Report 2014-111 Recommendation 7 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 #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 November 2018
The California Department of Public Health conducts monthly data analysis of Entity Reported Incidents (ERIs) and complaints reviewed by district office supervisors in a peer review process by having every supervisor review the priorities assigned to the complaint/ERI previously reviewed by the front-line supervisor. Complaints or ERIs must have different original and reviewing supervisors to ensure peer review is complete. The data is shared with district office management staff as well as CHCQ leadership. Additionally, the Quality Improvement team provides biannual reviews of 180 total complaints and ERI samples derived from all district offices (9 per office) to review quality of work and prioritization of complaints and ERIs. In 2018, supervisors were given training on assigning priority levels through the "Training Supervisor Training" and "New Supervisor Academy".
- Completion Date: October 2018
California State Auditor's Assessment of Annual Follow-Up Status: Fully Implemented
Annual Follow-Up Agency Response From December 2017
Public Health continues to conduct periodic reviews of ERIs and complaints for quality and adherence to policy. In September and November, 2016, the Quality Improvement (QI) team conducted the Abbreviated Survey Review project. We selected 19 abbreviated surveys for review, see report attached. We found all 19 to comply with state and federal case closure requirements.
- Completion Date: August 2017
California State Auditor's Assessment of Annual Follow-Up Status: Pending
The documentation that Public Health provided does not support its claim of full implementation. Specifically, the documentation provided does not show that Public Health is reviewing a sample of the priorities that district offices assign to ERIs. Without doing so, Public Health cannot ensure that district offices address ERIs consistently, efficiently, and comply with best practices.
- Auditee did not substantiate its claim of full implementation
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
All Recommendations in 2014-111
Agency responses received are posted verbatim.