Report 2010-108 Recommendation 3 Responses

Report 2010-108: Department of Public Health: It Reported Inaccurate Financial Information and Can Likely Increase Revenues for the State and Federal Health Facilities Citation Penalties Accounts (Release Date: June 2010)

Recommendation #3 To: Public Health, Department of

To increase revenue for the penalty accounts, Public Health should ensure that it conducts all state surveys of facilities every two years, as required by state law.

Agency Response*

In January 2016, California Department of Public Health implemented a new State Skilled Nursing Facility (SNF) Relicensing Survey. Each District Office will survey 50% of their SNFs in 2017 and the other 50% in 2018. By end of 2018, all SNFs will have a relicensing survey conducted no less than every two years. CDPH continues to post quarterly metrics of licensing surveys completed.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: December 2018
  • Response Date: May 2017

California State Auditor's Assessment of Status: Pending


Agency Response*

In January 2016, California Department of Public Health implemented a new State Skilled Nursing Facility (SNF) Relicensing Survey (see Attachment A). By March 2016, all district offices were using the new process. Each District Office will survey 50% of their SNFs in 2016 and the other 50% in 2017. By 2018, all SNFs will have a relicensing survey conducted no less than every two years.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: 12/2017
  • Response Date: June 2016

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

In July 2014, CDPH began reviewing its licensing survey methodologies for long-term care facilities to focus on eliminating redundancies between licensing and certification surveys. CDPH anticipates implementing the new survey tool in long-term care facilities by December 2016.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: December 16, 2016
  • Response Date: November 2015

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

The status of this recommendation is unchanged.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: 12/31/2015
  • Response Date: October 2015

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

The status of this recommendation is unchanged.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: 10/2015
  • Response Date: October 2014

California State Auditor's Assessment of Status: Not Fully Implemented


Agency Response*

In August 2013, CDPH hired a contractor to perform a workload analysis to assess program workload and barriers, perform a gap analysis, and identify immediate actions that CDPH can take to begin to remediate the gaps identified. The contractor will also identify areas that need additional in-depth review and will develop additional scopes of work for additional contracts (with other contractors) to fully assess issues identified and provide recommendations, including identifying staffing levels required to complete the workload and more efficient means of conducting surveys. The contractor will complete the initial assessment by June 30, 2014. The additional contracts will begin in July 2014 and be completed by December 31, 2015. CDPH anticipates implementing all contractor recommendations for completing state and federal workload, resources needed, methods to identify increased efficiencies, and addressing other identified gaps by December 31, 2017.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: December 31, 2017
  • Response Date: October 2013

California State Auditor's Assessment of Status: Not Fully Implemented

Although Public Health is performing a workload analysis, we are still concerned that it is not performing inspections as the law requires.


Agency Response*

CDPH agrees with the recommendation that the Department should ensure that it conducts all state surveys of facilities every two years as required by state law. CDPH is making a concerted effort to comply with this requirement. In fiscal year 2012-2013, Licensing and Certification (L&C) will continue to evaluate its workload to allocate staff resources in an effort to meet this requirement. This evaluation may result in reassigning surveyor activity to determine if additional resources are needed to conduct both federal and state mandated surveys as required.

  • Response Type†: Annual Follow Up
  • Estimated Completion Date: Unknown
  • Response Date: September 2012

California State Auditor's Assessment of Status: Not Fully Implemented


All Recommendations in 2010-108

†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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