Report 2014-111 Summary - October 2014

California Department of Public Health


It Has Not Effectively Managed Investigations of Complaints Related to Long-Term Health Care Facilities


Our audit of the California Department of Public Health's (Public Health) regulation of long-term health care facilities highlighted the following:


The California Department of Public Health (Public Health) is responsible for licensing and monitoring certain health care facilities, including more than 2,500 long-term health care facilities in the State. Public Health performs this work in accordance with a cooperative agreement with the federal Centers for Medicare and Medicaid Services (CMS), an agency within the U.S. Department of Health and Human Services, to ensure that facilities accepting Medicare and Medicaid payments meet federal requirements. According to the California Association of Health Facilities, as many as 300,000 Californians receive care annually in facilities licensed for long-term health care.

Federal and state laws, federal and state regulations, and department policies require Public Health to investigate complaints about long-term health care facilities and about certain individuals, including certified nurse assistants and home health aides, who provide care at those facilities. Complaints related to long-term health care facilities are investigated by the 15 district offices of Public Health's Licensing and Certification Division (licensing division), which include a contractor—the Los Angeles County Department of Public Health (LA County), that serves as the district office for that county—and the licensing division's State Facilities Unit. These entities also investigate incidents that the facilities self-report and that are generally referred to as entity-reported incidents (ERIs). The Professional Certification Branch (PCB) within the licensing division is responsible for investigating complaints against certified individuals.

As of April 2014 Public Health had more than 10,000 open complaints and ERIs related to long-term health care facilities and nearly 1,000 open complaints against individuals. Many of these open complaints and ERIs had relatively high priorities—indicating a safety risk to the residents—and had remained open for nearly a year on average. For example, the Santa Rosa-Redwood Coast district office prioritized 102 open complaints and ERIs related to facilities as immediate jeopardy—indicating a situation that poses a threat to an individual's life or health. These complaints and ERIs had remained open for an average duration of almost a year. Similarly, a significant number of complaints against individuals have remained open for long periods. By not ensuring that all complaints and ERIs are processed promptly, Public Health is placing at risk the well-being of residents of long-term health care facilities.

Several factors have contributed to the large number of open complaints and ERIs. Specifically, Public Health does not provide adequate oversight of complaint processing by the district offices and PCB. Until late 2013, when it established a tracking log of open complaints and ERIs, Public Health did not have a standardized method for monitoring the status of open complaints and ERIs at the district offices and for assessing whether these complaints were being addressed promptly. Further, PCB lacks accurate data about the status of investigations into complaints against individuals, and this deficiency prevents management from providing proper oversight and monitoring of complaint handling. PCB uses a spreadsheet to track the progress of its complaints; however, the spreadsheet's information displayed inaccuracies. As a result, PCB does not yet have an effective process for monitoring whether it is addressing those complaints in a timely manner.

Further, Public Health has not established formal policies and procedures for ensuring prompt completion of investigations of complaints related to facilities or the individuals it certifies. It also does not have any time frames for district offices to complete their investigations of complaints related to facilities. Public Health's data show that during 2012 and 2013, district offices took an average of 150 days to complete investigations of facility-related complaints. During the same period, district offices took an average of 119 days to close their investigations for ERIs. Similarly, Public Health did not have time frames for PCB to complete investigations of complaints against individuals. Although it now has a goal that PCB investigators will complete five to six complaints every month on average, Public Health has not formalized these expectations. PCB also does not have any formal policies and procedures for ensuring prompt completion of all complaints lodged against individuals. In fact, PCB did not assign an investigator to 14 of the 33 complaints closed in 2012 and 2013 that we reviewed until more than a year after it received those complaints. Having formal policies and procedures for processing complaints is important, especially considering that federal regulations require Public Health to conduct timely investigations of all complaints against individuals.

Moreover, Public Health data show that district offices vary significantly in the proportions of ERIs they prioritize into various categories. The data suggest that some district offices may be performing more on-site investigations of ERIs than others, while other offices may be closing more ERIs and categorizing them as no action necessary. For example, the Chico district office completed the investigations for 97 percent of the ERIs it received during 2012 and 2013 through on-site visits, while the Orange County district office and LA County generally performed on-site investigations for less than 20 percent of the ERIs they received during 2012 and 2013. Such large differences in how district offices assign priorities—which dictate whether to perform a site visit, to complete a desk review, or to close an ERI as no action necessary—highlight a need for Public Health to more closely monitor district offices' processing of ERIs and to assess whether the district offices can be more consistent and efficient in this area.

Three of the four district offices we visited claim they do not have enough resources to investigate all complaints promptly, and PCB noted a similar situation. However, Public Health has not performed staffing analyses to identify the number of staff it needs to eliminate the aging of outstanding open complaints and ERIs and to remain current on new complaints. In 2013 Public Health contracted with a consultant to develop a remediation plan that provides a road map for further and more detailed program assessments. The consultant made several recommendations in August 2014, including one specifying that Public Health should develop a staffing model and work plan to ensure appropriate staffing levels across all district offices. Public Health expects that implementing the consultant's recommendations will take more than two years. In the meantime, Public Health has obtained temporary positions for PCB to support its efforts to complete investigations more quickly. The interim deputy director of Public Health's licensing division stated that Public Health's Center for Health Care Quality has contracted with a consultant to perform an assessment of PCB's business processes.

Public Health did not always follow procedures to ensure consistent quality of complaint investigations. For instance, the San Francisco district office closed complaints without appropriate review by supervisors in four of the 10 investigations we reviewed there. For three of these four complaints, the supervisor both performed the investigation and signed off on his or her own work. When complaint investigations do not receive proper reviews, Public Health cannot ensure that it consistently follows procedures to properly determine the validity of complaints, to identify deficiencies that require correction, and to verify that facilities implement any required corrective actions.

In addition, the four district offices we reviewed did not consistently ensure timely receipt of corrective action plans or evidence of corrective actions when required to do so from facilities that were notified of deficient practices. CMS requirements state that a facility with identified instances of noncompliance must provide an appropriate plan of correction within 10 days of receiving the notification of deficient practices. This plan must specify how the facility will correct the deficient practices and ensure that they do not recur. In lieu of making on-site revisits, Public Health may require facilities to provide evidence of corrective actions taken, depending on the severity of the noncompliance. However, if actual harm has occurred at a facility, Public Health must reinspect the facility to verify corrective action. A manager for the San Francisco district office stated that the district office did not realize that such submissions were mandatory. Managers of the Bakersfield, Riverside, and Sacramento district offices were aware of the requirement but gave other reasons for not meeting it, such as overlooking the requirement erroneously or asserting that they had staffing shortages. Without obtaining evidence of completed corrective actions from facilities when required, Public Health cannot demonstrate that it is complying with federal requirements or ensuring the safety and well-being of residents in those facilities.

Public Health also could do more to ensure that district offices, including LA County, are conducting complaint investigations and ERIs appropriately. Specifically, although it has a process to review investigations stemming either from complaints categorized as immediate jeopardy or from complaints related to deficiencies that resulted in actual harm to residents of long-term health care facilities, Public Health does not routinely review other complaint investigations. In 2012 and 2014 CMS issued letters to Public Health, in which it identified a number of weaknesses in Public Health's management of the complaint investigation process, including a lack of policies and procedures governing investigation protocols and inconsistencies in the district offices' intake process. At the direction of CMS, Public Health conducted a quality review of LA County's complaint investigations and found, among other things, that it incorrectly prioritized complaints it received, leading to delayed investigations of serious allegations. Our review of complaint investigations also identified instances in which district offices inappropriately closed complaints. Public Health's limited review of the district officescomplaint investigations increases the risk that they could perform investigations that do not comply with the law or with Public Health's policies and procedures.

Public Health also did not consistently meet certain time frames for investigating complaints and ERIs. The four district offices we visited did not always initiate investigations or address appeals within required time frames established in state law or Public Health policy. For example, the Sacramento district office did not initiate two of the 10 investigations we reviewed within 10 days, as required. Further, PCB failed to comply with the statutory time frames for hearing appeals within 60 days and for making determinations on those appeals within 30 days. PCB—through its contractor—did not meet the hearing requirement for any of the 10 appeals we reviewed, in one case taking nearly 1,200 days to hear the appeal. Further, it did not meet the notification requirement in seven of nine appeals that were heard. Unless Public Health's investigative determination is effective immediately, individuals who are the subject of investigations and who are appealing Public Health's investigative determinations are not prohibited from working in facilities until the appeals are adjudicated. Thus, when Public Health does not comply with the required time frames, it may risk the safety and welfare of residents in long-term health care facilities.

Finally, Public Health did not report all statutorily required information to the Legislature in two of the four years we reviewed. Specifically, Public Health omitted from its 2012 and 2013 reports information related to the timeliness of its complaint investigations. When Public Health does not include statutorily required information in these reports, the Legislature does not have complete information to make fully informed decisions.


To protect the health, safety, and well-being of residents in long-term health care facilities, Public Health should do the following:

To ensure that district offices address ERIs consistently and that they investigate ERIs in the most efficient manner, Public Health should assess whether each district office is prioritizing ERIs appropriately. Using the information from its assessment, Public Health should provide guidance to district offices by October 1, 2015, on the best practices for the consistent, efficient processing of ERIs.

To make certain that district offices have the necessary resources to process facility-related complaints and ERIs promptly, Public Health should complete 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.

To ensure that PCB has the resources necessary to promptly complete investigations of complaints about certified individuals on an ongoing basis, Public Health should assess whether the temporary resources it has received are adequate to reduce the backlog of open complaints to a manageable level and also should 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.

To make certain that district offices investigate complaints and ERIs properly, Public Health should ensure that the district offices follow procedures requiring supervisory review and approval of their complaint and ERI investigations.

To ensure 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 district offices are obtaining corrective action plans and verifying that facilities have performed the corrective actions described in the plans when required.

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. Public Health should further establish a formal process to periodically review LA County's compliance with the terms of its contract, including compliance with the terms for investigating complaints.

To ensure 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 investigations and should direct PCB to comply with time frames for addressing appeals.

To make certain that the Legislature has information about the timeliness of Public Health's complaint processing related to long-term health care facilities, Public Health should include all statutorily required information in its annual report.


Public Health agrees with many of our recommendations and stated that it will take steps to implement them. However, Public Health disagrees with our recommendations that it should establish time frames for completing investigations of complaints and ERIs. It also does not believe that it is subject to statutory time frames for adjudicating appeals related to individuals.