed performance metrics that promote staff accountability without compromising the quality and the thoroughness of the work.

On November 7, 2014, CDPH posted on our website performance metrics on the volume, timeliness, and disposition of long-term care health facility complaint and ERI investigations for the first quarter of fiscal year 2014-2015.

By January 31, 2015, CDPH will provide district-specific data to the district offices to use as a management tool. CDPH will work with the district offices to monitor these performance metrics.

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

Public Health fails to provide any reason for why it does not agree with our recommendation to establish a specific time frame for completing facility-related complaints and entity-reported incident (ERI) investigations. As we state on page 32 of the report, we believe that Public Health's lack of accountability has contributed to its district offices' failure to complete investigations within reasonable time. Public Health states that it will provide data, including data on timeliness, to its district offices as a management tool. However, without first defining what it considers to be timely, the steps that Public Health outlines will be ineffective in ensuring that district offices promptly complete all investigations.

All Recommendations in 2014-111

Agency responses received are posted verbatim.