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San Diego County’s Health and Human Services Agency
It Cannot Demonstrate That It Employs the Appropriate Number of Public Health Nurses to Efficiently Serve Its Residents

Report Number: 2017-124

July 26, 2018 2017-124

The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California 95814

Dear Governor and Legislative Leaders:

As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report concerning San Diego County’s Health and Human Services Agency (Health Agency) and whether it has adequate staffing levels of public health nurses (PHNs) to appropriately serve county residents. This report concludes that the Health Agency should measure and assess PHN efficiency so it can better demonstrate that it employs the appropriate number of PHNs to efficiently serve its residents, and that it should better ensure its PHNs are prepared for future public health emergencies.

The Health Agency is responsible for providing a variety of health and social services to county residents, including child welfare, public health, and behavioral health services. San Diego County’s Code of Administrative Ordinances requires the Health Agency’s director to administer programs through its departments, divisions, and geographic service regions in a manner that integrates the administration and delivery of services to ensure effectiveness, efficiency, accessibility, and quality. We found that the Health Agency does not consistently use available information such as case assignment or caseload data to measure PHN efficiency and help assess its PHN staffing assignments. For instance, the Health Agency does not require its managers to monitor each PHN’s caseload. Our review of caseload information for the Health Care Program for Children in Foster Care and the California Children’s Services program revealed that the average caseload per PHN exceeded state benchmarks for both programs for the three fiscal years we reviewed.

In addition, San Diego County experienced an outbreak of hepatitis A in 2017, which the Health Agency detected in March 2017 and for which the county declared a local public health emergency in September 2017. The Health Agency used both its own PHNs and temporary staff, including staff from hospitals and fire departments, to respond to the hepatitis A outbreak. Although the Health Agency appears to have followed its plan for responding to public health threats to address the outbreak, the plan was still in draft form until June 2018. Distributing the plan to its PHNs and training them on its protocols would better ensure that the Health Agency’s PHNs understand their responsibilities during future public health emergencies.

Respectfully submitted,

State Auditor

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