Report 2014-111 Recommendation 6 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 #6 To: Public Health, Department of

To ensure that district offices address ERIs consistently and to ensure that they investigate ERIs in the most efficient manner, Public Health should use the information from its assessment to provide guidance to district offices by October 1, 2015, on best practices for consistent and efficient processing of ERIs.

Annual Follow-Up Agency Response From September 2016

On August 4, 2016, Public Health released updated policy and procedure 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 (ERIs). 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.

  • Completion Date: July 2016

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


1-Year Agency Response

CDPH undertook a quality improvement project to address the timeliness of complaint investigations; the same process is applicable to ERIs. Using a "plan, do, check, act" continuous quality improvement cycle, in September 2015 we implemented the revised process in selected district offices ("do" phase). In December 2015, we will review the effectiveness of the revised process and revise if needed and roll out to all the district offices ("check" and "act").

  • Completion Date: September 2015
  • Response Date: November 2015

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

The supporting document that Public Health provided focuses on improving timeliness of complaint investigations. Public Health has not yet provided documentation to support that it has issued guidance to district offices on best practices for consistent and efficient processing of ERIs.

  • Auditee did not substantiate its claim of full implementation

6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate investigation. L&C's Policy and Procedure for complaints was used as the basis of the study's criteria.

This review is currently conducted for LA County District offices. After April 2015, the review will expand to ensure all district offices are reviewed each quarter. Sample selection includes only completed and closed complaints and ERIs.

  • Estimated Completion Date: 10/31/2015
  • Response Date: June 2015

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


60-Day Agency Response

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.

  • Estimated Completion Date: 10/31/2015
  • Response Date: December 2014

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


All Recommendations in 2014-111

Agency responses received are posted verbatim.


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