Report 2014-111 Recommendation 13 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 #13 To: Public Health, Department of

To make certain 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 they are obtaining corrective action plans according to the required time frame and verifying that facilities have performed the corrective actions described in the plans when required.

Annual Follow-Up Agency Response From September 2016

In January 2016, Public Health's Licensing and Certification Program (L&C) joined other states in participating in Centers for Medicare/Medicaid Services (CMS) web-based electronic plan of correction (ePOC) program. The ePOC program is designed to allow providers, Public Health, and the CMS to view corrective action plans issued by state regulators and respond and upload documents that facilities provide in response to corrective action items. The ePOC program documentation includes the statement of deficiencies (CMS 2567) issued by State staff and facilities documented response(s). Public Health's District Offices (DO) serving all 58 California counties are phasing into this program and all will be using this system by June 2017.

L&C Training Unit conducted a webinar to providers and Public Health staff covering ePOC process. Participating in the ePOC program will strengthen Public Health's ability to monitor and review DO's timely and more efficiently document evidence of completion.

  • Estimated Completion Date: June 2017

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


1-Year Agency Response

CDPH developed criteria for reviewing plans of correction and verification of implementation. The criteria can be found on page 43-44 of the "LTC Abbreviated Survey P&P." This review was added to the Abbreviated Survey Review for LA County in April 2015 (fourth quarter 2014/15). Starting in October 2015, this review expanded to statewide.

  • Completion Date: October 2015
  • Response Date: November 2015

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

Pages 43 and 44 of the Abbreviated Survey Policies and Procedures describe district offices' responsibilities in obtaining and reviewing corrective plans from LTHC facilities. However, our recommendation was for Public Health to establish a process for headquarters or regional management to inspect district office records periodically to confirm that the district offices were obtaining corrective action plans according to the required time frame and verifying that facilities have performed the corrective actions described in the plans when required.

  • Auditee did not substantiate its claim of full implementation
  • Auditee did not address all aspects of the recommendation

6-Month Agency Response

CDPH continues to review complaints and ERI for appropriate prioritization level, timely onsite visit, and investigations. This review is currently conducted for LA County District offices. After April 2015, the review will expand to the other district offices ensuring all district offices are reviewed each quarter.

CDPH has developed and added criteria for reviewing plans of correction and verification the provider implemented their plans of correction to the LA County monthly reviews.

  • Estimated Completion Date: 10/31/2015
  • Response Date: June 2015

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

Public Health has not yet provided documentation of the actions noted in its response.


60-Day Agency Response

CDPH has developed criteria for reviewing complaint and ERI prioritization and quality of investigations. Beginning May 2014, CDPH has used these criteria to conduct monthly reviews of a sample of complaint and ERI investigations in LA County. CDPH prepares a quarterly report of these reviews. These reviews will continue in LA County until April 2015. By April 2015, CDPH will add criteria for reviewing plans of correction and supervisory review to the LA County monthly reviews. By October 2015, CDPH will use the criteria to monthly review a sample of the investigations in district offices statewide.

  • Estimated Completion Date: 10/31/15
  • Response Date: December 2014

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

Public Health did not provide documentation of the actions noted in its response. Additionally, it indicates the recommendation is not yet fully implemented.


All Recommendations in 2014-111

Agency responses received are posted verbatim.


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