Report 2012-107 Recommendation 15 Responses

Report 2012-107: Developmental Centers: Poor-Quality Investigations, Outdated Policies, Leadership and Staffing Problems, and Untimely Licensing Reviews Put Residents at Risk (Release Date: July 2013)

Recommendation #15 To: Public Health, Department of

To conduct licensing surveys at required intervals while minimizing additional workload, Public Health should explore further opportunities to coordinate the licensing and certification surveys. If Public Health questions the value of these surveys, it should seek legislation to modify the surveying requirements.

Annual Follow-Up Agency Response From August 2016

In January 2016, Public Health implemented a new state Skilled Nursing Facility (SNF) Relicensing Survey. By March 2016, all Public Health District Offices were using this new survey process and will survey 50% of their SNFs in 2016 and the other 50% in 2017. By 2018 and going forward, all SNFs will have a relicensing surveys conducted no less than every two years.

Additionally, Public Health has completed all required state licensing surveys for all Intermediate Care Facilities operated by the California Department of Developmental Services. On June 1, 2016, Public Health emailed supporting documentation to the California State Auditor.

  • Completion Date: June 2016

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

Our 2013 report found that Public Health was not conducting all of its state licensing surveys at developmental centers on time or at all. According to information provided by Public Health, the department is now up to date on licensing surveys for the developmental centers. Although the department's Deputy Director for Health Care Quality confirmed that it has not yet coordinated the federal certification surveys and the state licensing surveys for the developmental centers, they have begun to coordinate the surveys for other types of facilities and intend to begin coordination after the new regulations are completed. Because the transition to coordination has begun and the surveys are all up to date, we assess this recommendation as Resolved.


Annual Follow-Up Agency Response From October 2015

The status of this recommendation is unchanged.

  • Estimated Completion Date: 10/2015

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented


Annual Follow-Up Agency Response From October 2014

The status of this recommendation is unchanged.

  • Estimated Completion Date: 9/2015

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented


1-Year Agency Response

The California Department of Public Health (CDPH) agrees with this recommendation and is developing a survey protocol that coordinates the licensing and certification surveys.

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. Once a streamlined licensing survey protocol is in place for long-term care facilities, CDPH will work on extending a similar new protocol to developmental centers. This will entail conducting a separate crosswalk of state and federal requirements specific to intermediate care facilities for the developmentally disabled, the licensing category for the developmental centers.

  • Estimated Completion Date: December 2017
  • Response Date: October 2014

California State Auditor's Assessment of 1-Year Status: Pending


6-Month Agency Response

On August 26, 2013, CDPH fully executed a contract with Hubbert Systems Consulting for an organizational assessment of the effectiveness and performance of the Licensing and Certification (L&C) program. On October 31, 2013, Hubbert Systems Consulting delivered an in-person presentation of the preliminary analysis and assessment findings. On January 31, 2014, Hubbert Systems Consulting will provide the next contract deliverable, a final report of the findings associated with the program assessment. Beginning in January 2014, the consultants will conduct an in-depth gap analysis.

Hubbert Systems Consulting will provide final recommendations in June 2014.

  • Estimated Completion Date: June 2014
  • Response Date: January 2014

California State Auditor's Assessment of 6-Month Status: Pending


60-Day Agency Response

On August 2, 2013, CDPH signed a contract with the Hubbert Systems Consulting, Inc. for an organizational assessment of the effectiveness and performance of the Licensing and Certification (L&C) program. Hubbert Systems Consulting will:

Identify concerns and issue related to the timely annual completion of L&C's state licensing and federal certification workloads;

Prepare actionable recommendations for corrective measures including process and/or quality improvement initiatives;

Identify further opportunities to coordinate and streamline licensing and certification surveys;

Prepare a comprehensive implementation work plan that includes options for performing the work in stages; and

Identify barriers to timely workload completion.

The contract has been approved by the California Department of General Services. The contract will begin immediately and will expire on June 30, 2014.

  • Estimated Completion Date: June 30, 2014
  • Response Date: August 2013

California State Auditor's Assessment of 60-Day Status: Pending


All Recommendations in 2012-107

Agency responses received are posted verbatim.


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