Report 2014-111 Recommendation 4 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 #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 November 2018

The Provider Certification Branch (PCB) performance metrics are posted at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/PCB_MetricsDashboard.aspx. The metrics show that in state fiscal year (SFY) 2017, PCB received an additional 332 complaints when compared to SFY 2016. The number of open complaints increased from 246 at the start of SFY 17 to 467 at the end of SFY 17. The average age of the open complaints fluctuated from 61 calendar days at the start of SFY 17 to 90 calendar days at the end of SFY 17. As of September 1, 2018, PCB had no open complaints prior to SFY 17, with the exception of four complaints with law enforcement holds. PCB will continue to review policies and procedures for any quality improvement opportunities.

There are no federal requirements to complete investigations within specified timeframes nor has the Centers for Medicare and Medicaid Services (CMS) reported any concerns to the California Department of Public Health (CDPH) with PCB investigations. Given that enhanced oversight and interventions have led to sustained, significant reduction in open complaints as well as continually improved timeliness of complaint investigations since the issuance of findings for this audit in SFY 14, the CDPH has determined that specified timelines are not necessary.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Public Health's website shows that of the 467 open investigations within PCB during the quarter ending June 30, 2018, 197 were open for more than 90 days, including 56 that were open for more than 180 days. 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.

Annual Follow-Up Agency Response From December 2017

Public Health has developed investigation policies and procedures and continues to revise them as needed. The Provider Certification Branch (PCB) performance metrics are posted at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/PCB_MetricsDashboard.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 has reduced the number of open complaints from 761 at the start of state fiscal year (SFY) 16 to 246 by the end of SFY 17. PCB continues to reduce the average calendar days to investigate a complaint from186 at the start of SFY 16 to 61 by the end of SFY 17. As of August 1, 2017, PCB has no open complaints prior to SFY 17 with the exception of four complaints with law enforcement holds from SFY 16 that prevent them from being completed at this time. PCB will continue to review policies and procedures for any quality improvement opportunities. 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 significant reduction in open complaints as well as continually improved timeliness of complaint investigations, CDPH has determined that specified timelines are not necessary.

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

Although Public Health indicates the status of this recommendation as fully implemented, Public Health's response indicates that it disagrees with establishing specific time frames for investigations by its statement that it has determined that specified timelines are not necessary. Further, Public Health's website shows that as of June 30, 2017, it still had 246 open complaints, 47 of which have remained open for more than 90 days. 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.

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.

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.

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.

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.

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.

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.

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.

All Recommendations in 2014-111

Agency responses received are posted verbatim.