To ensure that it has closed complaints and ERIs appropriately, Public Health should take steps by April 2015 to verify that complaints that its field operations branch closed administratively were closed appropriately. For example, it could request the district offices to verify that the closures were appropriate.
On August 4, 2016, Public Health's Licensing and Certification Program (L&C) released updated policy and procedures for the Abbreviated Standard Survey (federal complaint process) in Skilled Nursing/Nursing Facilities, which includes guidance for administrative review and closure.
Additionally, L&C Quality Improvement Unit (QI) implemented a State Observation Survey Analysis (SOSA) of the federal recertification survey process where a team "shadows" the survey team which may include complaint/entity-reported incident (ERI) investigations.
The QI team conducts one SOSA per month for each district office including LA County. During the process, complaint investigative reports, including those administratively closed, are reviewed for quality control and appropriate use of administrative off-site closure. The SOSA includes a sample selection of nine closed complaints/ERIs, at least one is an administrative closure. The results of the SOSA are presented to the District Manager/Administrator in writing and discussed in a teleconference. The SOSA surveys are ongoing for all district offices and represent an opportunity for continuous process improvement over complaint processes.
Although Public Health provided documentation supporting its proposed actions going forward to help prevent inappropriate closures of complaints, it did not address whether it verified the complaints that its field operations branch closed administratively were closed appropriately. When we followed up with staff, Public Health told us that, because of its four year record retention policy, Public Health cannot perform a review of the 258 complaints we identified that were closed administratively.
CDPH will develop criteria to evaluate the appropriate use of administrative closure by end of November 2015. Starting third quarter FY 2015-2105 (January-March 2016) CDPH will review a sample of closed complaints and ERIs to evaluate the appropriate use of administrative closures and present findings for any additional training necessary. Based on our first review, we will determine the need for, and frequency of, any ongoing sampling and review.
By June 2015, CDPH will develop criteria to evaluate the appropriate use of administrative closure and implement reviews in LA County by July 2015. By October 2015, CDPH will use the criteria to monthly review a sample of the investigations in district offices statewide to include assessment of appropriate administrative complaint closures.
Beginning in September 2014, CDPH Branch Chiefs initiated visits to each district office to ensure compliance with policies and procedures including those related to complaint and ERI closure and will continue this during their quarterly visits. During these visits, the Branch Chiefs discuss complaint and ERI investigation monitoring with district office administrative, supervisory, and management staff.
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, including assessing whether any administrative complaint closures were appropriate.
Agency responses received are posted verbatim.