Report 2014-111 Recommendation 8 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 #8 To: Public Health, Department of

To protect the residents in long-term health care facilities from potential harm, Public Health should ensure that its district offices have adequate staffing levels for its licensing and certification responsibilities, including staffing levels that allow prompt investigations of complaints. Specifically, Public Health should continue working with CalHR to complete the reclassification of district offices' investigator supervisor and manager positions and then quickly fill the vacant positions at district offices.

Annual Follow-Up Agency Response From October 2020

1. The 2020-21 Budget Act added 115.6 positions to be phased in over three years; 20 positions will be phased in over fiscal year 2020-21, 40 will be phased in over fiscal year 2021-22, and the final 55.6 will be phased in during fiscal year 2022-23. The additional staffing will:

- Improve processing times of complaint and FRI investigations;

- Improve responsiveness to long-term care complaints;

- Complete mandated workload efficiently, including licensure workload for changes of service and change of location etc.

2. By October 2019, the Center for Health Care Quality had recruited and filled a number of vacant Health Facility Evaluator Nurse (HFEN) positions, which reduced the vacancy rate to 2.9%. CDPH was authorized an additional 75 surveyor positions, which increased the vacancy rate to 6.9% and we are working to fill those positions now. The new positions will fulfill the need for staff at district offices.

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

Annual Follow-Up Agency Response From September 2019

The Health Facilities Evaluator Nurse (HFEN) applications have increased in general throughout the state and HFEN vacancy rates have fallen in all areas of the state in general. However, the San Francisco Bay Area has proven to be the most challenging in meeting program goals due to the highly competitive labor market for nurses in the economic region. The San Francisco Bay Area's HFEN vacancy rates in June were as follows:

East Bay: 30% (18/60 PYs)

San Francisco: 17% (6/35 PYs)

Santa Rosa: 22% (9/41 PYs)

In addition, supervisor vacancies as of June were as follows:

East Bay: 22% (7/9 PYs)

San Francisco: 83% (1/6 PYs)

Santa Rosa: 14% (6/7 PYs)

The Center for Health Care Quality (CHCQ) is contracting with a consultant who will develop strategies for improving hiring practices in high-vacancy districts, such as the San Francisco Bay Area, and CHCQ has been investing significantly into recruiting in the Bay Area. Currently 60 percent of the web traffic to the predominant recruiting website (www.CDPHnurse.org) originates from the Bay Area. CHCQ continues to expand outreach efforts in the Bay Area and refine messaging to increase numbers of applications and improve conversion rates. To ensure that workloads are addressed, CHCQ has offset the vacancies through several methods: 1. Borrowing surveyors from other districts, 2. Increasing the classifications we hire as surveyors, including vocational nurses and AGPAs, as we have determined surveyors do not need to be an RN. Public Health hopes to expand the workforce and free up registered nurses to do more work at their level, such as investigative work requiring RN-level of care. Public Health is working with the Department of Health Care Services to merge duty statements for nurses and supervisors and ensure that they are in the same bargaining unit. The nurse classification series revision package was sent to CalHR in April 2019.

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

Public Health's response does not support its claim of full implementation. Specifically, as Public Health notes in its response, a few of its district offices continue to have high vacancy rates. Further, Public Health did not provide any documentation to support that it has offset the vacancies through 1) borrowing surveyors from other districts; and 2) increasing the classifications, including vocational nurses and AGPAs, it hires as surveyors.

Annual Follow-Up Agency Response From November 2018

In 2017, Center for Health Care Quality (CHCQ) hired consultants to identify improvements in recruiting and reduce delays between candidate selection and approval for hire.

The average time to process new hires after selection was reduced by 56%; 27 days in 2016 to 12 in 2018. The processing time for Health Facilities Evaluator Nurses (HFENs) improved from an average of 43 days in 2016 to 15 days in 2018, a 65% decrease. The overall vacancy rate decreased by 53%, from 17.4% in July 2016 to 8.2% in July 2018. The HEFN vacancy rate in 2016 and 2018 were 16.48% and 3.22%, respectively, an 80.5% decrease.

CHCQ improved the hiring time and decreased the vacancy rate by:

- Staff participated in statewide job fairs hosted by medical and educational institutions

- California Human Resources (CalHR) eliminated the medical clearance requirement for HFEN candidates

- Sent recruitment postcards to thirteen counties

- Ongoing ads in the Nursing Voice and local newspapers near district offices

- Started using Indeed online ads, and created a virtual job fair for HFEN hiring

- Switched to biweekly ads in the state's Examination Certification Online System

CDPH's annual estimate of workload and staffing via the November Estimate process (https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/EstimateReports.aspx) projects programmatic workload functions and positions needed to perform these functions.

At CalHR's direction, CDPH discontinued its reclassification project for investigator supervisor and manager positions in 2016 due to CalHR's Civil Service Initiative (CSI). CSI reduced the overall number of civil service classifications through consolidation. CDPH's proposal included an increase in classifications, conflicting with CSI efforts. CalHR didn't support CDPH's reclassification and did not schedule additional meetings with the Union to adopt the proposed changes. CDPH decreased vacancy rates for HFEN and Health Facilities Evaluator II Supervisory classifications.

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

The documentation provided by Public Health shows that overall the district offices had eight vacant supervisory positions of 102 positions and 20 vacant staff HFEN positions of 621 positions as of September 2018. However, some district offices still have large number of vacant supervisory and staff positions. Specifically, 4 of 6 supervisory positions at the San Francisco district office and 4 of 7 supervisory positions at the Santa Rosa district office were vacant as of September 30, 2018. Similarly, 14 of 41 HFEN positions at the Santa Rosa district office and 15 of 60 HFEN positions at East Bay district office were vacant. As we state on page 39 of the report, until Public Health ensures that it has the necessary staffing levels at each district office to address adequately the district office's workload related to licensing and certification of long-term health care facilities, including prompt investigations of complaints, Public Health is hampered in its ability to ensure the safety, health, and well-being of residents living in these facilities.

Annual Follow-Up Agency Response From December 2017

CalHR, as part of civil service improvement initiatives, is focused on reducing the number of civil service classifications through classification consolidation efforts. Since the Public Health reclassification proposal does not reduce the number of classifications in the series, CalHR is not acting on the proposal. Despite the reclassification not moving forward, Public Health has taken numerous other recruitment actions to reduce vacancy rates.

Public Health has successfully streamlined the hiring process by eliminating the health questionnaire with approval from CalHR. Public Health has all complaint team supervisors positions filled. The vacancy rate for the HFEN classification has dropped in 8 of the past 10 months, from 17% to 12% (72 vacancies out of 620 positions) as of September 30, 2017. Also as of September 30, 2017, 43 of 49 Health Facilities Evaluator Manager I and Manager II positions are filled, a vacancy rate of 12%.

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

Public Health's previous response stated that fiscal year 2015-16 Budget Act authorized 77 health facilities evaluator nurse (HFEN) positions and it had filled 21 positions and had 17 pending hires. Although it currently claims that it has streamlined the hiring process and reduced vacancy rates, it did not provide any supporting documentation.

Annual Follow-Up Agency Response From September 2016

Annually, the Center for Health Care Quality (CHCQ) allocates district office surveyor positions based on a workload needs analysis to ensure staff allocations are appropriate to promptly address all licensing and certification workload, including the investigation of complaints.

Public Health continues to look for ways to expedite the hiring process to fill vacant positions. Public Health's Human Resources Branch staff and CHCQ meet at least monthly to address barriers to hiring. In addition, CHCQ executed two consultant contracts in April 2016 to provide recommendations to improve CHCQ recruitment and onboarding practices.

To date, Public Health has filled 136 of the 240 approved positions from the 2015-2016 Budget Act.

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

1-Year Agency Response

The 2015-16 Budget Act increased CDPH's positions by 240 to complete licensing and certification workload. Of these 240, on July 1, 2015, 77 health facilities evaluator nurse (HFEN) position were authorized. As of November 6, 2015, CDPH has 21 completed and 17 pending hires of HFENs

The Center will address ongoing recruiting, onboarding and retention issues through two consultant contracts. The Center expects to execute a recruitment contract, and an onboarding and retention contract by December 2015.

CDPH continues to work with CALHR to complete the reclassification of district office investigator, supervisor, and manager positions.

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

Public Health identifies this recommendation as fully implemented. However, Public Health's response states that it continues to work with CalHR to complete the reclassification of district office investigator, supervisor, and manager positions. Therefore, we have assessed this recommendation as partially implemented.

6-Month Agency Response

Based on the L&C Program November Estimate, the January 2015 Governor's Budget includes a request for additional staff and funding to complete licensing and certification workload.

CDPH continues to work with CALHR to complete the reclassification of district office investigator, supervisor, and manager positions.

CDPH has established a workgroup to look into ways for expediting filling vacant positions at district offices.

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

60-Day Agency Response

On November 19, 2014, CDPH posted on our website "Vacancy Rates by Position Classification for the Center of Health Care Quality" with data as of September 30, 2014.

CDPH will continue to post this information quarterly.

As of December 1, 2014, CDPH completed examinations for Health Facilities Evaluator II (Supervisor), Health Facilities Evaluator Manager I, and Health Facilities Evaluator Manager II. Certification lists for these classifications are now available and district offices are recruiting for these positions.

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

All Recommendations in 2014-111

Agency responses received are posted verbatim.