Report 2006-106 Recommendation 3 Responses

Report 2006-106: Department of Health Services: Its Licensing and Certification Division Is Struggling to Meet State and Federal Oversight Requirements for Skilled Nursing Facilities (Release Date: April 2007)

Recommendation #3 To: Health Services, Department of

To proactively manage its complaint workload following the conclusion of the court order, Health Services should periodically evaluate the timeliness with which district offices initiate and complete complaint investigations. Based on this information, Health Services should identify strategies, such as temporarily lending its staff to address workload imbalances occurring among district offices.

Agency Response*

CDPH has fully implemented corrective action.

CDPH agrees with BSAs recommendation to proactively manage its complaint workload, Health Services should periodically evaluate the timeliness with which District Offices initiate and complete complaint investigations. Based on this information, Health Services should identify strategies, such as temporarily lending its staff to address workload imbalances occurring among District Offices.

CDPH has and continues to routinely conduct quality improvement studies and monitors initiation and completion of complaint investigations. Also, CDPH continues to send out weekly alerts to district offices regarding long-term care complaints that are approaching the statutory timeframe for initiation. CDPH routinely re-deploys surveyor staff to other district offices to help complete mandated survey workload.

In addition to these activities, this year CDPH has participated in a complaint policy workgroup with the Centers for Medicare and Medicaid (CMS) Regional IX Office and the 14 states that compose the CMS Western Consortia of state survey agencies. This workgroup seeks to identify the challenges that face the state surveying agencies in CMS Regions VIII, IX, and X. The workgroup has compiled statistics, on complaint intake and completion of investigations and has identified complaint investigations best practices among the Western Consortia states. The workgroup has prepared a white paper that it will present to the CMS Survey and Certification Director on October 5, 2011 during the annual Association of Health Facility Survey Agency Conference in Seattle. In addition, CMS selected CDPH Licensing and Certification (L&C) to participate in a separate project commissioned by CMS to identify barriers to complaint investigations and identify recommendations to streamline and improve the complaint investigation process. The CMS Western Consortia will request that its white paper be reviewed and folded into the CMS complaint project for consideration.

CDPH management directed district office managers during its monthly call meeting (September 21, 2011) to implement a policy for closing state entity reported incidents that mirrors direction included in the CMS State Operations Manual (SOM) 5070. This policy provides that events occurring more than 12 months prior to the intake date may not require the State Agency to conduct an investigation and that an on-site survey may not be required if there is sufficient evidence that the facility does not have continued noncompliance and the alleged event occurred before the last standard survey. District Office Managers will use the SOM instructions to determine which incidents do not need on-site investigations and close these events. Those events that are received prior to a survey will be reviewed as part of the off-site survey preparation for any upcoming recertification survey and any substantiated findings will be documented as part of the recertification survey. (2011-041, pp. 51-52)

  • Response Type†: Annual Follow Up
  • Response Date: January 2012

California State Auditor's Assessment of Status: Fully Implemented


All Recommendations in 2006-106

†Response Type refers to the interval in which the auditee is providing the State Auditor with their status in implementing recommendations made in an audit report. Auditees must submit a response regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year or subsequent to one year.

*Agency responses received after June 2013 are posted verbatim.


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