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California Department of Public Health It Could Do More to Ensure Federal Funds for Expanding the State’s COVID-19 Testing and Contact Tracing Programs Are Used Effectively Report Number: 2020-612

Audit Results

Public Health Is Exceeding Its Testing Targets, but Contact Tracing Efforts Statewide Are Lagging

In May 2020, Public Health created a plan for laboratories in the State to test an increasing number of individuals for COVID-19 each month. The plan projected testing 1.4 million individuals in May and a total of almost 4 million in December. As Figure 2 illustrates, collectively, entities statewide generally exceeded planned testing levels from August through December 2020. The significant month-over-month growth started in October. Entities statewide processed 1.5 million more tests in November than the plan had anticipated and exceeded December’s projections by more than 4.9 million tests. Moreover, since August 2020, the laboratories have maintained an average time from administering tests to reporting the results (turnaround time) of fewer than two days, even when cases significantly increased in December. Consistently fast turnaround times are important to ensuring that the State and COVID-19 patients can take timely actions, such as contact tracing or self-isolating, that help reduce the spread of the disease. Taken together, the data about tests processed and test turnaround times support that the State has expanded its laboratory capacity, meeting one goal of the ELC COVID-19 funding.

Figure 2
In November and December 2020, COVID-19 Testing in California Significantly Exceeded Public Health’s Targets

Source: Analysis of Public Health’s ELC COVID-19 testing plan and online daily testing information.

In contrast, Public Health and local health jurisdictions have struggled to meet their goals related to contact tracing. In April 2020, Public Health prepared a contact tracing program report that estimated a need for 31,400 contact tracers, case investigators, and supervisory and administrative staff (tracing staff) statewide. Public Health based its estimate on a survey in which the jurisdictions reported their existing staff levels and projected the number of staff they needed. This projection was predicated on an eventual surge in case levels to three times the April 2020 levels in each jurisdiction and on each case producing a total of 10 contacts requiring follow-up. To supplement the jurisdictions’ staffing numbers, the State launched a plan in May 2020 to create a pool of 10,000 state employees who would be reassigned from various state agencies. The local health jurisdictions could draw from this pool for help when needed.

Public Health has continued to survey local health jurisdictions’ tracing staff levels, and as of January 2021, its contact tracing data and survey results highlight persistent struggles to expand tracing staff capacity to meet the initial plan’s estimated levels. As Figure 3 shows, in its January 2021 report, Public Health calculated that the statewide tracing staff totaled nearly 12,100, including local health jurisdictions’ staff and more than 2,200 reassigned state employees. This number is far below the original goal of 31,400. Moreover, Public Health has not reached its goal of 10,000 for the pool of reassigned state employees.

Figure 3
Public Health and Local Jurisdictions Have Not Hired or Reassigned Sufficient Tracing Staff to Meet the State’s Estimated Need

Fewer-than-expected numbers of tracing staff and the influx of new cases have resulted in only a small fraction of COVID-19 cases undergoing the full contact tracing process. Local health jurisdictions reported that they attempted to contact about 85 percent of the roughly 834,000 COVID-19 cases included in the January 2021 report, but they had successful interviews for only 40 percent of the total cases. Moreover, the tracing staff were able to identify an additional person to contact and notify of potential exposure in only 16 percent of the total cases, as Figure 4 illustrates. Public Health’s report does not specify the reasons for the low numbers of successful interviews and contacts with people possibly exposed to COVID-19, although Public Health’s CA COVID-19 Contact Tracing Program director (contact tracing director) explained to us that many individuals did not report contacts because they did not remember them or had limited exposure to others because of stay-at-home orders. However, these factors do not account for the low number of successful interviews with individuals who had tested positive for COVID-19.

Figure 4
In December 2020, Contact Tracing Successfully Identified Additional People to Contact in Only a Small Fraction of Cases

State and local entities have encountered a variety of obstacles to assembling an adequate number of tracing staff. According to the contact tracing director, coordinating remote work was difficult; the initial training was overly abbreviated, resulting in staff needing additional on-the-job training; and staff had to continually adapt to constantly evolving protocols and technology, such as a new database in which to record contact tracing efforts. Local health jurisdictions’ December and January surveys also show that they often redirected their existing staff from their assigned duties to perform the contact tracing duties rather than expanding their overall staff numbers through hiring. Some jurisdictions have also experienced turnover in tracing staff positions.

Moreover, the sheer number of cases has overwhelmed local health jurisdictions’ contact tracing efforts. Public Health based its estimate of needing 31,400 tracing staff on an average daily new case count of just under 5,000. The statewide daily average total number of newly reported cases at the end of April 2020 was about 1,600. However, from late November through late December 2020, the cases Public Health tracked for contact tracing averaged more than 25,000 per day. ² According to Public Health’s California Local Health Jurisdiction Contact Tracing Performance Metrics & Program Assessment (January 2021, Revised), not every case is appropriate for contact tracing. For example, case counts do not include those in which no community, meaning the general public, exposure was anticipated. In the January survey, 15 local health jurisdictions reported that they could not investigate every new case because of the influx of new cases; this number had increased from 11 jurisdictions in the December survey. Public Health determined that caseloads at the majority of local health jurisdictions were at or exceeding their contact tracing capacity.

Public Health is taking steps to support the local health jurisdictions’ contact tracing efforts. The contact tracing director explained that because the goal of contact tracing is to notify individuals that they may have been exposed to the virus so that they can self-quarantine, Public Health has focused on improving the efficiency of the existing workforce’s efforts to reach and notify people as a way to improve the tracing program’s outcomes. For example, Public Health has recognized that it is not possible to trace every COVID-19-positive case while there is widespread transmission, and it is working with the jurisdictions as they determine how to prioritize high-risk cases and outbreaks. Public Health is also working to improve the technology tracing staff use. For example, it released a tool for schools and businesses to upload information directly to the State’s contact tracing database, and as such, Public Health can reduce the time it takes for tracing staff to enter information to initiate a case. The contact tracing director also noted that the additional ELC funds the State received in January may provide opportunities for Public Health to further improve tracing technology and to hire support staff, as well as for local health jurisdictions to hire tracing staff.

Although new funding may help improve the State’s contact tracing capacity, Public Health has also identified gaps in the assumptions that informed its April 2020 plan’s estimates of the number of staff needed. For example, the plan’s predicted number of daily cases was too low, while the assumption that tracers would identify 10 contacts per case was too high. The plan also did not account for efficiencies gained from using technology—such as cell phone tools and computer databases—to assist in contacting COVID-19-positive individuals and those whom they had possibly exposed. Nonetheless, the contact tracing director acknowledged that Public Health has not yet updated its original plan to reflect new information and assumptions. We believe that by doing so, Public Health could better track the effect of its efforts to increase contact tracing capacity and more accurately assess the extent of the shortfall in the State’s tracing staff.

Local health jurisdictions have indicated that they are preparing action plans to rectify the shortfalls in their individual contact tracing efforts. In response to Public Health’s December survey, almost all of the local health jurisdictions reported that if cases continued to surge, they would modify outreach protocols by focusing on outbreaks in specific settings, focusing on the newest reported cases, or reducing the number of outreach attempts per case, among other options. In response to the January survey, a majority reported that they had begun using such strategies to prioritize cases by, for example, tracing cases with the most recent testing dates. Further, the majority of local health jurisdictions reported to Public Health in both December and January that they planned to expand their workforce immediately, either through hiring, requesting support from the pool of reassigned state employees, or reactivating local staff.

CDC guidelines highlight the ongoing need for contact tracing to identify exposure to COVID-19 and to encourage self-quarantine, even as the number of people receiving vaccinations increases and the number of cases decreases. Therefore, it remains important that Public Health and local health jurisdictions work together to implement action plans that build contact tracing capacity so that the State may further limit COVID-19’s spread during the remainder of the pandemic.

Public Health Has Been Slow to Approve Grant Work Plans and Collect Quarterly Updates from Local Health Jurisdictions

When allocating ELC COVID-19 funds to local health jurisdictions, Public Health has required them to provide work plans and spending plans, as well as two quarterly update reports (quarterly updates) about implementing these two plans. However, Public Health has been slow to approve the jurisdictions’ work plans. Public Health required the 58 jurisdictions to which it had made advance allocations to submit their draft work plans by August 31, 2020—a deadline which 32 jurisdictions met. The remaining 26 jurisdictions had submitted their plans by October 2, 2020. Public Health has been using subject-matter experts to review and comment on each element of each work plan. According to the assistant chief of the Division of Communicable Disease Control at Public Health (assistant chief), its process for approving the work plans is slow. By December 2020, Public Health had reviewed substantial portions of many of the work plans and provided feedback to the jurisdictions about how to modify their plans. As of mid-February 2021—more than five months after they were first due—Public Health had approved 48 work plans, and it had reviewed the remaining 10 plans, which were still awaiting its approval

According to the assistant chief, Public Health is approaching its work plan review as a “continual, iterative process.” She commented that as part of the work plan review and approval process, Public Health is working with local health jurisdictions to adapt their plans to reflect additional guidance Public Health and CDC have issued since Public Health made its advance allocations in August 2020. Nonetheless, pending Public Health’s plan approval, local health jurisdictions may have hesitated to take planned steps that could help in their fight against COVID-19. For example, in fall 2020, one local health jurisdiction reported to Public Health that the county would need plan approval before hiring positions that its ELC COVID-19 funds supported; this jurisdiction did not receive plan approval from Public Health until February 2021. The jurisdiction’s comments indicate that Public Health’s delay may have impacted its ability to meet its plan and goals in the early months after receiving ELC COVID-19 funds.

In contrast, Public Health proactively approved almost all of the spending plans that the local health jurisdictions submitted. As a condition of accepting the 25 percent advance in ELC COVID-19 funds, Public Health required the jurisdictions to prepare spending plans to accompany their work plans and to group their intended expenditures by program goal and cost category, such as salary or equipment. By October 2020, Public Health had approved 54 of the spending plans; it approved three more by February 2021; and it is currently working with the one remaining local health jurisdiction to complete and approve its spending plan. Because Public Health approved these spending plans and issued advance payments, local health jurisdictions were able to begin using the funds to support critical activities, even though their work plans were still under review. The assistant chief told us that Public Health’s priority was to ensure that the jurisdictions’ budgets included only allowable expenses. The chief of the ELC unit at Public Health’s Emergency Preparedness Office (ELC chief) noted that the four local health jurisdictions it did not approve by October required extensions because COVID-19 case surges occupied their staff time.

That said, Public Health has been slow to establish processes to monitor local health jurisdictions’ spending and activities linked to the ELC COVID-19 funding allocations. Public Health set a reporting schedule for each jurisdiction that received this funding to prepare and submit quarterly updates, the first describing the jurisdiction’s progress and challenges related to implementing its work plan and the second summarizing the types and amounts of reimbursable expenses it has incurred. The first set of quarterly updates was due to Public Health in November 2020. However, as of February 2021, Public Health had received both quarterly updates from only 16 of the 58 local health jurisdictions to which it made ELC COVID-19 funding advances. The 42 jurisdictions that did not submit one or both quarterly updates include several of the State’s most populous jurisdictions, such as Sacramento and San Mateo counties. Overall, the gaps in reporting leave more than $40 million in ELC COVID-19 funding untracked. Because Public Health has not received all quarterly updates, it has had limited ability to assess local health jurisdictions’ use of COVID-19 funds and determine their progress in meeting program goals and fighting the spread of COVID-19.

Public Health did not communicate clear expectations to the local health jurisdictions about the quarterly update reports it expected them to prepare and submit. Though Public Health staff explained to us that the department expected all local health jurisdictions that received advances to submit quarterly updates in November 2020 regardless of work plan approval status, its original allocation letters to the jurisdictions indicated that only those with approved work plans needed to submit quarterly updates. Therefore, some of the local health jurisdictions may have believed that they did not have to prepare or send these update reports. To get the local health jurisdictions to submit the needed reports, Public Health created notices to remind the jurisdictions about reporting requirements and deadlines, which it began sending out in early February 2021.

The assistant deputy director of the Emergency Preparedness Office explained that Public Health’s original wording of its reporting instructions was an administrative oversight and that Public Health would revise future allocation letters to clarify that it requires quarterly updates even from local health jurisdictions whose work plans are still pending approval. It is important that Public Health continue to improve response rates—the number of jurisdictions submitting quarterly updates—because without these updates, Public Health lacks an important means of verifying that the jurisdictions are using their ELC COVID-19 funding effectively and appropriately.

Public Health also lacked a process by which to review the quarterly updates it did receive until nearly six months after it made advance allocations in August 2020. In early February 2021, Public Health finalized procedures for its staff to review the quarterly updates upon receiving them and to contact the local health jurisdictions to ask questions or provide guidance as necessary. The ELC chief explained that Public Health had waited until January 2021 to assign staff to set up a review process for the quarterly updates and that Public Health did not consider review of the expenditure reports to be an urgent issue because local health jurisdictions were not yet reporting costs that exceeded their initial 25 percent advances. Nonetheless, because Public Health delayed creating this process and reviewing the quarterly updates, it may have missed an opportunity to make course corrections that could improve the appropriateness and effectiveness of the jurisdictions’ future spending. However, we are encouraged by Public Health’s work to remedy this deficiency and its plans to perform reviews in the future.

Public Health’s progress in improving its collection and use of local health jurisdictions’ quarterly updates is important to support both current COVID-19-related efforts and long-term activities to prepare for future infectious disease emergencies. As we discuss in the Introduction, one of the ELC COVID-19 funding’s key goals is to build capacity, or the long-term ability for recipients to perform necessary testing and information gathering related to infectious diseases. Their increased capacity will help jurisdictions be better prepared to respond to future infectious disease emergencies in ways they were not prepared to respond to COVID-19. Public Health has set a deadline of November 2022 for jurisdictions to use the ELC COVID-19 funds, more than a year after experts predict the COVID-19 pandemic to peak. ³ We based this estimate on modeling by the Institute for Health Metrics and Evaluation, University of Washington, updated on February 12, 2021. Therefore, it is important for Public Health to continue working to improve the timeliness of jurisdictions’ submission of quarterly updates and its own review of those reports.

More robust collaboration between Public Health and local health jurisdictions for long-term planning may also become easier in the later months of the pandemic if local and state government workloads related to COVID-19-specific issues decrease. Thus, Public Health must ensure that it is establishing productive lines of communication and that it is prepared to provide the jurisdictions with constructive feedback and guidance as the funding program continues.

Public Health Was Lax in Performing and Securing Required IT Project Oversight for Its COVID-19 Test Results System

Of the approximately $181 million in ELC COVID-19 funds Public Health initially retained, it budgeted $49 million over three years to replace its system that collects laboratory results–CalREDIE. Accurate and timely laboratory results are a critical component of the State’s efforts to document the spread of COVID-19 and assess the effectiveness of its preventive measures. However, in August 2020, the California Health and Human Services Agency reported that two information system issues affecting CalREDIE in the prior weeks resulted in the State undercounting new COVID-19 cases. As a result, Public Health had to hasten its plans for both long- and short-term solutions to replacing CalREDIE.

As a significant first step in this effort, Public Health initiated a $15 million information technology (IT) contract in August 2020 for the California COVID Reporting System (CCRS), a new system for securely and accurately collecting, storing, analyzing, and publishing COVID-19 laboratory and case data. This IT project reflects the CDC’s guidance to use ELC COVID-19 funds to obtain systems that enable relevant entities to exchange laboratory data and to monitor and analyze measures to fight COVID-19. Public Health’s contractor (IT vendor) conducted the project in two phases. The first phase, which Public Health declared complete in December 2020, focused on system development and migrating historical laboratory data from CalREDIE to CCRS. The second phase, which Public Health declared complete in late February 2021, focused on connecting entities so they can upload laboratory results data directly. According to the chief of the Division of Communicable Disease Control, the new CCRS system was key to stabilizing laboratory reporting to Public Health by the end of 2020—one of Public Health’s critical goals for the system.

Because of the critical nature of new system development, both the State’s IT policies and Public Health’s contract with the IT vendor require multiple forms of oversight. However, Public Health’s oversight of the IT vendor was initially deficient. Specifically, the project contract required the IT vendor to provide Public Health with weekly and monthly status reports containing information such as lists of tasks completed and in progress. Despite this requirement, Public Health did not collect either of these reports from the IT vendor until mid-October 2020, two months after it initiated the contract. The chief of the project management branch at Public Health (project management chief) explained that before October 2020, Public Health received daily project updates from the IT vendor. However, the sample daily update that she provided to us was missing elements the contract requires in the monthly and weekly status reports. Although Public Health demonstrated that it rectified this issue, it did not do so until a significant portion of the first project phase—system development—was complete. Thus, we are concerned that for the initial development process, Public Health did not ensure that it received complete updates, potentially affecting its ability to assess the status of work performed at that time.

In addition, the State’s most critical IT projects have two primary forms of oversight: independent verification and validation services (IV&V) and reports the California Department of Technology (CDT) prepares regarding issue areas including schedule management, cost management, scope management, and risks. Typically performed by an independent contractor, IV&V is an important step to identify system deficiencies and verify that development incorporates industry standards and best practices. For this reason, the State Administrative Manual requires agencies to have an independent technical evaluator in place by the start date of a project. However, Public Health did not secure an outside oversight entity to perform IV&V until January 2021—months after the project began and weeks after Public Health had formally determined that the CCRS project was ready to move to the final project phase. The project management chief explained that the delay was caused by the unusual speed with which the project progressed. Although she stated that Public Health kept CDT informally apprised of the delay, Public Health could not demonstrate that it received CDT’s approval to depart from the State Administrative Manual requirement.

In addition, Public Health’s IV&V contract bundles the IV&V for the CCRS project with several other ongoing IT projects, which leads us to question whether the contract has provided the CCRS project with all of the necessary safeguards. The State Administrative Manual describes IV&V as a function that continues from project initiation through completion. Nonetheless, with the bundled contract structure, Public Health had significant leeway to determine the amount of CCRS-specific work it assigned to the IV&V consultant. According to the project management chief, IT projects get the most value from technical oversight earlier in the development process, so Public Health structured the bundled IV&V contract so that the IV&V consultant would focus primarily on other projects that were still in early development. Although the project management chief asserted that Public Health plans to continue working with the IV&V consultant to continue to reevaluate the system and address risks, the contract’s structure does not guarantee that these important efforts will continue. By the time of the IV&V contract’s start, the CCRS project was in its final phase, and it concluded less than two months later. As a result, Public Health may have failed to detect potential system development errors, which creates a risk to future system functionality and the State’s plan for managing the COVID-19 pandemic.

Public Health Is Using ELC COVID-19 Funds for Subcontracts and Staffing

In addition to securing a new IT system, Public Health has budgeted funding to use for contracts and staffing for various COVID-19-related activities. Public Health has until November 2022 to spend the COVID-19 funds and has begun doing so. For example, it budgeted $97 million for contracts for mobile laboratory testing capacity, which includes specimen transportation and testing site operations. The assistant deputy director of Public Health’s Emergency Preparedness Office (assistant deputy director) explained that the department has used these funds for a contract with a diagnostics company. The contract requires the company to provide testing through a number of means, including a mobile bus, at-home testing kits, and a traveling team that can be deployed to locations such as skilled nursing facilities. The goal of this contract is to ensure that individuals who are disproportionately affected by or are more susceptible to the virus can easily access testing services.

Public Health also budgeted $10 million for contracts that focus on COVID-19 testing disparities and vulnerable populations. It has allocated about $4 million to support the California Health Interview Survey for 2021 and 2022. The University of California, Los Angeles, administers the survey, which covers a wide range of health topics and gives a detailed picture of the health and health care needs of California’s population. The university has administered the survey since 2001. According to the assistant deputy director, Public Health will use the remaining $6 million for projects focusing on populations that may be particularly vulnerable to COVID-19 and have less access to testing. However, it has not yet allocated these funds.

In addition, Public Health is using ELC COVID-19 funds to hire a small number of staff for COVID-19-related assignments. As of the end of January 2021, it had used the state hiring process to fill six of nine total positions. The chief of the ELC unit at Public Health’s Emergency Preparedness Office (ELC chief) explained that because many of these positions are limited-term, Public Health has had difficulty attracting enough qualified applicants. It will be reposting the open positions to try to get additional applicants.

Heluna is also using a large portion of the $68 million in ELC COVID-19 funding it retained for hiring. It is filling 133 positions for the COVID-19-related programs it and Public Health have established. The two entities have developed lists of positions needed to staff these programs. Many of these positions will work for specific terms linked to the availability of ELC COVID-19 funds. An attorney for Public Health explained how Heluna and Public Health cooperate during the hiring process. Specifically, Heluna first conducts initial screenings, then Public Health conducts interviews and makes final hiring decisions, and finally Heluna makes the job offers to the candidates. Although Heluna will employ these individuals, they will be working on statewide public health efforts. For example, Heluna is hiring several epidemiologists for Public Health’s Center for Infectious Diseases and infection preventionists for Public Health’s Healthcare-Associated Infections Program.

As of February 2021, Heluna had filled 88 of the 133 positions (66 percent). The chief of the business operations support section at Public Health’s Center for Infectious Diseases (support section chief) noted that hiring had initially been slow as Heluna dealt with various administrative difficulties that receiving the additional COVID-19 funds raised, such as developing new budgets and filling needed positions quickly. However, Public Health established weekly meetings with Heluna to provide assistance, and by September 2020, the process had become smoother. The support section chief stated that Public Health continues to hold regular meetings with Heluna to discuss staffing.

Recommendations

To better leverage contact tracing as a tool to limit the spread of COVID-19, Public Health should do the following:

• By May 15, 2021, reevaluate its contact tracing plan and update it to incorporate technological and medical advances in order to redefine how many tracing staff California needs and for how long it will need them.
• By June 15, 2021, create and implement an updated plan, in partnership with local health jurisdictions, to hire, train, and retain the number of tracing staff it determines is necessary to limit the spread of COVID-19, including expanding the pool of reassigned state employees functioning as tracing staff.
• By June 15, 2021, and in collaboration with local health jurisdictions, determine what barriers exist to contact tracers successfully identifying and contacting people who may have been exposed to COVID-19. After studying those barriers, it should share best practices with the jurisdictions and encourage them to implement those practices that will be successful at overcoming the barriers.

To ensure that it has all the necessary planning information in place related to the allocations it has made to the local health jurisdictions, Public Health should, by April 15, 2021, review and approve all initial work plans that it has received.

To ensure that it is performing necessary oversight and can provide local health jurisdictions with guidance to improve their activities using the ELC COVID-19 funding, Public Health should, by April 15, 2021, put in place procedures to ensure that it receives all required quarterly work plans and expenditure updates from local health jurisdictions to which it made grants.

To ensure that the State has accurate COVID-19 data and to help mitigate the risks it caused by not having IV&V during the development phase of the CCRS project, Public Health should direct its IV&V consultant to monitor system performance and Public Health’s data validation efforts and to provide regular reports on the system’s reliability until the IV&V contract expires in December 2021.

We conducted this performance audit in accordance with generally accepted government auditing standards and under the authority vested in the California State Auditor by Government Code sections 8543 et seq. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on the audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

ELAINE M. HOWLE, CPA
California State Auditor

April 1, 2021

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