Report 2014-111 All Recommendation 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 #1 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 establish and implement a formal process for monitoring the status and progress in resolving open facility-related complaints and ERIs at all district offices. This process should include periodically reviewing a report of open complaints and ERIs to ensure that all complaints and ERIs are addressed promptly.

1-Year Agency Response

In July 2015, CDPH provided to all district offices an Open Complaints Data (OCD) Query Tool.

The OCD Query Tool has:

- current data - refreshed weekly

- a summary table showing Open Complaints by District Office and SFY Received

- a summary table highlighting data clean-up issues

- an exportable detail file for taking action on the open complaints and clean-up issues

OCD resources include:

- User Instructions

- Data Dictionary

- Feedback Survey

  • Completion Date: July 2015
  • Response Date: November 2015

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

Public Health provided documentation showing periodic review of district offices' status and progress in resolving open facility-related complaints and ERIs.


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.

http://www.cdph.ca.gov/programs/Pages/CHCQPerformanceMetrics.aspx

  • Completion Date: May 2015
  • Response Date: July 2015

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

Although Public Health provided a link to its website where it posts district office-specific data, it did not provide documentation to demonstrate that it established and implemented a formal process for monitoring the status and progress to ensure that all complaints and ERIs are addressed promptly.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

60-Day Agency Response

On November 7, 2014, CDPH posted on our website performance metrics on the volume, timeliness, and disposition of long-term care health facility complaints 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.

  • Estimated Completion Date: 1/31/2015
  • Response Date: December 2014

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


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.

  • Completion Date: April 2015

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.

  • Completion Date: April 2015
  • Response Date: November 2015

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.

  • Auditee did not substantiate its claim of full implementation

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.

  • Completion Date: April 2015
  • Response Date: July 2015

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.

  • Auditee did not substantiate its claim of full implementation

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.

  • Estimated Completion Date: 5/1/2015
  • Response Date: December 2014

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


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 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.

  • Completion Date: July 2016

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.

  • Auditee did not address all aspects of the recommendation

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.

  • Response Date: November 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

  • Response Date: June 2015

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.

  • Response Date: December 2014

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.


Recommendation #4 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 develop formal written policies and procedures for PCB to process complaints about certified individuals in a timely manner. These policies and procedures should include specific time frames for prioritizing and assigning complaints to investigators, for initiating investigations, and for completing the investigations. Public Health should also inform staff of the expectation that they will meet these time frames. It should require PCB to provide adequate, documented justification whenever PCB fails to meet the time frames.

Annual Follow-Up Agency Response From September 2016

As noted in our previous response, PCB has developed investigation policies and procedures and updates them as needed. PCB's performance metrics are posted at http://www.cdph.ca.gov/programs/Pages/CHCQPerformanceMetrics.aspx. The metrics demonstrate that PCB continues to reduce the number of open complaints and decrease the time taken to complete a complaint investigation. PCB reduced the number of open complaints from 1,097 at the start of fiscal year (FY) 2014-15 to less than 600 in the third quarter of FY 2015-16, even as the number of new complaints continues to increase. Further PCB reduced the average days to investigate a complaint from receipt to completion from 285 in the second quarter of FY 2013-14 to 133 in the third quarter of FY 2015-16. As of September 1, 2016, PCB has no open complaints from prior to 2015 and only five open complaints from 2015. Law enforcement holds are delaying PCB's completion of the 2015 investigations. These improved outcomes are the result of increased staffing, quarterly performance reporting and monitoring, and enhanced management oversight. PCB expects to continually reduce the number of open complaints and improve the timeliness of complaint investigations. Further, as the audit report noted, there are no federal requirements to complete investigations within specified time frames nor has the Centers for Medicare and Medicaid Services (CMS) reported any concerns to CDPH with PCB investigations. Given that enhanced oversight and interventions have led to continually improved timeliness of complaint investigations, CDPH has determined that specified timelines are not necessary.

  • Completion Date: October 2015

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

As we state on page 33 of the report, it is especially important for Public Health's PCB to develop formal written policies and procedures, including the establishment of specific steps and time frames for completing those steps because federal regulations require Public Health to investigate complaints about certified individuals in a timely manner. Although Public Health's data show a decline in the backlog of open cases, as reported in its third quarter metrics for fiscal year 2015-16 posted on Public Health's website, the data also show that it closed 820 cases, or 68 percent of the 1,195 complaints closed during the period, more than 90 days after receipt of the complaint. We continue to stand by our recommendation that Public Health's policies should include specific time frames for prioritizing and assigning complaints to investigators, for initiating investigations, and for completing the investigations.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

1-Year Agency Response

PCB's documented policies and procedures are completed and PCB will update them any time procedures are revised. The attached "PCB Intake Staff Services Analyst Procedure" and "PCB Program Technician Procedures" are samples of PCB procedures. Additional PCB policies and procedures total hundreds of pages; we can provide additional documents at your request.

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). We will review the effectiveness of the revised process and revise if needed and roll out to all the district offices ("check" and "act").

CDPH disagrees with establishing specific timeframes for investigations, but continues with our commitment to improve upon the timeliness of investigations.

As seen in our performance metrics posted on our website, trends continue to show a reduction in the amount of open investigations as well as improved timeliness of investigations.

  • Completion Date: October 2015
  • Response Date: November 2015

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

Although Public Health indicates the status of this recommendation as fully implemented, Public Health's response states that it developed policies and procedures, but that it disagrees with establishing specific time frames for investigations. Public Health does not provide a reason for why it disagrees with establishing specific time frames for investigations, but states that it is committed to improving timeliness of investigations. However, as we state on page 33 of the report, it is especially important for Public Health's PCB to develop formal written policies and procedures, including the establishment of specific steps and time frames for completing those steps because federal regulations require Public Health to investigate complaints about certified individuals in a timely manner.

  • Auditee did not substantiate its claim of full implementation

6-Month Agency Response

PCB has completed documenting many of its policies and procedures and is currently working with the Results Group to identify methods to enhance efficiencies for the investigative process before finalizing the documented procedures. CDPH is awaiting the final report from the Results Group. Findings from the report may result in modifications to existing policies.

CDPH disagrees with establishing specific timeframes for investigations but continues with our commitment to improve upon the timeliness of investigations.

As seen in our performance metrics posted on our website, trends continue to show a reduction in the amount of open investigations as well as improved timeliness of investigations.

  • Estimated Completion Date: Unknown
  • Response Date: June 2015

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

Public Health's response indicates that it has not yet finalized the documented procedures for PCB. We look forward to receiving documentation of the procedures once Public Health finalizes them. Additionally, Public Health does not provide a reason for why it disagrees with establishing specific time frames for investigations but states it is committed to improving timeliness of investigations. However, as we state on page 33 of the report, it is especially important for Public Health's PCB to develop formal written policies and procedures, including the establishment of specific steps and time frames for completing those steps because federal regulations require Public Health to investigate complaints against certified individuals in a timely manner. Without defining what it considers to be timely completion of investigations, it is unclear how Public Health will ensure that PCB complies with federal regulations.


60-Day Agency Response

PCB continues to develop and implement written policies and procedures for investigating complaints against certified individuals. In September 2014, CDPH began work with The Results Group to review the current processes, practices, policies, and data technology. The Results Group has documented the existing processes and by December 31, 2014, will provide PCB with recommendations to enhance efficiencies, data collection and maintenance, and timeliness.

CDPH disagrees with establishing specific timeframes for investigations.

CDPH is committed to investigating complaints against certified individuals in a timely manner. Rather than establishing 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 complaints against certified individuals for the first quarter of fiscal year 2014-2015.

  • Estimated Completion Date: 5/1/2015
  • Response Date: December 2014

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

Public Health fails to recognize the importance of our recommendation. As we state on page 33 of the report, it is especially important for Public Health's Professional Certification Branch (PCB) to establish specific steps and time frames for completing those steps because federal regulations require Public Health to investigate complaints against certified individuals in a timely manner. Without defining what it considers to be timely completion of investigations, it is unclear how Public Health will ensure that PCB complies with federal regulations.


Recommendation #5 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 assess whether each district office is appropriately prioritizing ERIs. Specifically, it should determine, on a district-by-district basis, whether district offices' assigning ERIs a priority level that requires an on-site visit is justified. This assessment should also determine whether each district office is prioritizing ERIs appropriately when determining that on-site investigations are not necessary.

1-Year Agency Response

CDPH continues to review complaints and ERIs for appropriate prioritization level and timely onsite visits through by a quarterly lookback review of a sample of complaints and ERIs. We began this review with Los Angeles County and expanded it to all district offices beginning with the first quarter of FY 2015/16.

  • Completion Date: October 2015
  • Response Date: November 2015

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


6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate prioritization level and timely onsite visit. This review is 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.

  • 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


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


Recommendation #7 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 review periodically a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

Annual Follow-Up Agency Response From September 2016

Public Health continues to review complaints and ERIs for appropriate prioritization level and timely onsite visits through by a quarterly lookback review of a sample of complaints and ERIs.

Training presented during the Center's Supervisor Academy as well as the Quarterly Training Supervisor Academy in 2016, included detailed curriculum, instruction and practical examples for triaging complaints/entity-reported incidents (ERIs). Additional content included evaluation of the timeliness of the onsite visit investigation

  • Completion Date: July 2016

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

Public Health provided documentation that it identified best practices for prioritizing ERIs, provided the training to its staff in January 2016, and updated its policies in August 2016. However, it did not provide documentation that subsequent to its training and updated policies, it has performed periodic reviews of a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

  • Auditee did not substantiate its claim of full implementation

1-Year Agency Response

CDPH continues to review complaints and ERIs for appropriate prioritization level and timely onsite visits through by a quarterly lookback review of a sample of complaints and ERIs. We began this review with Los Angeles County and expanded it to all district offices beginning with the first quarter of FY 2015/16.

  • Completion Date: October 2015
  • Response Date: November 2015

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

As we noted in our public reasoning for recommendation #6, Public Health has not yet provided documentation to support that it has issued guidance to district offices on best practices. Until it issues such guidance, it cannot review periodically a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate prioritization level, timely onsite visit, and investigations. This review is 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.

  • 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


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 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.

  • Estimated Completion Date: June 2018

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.

  • Completion Date: October 2015
  • Response Date: November 2015

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.

  • Auditee did not substantiate its claim of full implementation

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.

  • Estimated Completion Date: Unknown
  • Response Date: June 2015

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.

  • Estimated Completion Date: Unknown
  • Response Date: December 2014

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


Recommendation #9 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 complete by May 1, 2015, a staffing assessment to identify the resources necessary for district offices to investigate open complaints and ERIs and to promptly address new complaints on an ongoing basis. Public Health should use this assessment to request additional resources, if necessary.

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.

CDPH's request for these positions was based on an analysis completed and documented in L&C's November Estimate.

http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LC%20November%20Estimate%20for%202015-16%20final%2001-08-15.pdf.

Appendix C, beginning on page 16, describes our detailed methodology for determining total position needs.

  • Completion Date: May 2015
  • Response Date: November 2015

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


6-Month Agency Response

The Governor's 2015-16 Budget, updated at the May Revision, includes a request for funding for 237 state positions and $14.85 million for LA County to conduct L&C state and federal work. These requests were based on an analysis completed and documented in L&C's November Estimate.

http://www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LC%20November%20Estimate%20for%202015-16%20final%2001-08-15.pdf

  • Completion Date: May 2015
  • Response Date: July 2015

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

The link included in Public Health's response shows the method Public Health used to determine the staffing needs. However, the estimates included in the referenced document is at the department level and not at the individual district office level. Further, Public Health did not provide any data or calculations to support the estimates included in the referenced document.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

60-Day Agency Response

CDPH's annual estimate of the workload and staffing needs of the Licensing and Certification Field Operations Division will be released with the Governor's Budget on January 10, 2015.

  • Estimated Completion Date: 5/1/2015
  • Response Date: December 2014

California State Auditor's Assessment of 60-Day Status: No Action Taken

Public Health did not provide any documentation to support its annual estimate of the workload and staffing needs to be released with the Governor's Budget on January 10, 1015. As a result, it is unclear whether Public Health completed a staffing assessment to identify the resources necessary for district offices to investigate open complaints and ERIs and to promptly address new complaints on an ongoing basis.


Recommendation #10 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, by January 1, 2015, Public Health should establish a time frame for fully implementing the recommendations that its consultant identified related to the processing of complaints about long-term health care facilities.

1-Year Agency Response

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 Center for Health Care Quality has developed a staffing model to identify the needs of each district office, and has used this model to allocate the new 240 new positions.

CDPH's work plan for implementing the consultant's recommendations is available at the link below. The work plan includes a timeline for each recommendation.

http://www.cdph.ca.gov/programs/Documents/Amended%20August%202015%20Remediation%20Work%20Plan%20Update.pdf

  • Completion Date: July 2015
  • Response Date: November 2015

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


6-Month Agency Response

The Governor's 2015-16 Budget, updated at the May Revision, includes a request for funding for 237 state positions and $14.85 million for LA County to conduct L&C state and federal work. These requests were based on an analysis completed and documented in L&C's November Estimate.

  • Estimated Completion Date: 12/31/2016
  • Response Date: June 2015

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


60-Day Agency Response

CDPH agrees with this recommendation but not the January 1, 2015 timeline.

On November 7, 2014, CDPH posted on our website a work plan for implementing the assessment report recommendations.

The work plan includes anticipated timelines for the initiation and completion of each recommendation. On November 13, 2014, CDPH held a stakeholder meeting to discuss and receive feedback on the work plan. CDPH will update the work plan monthly with progress reports and any changes to the timeline.

  • Estimated Completion Date: 12/31/16
  • Response Date: December 2014

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

Public Health did not provide any documentation to support the activities it outlines in its response. It also does not specify when it expects to establish a time frame for fully implementing the recommendations that its consultant identified in August 2014. We believe that Public Health should establish a time frame as soon as possible.


Recommendation #11 To: Public Health, Department of

Public Health should take steps to ensure that PCB has the resources necessary on an ongoing basis to complete investigations of complaints against individuals. Specifically, Public Health should assess whether the temporary resources it has received are adequate to reduce the number of open complaints to a manageable level. This assessment should also determine whether permanent resources assigned to PCB are adequate to address future complaints. Public Health should use this assessment to request additional resources, if necessary.

Annual Follow-Up Agency Response From September 2016

As previously stated, the Professional Certification Branch continues to reduce the number of open complaints to a manageable level while adequately addressing newly received complaints. http://www.cdph.ca.gov/programs/Pages/CHCQPerformanceMetrics.aspx

An analysis of actual data regarding the number of complaints received, and investigations pending and completed in each of the last five full fiscal years was used to project data for the current and next three fiscal years. Based on the trends of the actual data and these projections, current staffing levels are adequate to address future complaints.

  • Completion Date: July 2016

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

Public Health provided a budget change proposal (BCP), approved by the Department of Finance, requesting to convert 18 existing limited-term positions in its PCB to permanent positions and requesting two additional positions in its Office of Legal Services to improve the timeliness of investigation of complaints against caregivers. Public Health's BCP states that augmenting the existing analysts with position and spending authority by converting the 18 two-year limited-term positions will allow the PCB to improve the timeliness of complaint investigations from greater than one year to less than three months by fiscal year 2018-19. It also states that adding the two attorney positions to serve as the PCB's house counsel and litigation support will better represent Public Health at administrative appeal hearings.


1-Year Agency Response

The performance metrics posted on our website indicates that PCB continues to reduce the number of open, aged complaints despite the increase of received complaints. As of September 30, 2015, all complaints received in fiscal year 2013/2014 were complete with the exception of three investigations with law enforcement barriers. There are 408 open complaints remaining from fiscal year 2014/2015 and 348 open complaints from fiscal year 2015/2016. This number of open, pending complaints is manageable with the temporary resources.

http://www.cdph.ca.gov/programs/Pages/CHCQPerformanceMetrics.aspx

  • Completion Date: October 2015
  • Response Date: November 2015

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

Although the data that Public Health references on its website show that it reduced the number of open complaints, it did not provide an assessment to determine whether the permanent resources assigned to PCB are adequate to address future complaints.

  • Auditee did not substantiate its claim of full implementation

6-Month Agency Response

As of April 1, 2015, PCB has filled all 18 new positions established in the Budget Act.

According to the performance metrics posted on our website, trends show that PCB continues to reduce the number of open, aged complaints. As of March 31, 2015, all complaints received in fiscal year 2012/2013 have been completed. There are 276 open complaints received in fiscal year 2013/2014 and 618 open complaints received in 2014/2015.

CDPH will continue to monitor and report progress of PCB's investigation as well as assess the staffing needs of PCB to perform this work.

  • Estimated Completion Date: 112/31/2015
  • Response Date: June 2015

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


60-Day Agency Response

As of December 1, 2014, PCB has filled 15 of the 18 new positions established in the Budget Act and is recruiting to fill the remaining three positions.

On November 7, 2014, CDPH posted on our website performance metrics on the volume, timeliness, and disposition of complaints against certified individuals for the first quarter of the 2014-2015 state fiscal year.

As of December 5, 2013, PCB has further reduced the number of open, aging complaint investigations to 17 received in fiscal year 2012/2013, 609 received in fiscal year 2013/2014, and 409 received in fiscal year 2014/2015.

  • Estimated Completion Date: 12/31/15
  • Response Date: December 2014

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

Public Health's response does not discuss whether it assessed the temporary resources and whether they are adequate to reduce the number of open complaints to a manageable level.


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 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.

  • Estimated Completion Date: January 2017

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.

  • Estimated Completion Date: January 31, 2016
  • Response Date: November 2015

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.

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

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.

  • Estimated Completion Date: 10/31/15
  • Response Date: December 2014

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


Recommendation #13 To: Public Health, Department of

To make certain that its district offices comply with federal requirements regarding corrective action plans, Public Health should establish a process for its headquarters or regional management to inspect district office records periodically to confirm that they are obtaining corrective action plans according to the required time frame and verifying that facilities have performed the corrective actions described in the plans when required.

Annual Follow-Up Agency Response From September 2016

In January 2016, Public Health's Licensing and Certification Program (L&C) joined other states in participating in Centers for Medicare/Medicaid Services (CMS) web-based electronic plan of correction (ePOC) program. The ePOC program is designed to allow providers, Public Health, and the CMS to view corrective action plans issued by state regulators and respond and upload documents that facilities provide in response to corrective action items. The ePOC program documentation includes the statement of deficiencies (CMS 2567) issued by State staff and facilities documented response(s). Public Health's District Offices (DO) serving all 58 California counties are phasing into this program and all will be using this system by June 2017.

L&C Training Unit conducted a webinar to providers and Public Health staff covering ePOC process. Participating in the ePOC program will strengthen Public Health's ability to monitor and review DO's timely and more efficiently document evidence of completion.

  • Estimated Completion Date: June 2017

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


1-Year Agency Response

CDPH developed criteria for reviewing plans of correction and verification of implementation. The criteria can be found on page 43-44 of the "LTC Abbreviated Survey P&P." This review was added to the Abbreviated Survey Review for LA County in April 2015 (fourth quarter 2014/15). Starting in October 2015, this review expanded to statewide.

  • Completion Date: October 2015
  • Response Date: November 2015

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

Pages 43 and 44 of the Abbreviated Survey Policies and Procedures describe district offices' responsibilities in obtaining and reviewing corrective plans from LTHC facilities. However, our recommendation was for Public Health to establish a process for headquarters or regional management to inspect district office records periodically to confirm that the district offices were obtaining corrective action plans according to the required time frame and verifying that facilities have performed the corrective actions described in the plans when required.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate prioritization level, timely onsite visit, and investigations. This review is 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.

CDPH has developed and added criteria for reviewing plans of correction and verification the provider implemented their plans of correction to the LA County monthly reviews.

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

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

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: 10/31/15
  • Response Date: December 2014

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

Public Health did not provide documentation of the actions noted in its response. Additionally, it indicates the recommendation is not yet fully implemented.


Recommendation #14 To: Public Health, Department of

To ensure that it has closed complaints and ERIs appropriately, Public Health should take steps by April 2015 to verify that complaints that its field operations branch closed administratively were closed appropriately. For example, it could request the district offices to verify that the closures were appropriate.

Annual Follow-Up Agency Response From November 2016

On August 4, 2016, Public Health's Licensing and Certification Program (L&C) released updated policy and procedures for the Abbreviated Standard Survey (federal complaint process) in Skilled Nursing/Nursing Facilities, which includes guidance for administrative review and closure.

Additionally, L&C Quality Improvement Unit (QI) implemented a State Observation Survey Analysis (SOSA) of the federal recertification survey process where a team "shadows" the survey team which may include complaint/entity-reported incident (ERI) investigations.

The QI team conducts one SOSA per month for each district office including LA County. During the process, complaint investigative reports, including those administratively closed, are reviewed for quality control and appropriate use of administrative off-site closure. The SOSA includes a sample selection of nine closed complaints/ERIs, at least one is an administrative closure. The results of the SOSA are presented to the District Manager/Administrator in writing and discussed in a teleconference. The SOSA surveys are ongoing for all district offices and represent an opportunity for continuous process improvement over complaint processes.

  • Completion Date: March 2016

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

Although Public Health provided documentation supporting its proposed actions going forward to help prevent inappropriate closures of complaints, it did not address whether it verified the complaints that its field operations branch closed administratively were closed appropriately. When we followed up with staff, Public Health told us that, because of its four year record retention policy, Public Health cannot perform a review of the 258 complaints we identified that were closed administratively.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

1-Year Agency Response

CDPH will develop criteria to evaluate the appropriate use of administrative closure by end of November 2015. Starting third quarter FY 2015-2105 (January-March 2016) CDPH will review a sample of closed complaints and ERIs to evaluate the appropriate use of administrative closures and present findings for any additional training necessary. Based on our first review, we will determine the need for, and frequency of, any ongoing sampling and review.

  • Estimated Completion Date: March 2016
  • Response Date: November 2015

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


6-Month Agency Response

By June 2015, CDPH will develop criteria to evaluate the appropriate use of administrative closure and implement reviews in LA County by July 2015. By October 2015, CDPH will use the criteria to monthly review a sample of the investigations in district offices statewide to include assessment of appropriate administrative complaint closures.

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

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


60-Day Agency Response

Beginning in September 2014, CDPH Branch Chiefs initiated visits to each district office to ensure compliance with policies and procedures including those related to complaint and ERI closure and will continue this during their quarterly visits. During these visits, the Branch Chiefs discuss complaint and ERI investigation monitoring with district office administrative, supervisory, and management staff.

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, including assessing whether any administrative complaint closures were appropriate.

  • Estimated Completion Date: 10/31/15
  • Response Date: December 2014

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


Recommendation #15 To: Public Health, Department of

To improve oversight of its district offices' complaint and ERI investigation process, Public Health should increase its monitoring of the district offices' compliance with federal and state laws as well as with its policies. For example, Public Health could accomplish this by directing its regional managers to spend more time at the district offices to enforce district office compliance with policies, or by directing its quality improvement section to review a random sample of investigations for quality and adherence to policy. Public Health should further establish a formal process to review periodically LA County's compliance with the terms of its contract, including compliance with the terms for investigating complaints.

6-Month Agency Response

CDPH Branch Chiefs have increased their visits to district offices, and increased regional meetings to ensure compliance with policies and procedures related to complaint and ERI closure. During these visits, the Branch Chiefs discuss complaint and ERI investigation monitoring with district office administrative, supervisory, and management staff.

CDPH has implemented a monitoring unit in LA County that consists of a former District Office Manager (retired annuitant), a Health Facility Evaluator Supervisor, and 2 Health Facility Evaluator Nurses. This unit ensures LA County's compliance with the terms of its contract, including compliance with the terms for investigating complaints. In addition, weekly calls occur between L&C Headquarters and LA County officials to monitor workload progress and provide guidance and direction as needed.

CDPH continues to review complaints and ERI for appropriate prioritization level, investigative process, and adherence to regulatory requirements and policy.

  • Completion Date: May 2015
  • Response Date: July 2015

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


60-Day Agency Response

Beginning in September 2014, CDPH Branch Chiefs initiated visits to each district office to ensure compliance with policies and procedures including those related to complaint and ERI closure and will continue this during their quarterly visits. During these visits, the Branch Chiefs discuss complaint and ERI investigation monitoring with district office administrative, supervisory, and management staff.

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: 10/31/15
  • Response Date: December 2014

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


Recommendation #16 To: Public Health, Department of

To better protect the safety of residents in long-term health care facilities, Public Health should direct its district offices to comply with required time frames for initiating and closing completed investigations. If a district office lacks sufficient resources to initiate or close investigations within those time frames, Public Health should arrange to assist that district until such time that the district complies with the statute.

1-Year Agency Response

On May 8, 2015, CDPH posted district-specific data to our website. Subsequent reports will continue to report district office specific details of the complaints and entity reported incidents volume, timeliness, and disposition. CDPH Branch Chiefs use this district-specific data as a management tool and will continue to work with the district office managers to monitor these performance metrics, including meeting required timeframes.

As documented in our benchmark report to CMS, if a district office lacks sufficient resources to initiate or close investigations within those time frames, CDPH Branch Chiefs will collaborate to assist that district until such time that the district complies with the statute.

  • Completion Date: October 2015
  • Response Date: November 2015

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

We reviewed Public Health's website and verified it is providing district-specific data on the timeliness of completing complaints investigations. Public Health also provided documentation showing it has provided assistance to district offices experiencing workload issues.


6-Month Agency Response

On May 8, 2015, CDPH post district-specific data to our website. Subsequent reports will continue to report district office specific details of the complaints and entity reported incidents volume, timeliness, and disposition. CDPH Branch Chiefs use this district-specific data as a management tool and will continue to work with the district office managers to monitor these performance metrics.

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

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

Public Health's response states that it posted district-specific data on its website about volume, timeliness, and disposition of complaint and ERI investigations. However, Public Health does not address our recommendation that it direct its district offices to comply with required time frames for initiating and closing completed investigations and provide assistance to districts unable to meet those time frames.


60-Day Agency Response

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 the 2014-2015 state fiscal year.

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.

  • Estimated Completion Date: 10/31/15
  • Response Date: December 2014

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


Recommendation #17 To: Public Health, Department of

To make certain that it complies with statutory time frames for adjudicating appeals related to individuals, Public Health should establish a process to monitor its contractor's performance with contract terms.

1-Year Agency Response

CDPH has developed a tracking log to monitor the contractor's performance and updates the log monthly.

In addition, CDPH has scheduled quarterly meetings with DHCS to review the status of the hearings. Meeting dates as follows:

- October 6, 2015

- January 14, 2016

- April 6, 2016

- July 6, 2016

- October 5, 2016

  • Completion Date: May 2015
  • Response Date: November 2015

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


6-Month Agency Response

CDPH has developed a tracking log to monitor the contractor's performance. This log is updated monthly.

  • Completion Date: May 2015
  • Response Date: July 2015

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

Although Public Health's response states that it has developed a tracking log to monitor the contractor's performance, Public Health did not provide the tracking log and does not describe what is included in the tracking log or how the log will be used to monitor its contractor's performance with the contract terms. Also, in August 2015, Public Health indicated to us that it plans to set up quarterly meetings with its staff to review the tracking log but has not set the dates of the meetings.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

60-Day Agency Response

The statutory provision that governs Administrative Hearings for CDPH is Section 131071 of the Health and Safety Code, which states that notwithstanding any other provision of law, CDPH will conduct hearings pursuant to the Administrative Procedures Act and Section 131071. Those provisions do not designate specific deadlines for setting or conducting hearings.

CDPH will review and monitor the contract.

  • Response Date: December 2014

California State Auditor's Assessment of 60-Day Status: No Action Taken

As we state on pages 56 and 57 of the report, Public Health's interpretation of the law is incorrect for two reasons. First, rules of statutory construction provide that significance should be given to every word in a statute, which must be read in the light of its historical background and evident objective. The statutory requirements concerning time deadlines for hearings affecting these individuals specifically state that Administrative Procedures Act (APA) procedures apply unless those procedures conflict with the specific statutory provisions governing appeals by nurse assistants and home health aides. Because the statutory time deadline for hearing an appeal clearly conflicts with otherwise applicable APA provisions, we conclude that the deadline supersedes the APA.

Second, when two laws upon the same subject are passed at different times and are inconsistent with each other, the one last passed must prevail. In this case, the pertinent section referring to the APA was enacted in 2007 and has not been amended since. The section of state law prescribing the time frames for Public Health was last amended in 2013, at which time the Legislature declined to remove the 60-day time requirement, thereby evidencing an intention to preserve this provision.


Recommendation #18 To: Public Health, Department of

To ensure that the Legislature promptly receives information about the timeliness of Public Health's complaint processing related to long-term health care facilities, Public Health should continue to include all of the statutorily required information in its annual report and submit it by the due date.

6-Month Agency Response

On May 8, 2015, CDPH post district-specific data to our website. Subsequent reports will continue to report district office specific details of the complaints and entity reported incidents volume, timeliness, and disposition.

In February 2015, CDPH posted its annual Fee Report for FY 15/16 on the website. The report contains all statutorily required information.

The Legislature is informed via the Fee Report, posted at:

www.cdph.ca.gov/pubsforms/fiscalrep/Documents/LicCertAnnualReport2015.pdf

  • Completion Date: February 2015
  • Response Date: June 2015

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


60-Day Agency Response

On November 7, 2014, CDPH posted on our website performance metrics on the volume, timeliness, and disposition of long-term care health facility complaints 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.

In February 2015, CDPH will release its annual fee report containing all of the statutorily required information, as defined above.

  • Estimated Completion Date: 2/28/15
  • 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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