Report 2014-111 Recommendation 14 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 #14 To: Public Health, Department of

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.

Annual Follow-Up Agency Response From October 2019

In August 2013 the Center for Health Care Quality (CHCQ) within the California Department of Public Health (CDPH) began a clean-up project to close backlogged cases. Those lacking a complete investigation report were re-analyzed. Often records were no longer available for review and, due to lack of evidence, the files were closed by the field office. CDPH's retention policy is five years. All 258 files specified by CSA were older than five years from initial receipt of the Entity Reported Incidents, now called Facility Reported Incidents (FRI), or complaint. The QI specialists pulled the specified files and spent three months analyzing the records on a case-by-case basis. The 258 files were intakes received from 2001-2008; All 258 files were administratively closed by the field office where the initial report/complaint was received; The majority were closed by the field office from December 2013 through January 2014; None were administratively closed by headquarters; Some files were investigated or re-investigated by the field office six years after the incident; All the files were initiated and investigated prior to the state dual enforcement guidance.

CHCQ developed a process to upload justifications for FRI administrative closures into a departmental database. Feedback and comments from district managers in field offices were incorporated into the process. Staff presented a draft at the May 2, 2019, DM/DA meeting. We then streamlined the process and finalized for use. This new process is integrated into the curricula for the New Supervisor Academy and New Surveyor Academy in advance of the final adoption of the Complaint P&P.

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

The agency response incorrectly indicates that these complaints were administratively closed by the field offices. As we stated on page 48 of the report, Public Health's interim deputy director stated that the field operations branch "...made a strategic decision to close these cases administratively because it believed, due to the completion dates recorded in the database, that the risk was low that any of the cases were actually still open after five years or more." The interim deputy director further stated that "...staff at headquarters relied on the information in the database to close the complaints and ERIs, without reviewing the file or verifying with the district offices that they had completed the investigations and sent out all the necessary notifications."

Nevertheless, we consider that Public Health has resolved this issue because it states that CHCQ re-analyzed the administratively-closed complaints and ERIs that lacked a complete investigation. Public Health provided us with a summary of the results of its analysis indicating that the complaints it closed administratively were done appropriately. For example, it states that 113 of the 258 complaints it administratively closed were unsubstantiated claims due to a lack of evidence, and that another 99 of those administratively-closed claims were unsubstantiated due to no identified violations. Public Health also identified 14 claims that it could not locate the records for review, and another three claims were substantiated with state violations. Public Health correctly indicates that these files, administratively closed in 2013, were filed with the agency between 2001 and 2008. All of these files are now well beyond the agency's 5-year record retention policy.

Annual Follow-Up Agency Response From November 2018

The California Department of Public Health monitors closed complaints and Entity Reported Incidents (ERIs) for appropriate closure within the Prioritization Project. Quality Improvement (QI) Specialists perform an annual review of the prioritization of intake samples and compare their determination with that of the district office. If a disparity exits, a second QI reviewer evaluates the packet. Fifteen samples were identified as "Administrative Review/Offsite investigation," and nine showed a discrepancy between QI Specialists and the district offices regarding prioritization. The intake form may omit pertinent information supporting the decisions. A report of the evaluation discrepancies is sent to the district manager, administrator, and supervisors to review and make corrective actions. QI specialists have collected data for May 2018 and July 2018 but have not yet analyzed the data.

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

Public Health's response and documentation provided do not specify whether the ERIs and complaints its QI unit reviewed were for those that its field operations branch closed administratively (as opposed to those that the district offices closed after performing a review of the ERI or complaint). As such, Public Health has not demonstrated it has verified that complaints that its field operations branch closed administratively were closed appropriately.

Annual Follow-Up Agency Response From December 2017

Public Health continues to monitor the entity-reported incident (ERI) process for quality improvement. From March 28 to April 7, 2017, Quality Improvement (QI) team and Los Angeles (LA) Monitoring Unit [LAMU] supervisors conducted quality review of 20 ERI/Complaint abbreviated survey packets/samples (five samples each district office). The result of these reviews determined 8 of 20 samples were closed appropriately. 12 of 20 samples were determined requiring further investigation to ensure the allegations were completely investigated before closing the cases. The result of these reviews was discussed with the District Office's managers.

The QI team and LAMU staff continue implementing the State Observation Survey Analysis (SOSA) of the federal recertification survey process. There were total of 14 SOSA surveys (State DOs: nine surveys; LA DOs: five surveys) conducted in 2016; and ten SOSA surveys (State DOs: six surveys; LA DOs: four surveys) conducted in 2017. The results of the SOSA were presented to the District Managers/Administrators in writing and discussed in teleconferences or face-to-face meeting.

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

Neither Public Health's response nor the documentation provided specify whether the ERIs and complaints its QI and LAMU units reviewed were for those that the district offices closed administratively (as opposed to those that the district offices closed after performing a review of the ERI or complaint). As such, Public Health has not demonstrated it has verified that complaints that its field operations branch closed administratively were closed appropriately.

Annual Follow-Up Agency Response From November 2016

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.

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

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.

1-Year Agency Response

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.

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

6-Month Agency Response

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.

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

60-Day Agency Response

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.

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

All Recommendations in 2014-111

Agency responses received are posted verbatim.