Report 2014-111 Recommendation 7 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 #7 To: Public Health, Department of

To ensure that district offices address ERIs consistently and to ensure that they investigate ERIs in the most efficient manner, Public Health should review periodically a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

Annual Follow-Up Agency Response From September 2016

Public Health continues to review complaints and ERIs for appropriate prioritization level and timely onsite visits through by a quarterly lookback review of a sample of complaints and ERIs.

Training presented during the Center's Supervisor Academy as well as the Quarterly Training Supervisor Academy in 2016, included detailed curriculum, instruction and practical examples for triaging complaints/entity-reported incidents (ERIs). Additional content included evaluation of the timeliness of the onsite visit investigation

  • Completion Date: July 2016

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

Public Health provided documentation that it identified best practices for prioritizing ERIs, provided the training to its staff in January 2016, and updated its policies in August 2016. However, it did not provide documentation that subsequent to its training and updated policies, it has performed periodic reviews of a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

  • Auditee did not substantiate its claim of full implementation

1-Year Agency Response

CDPH continues to review complaints and ERIs for appropriate prioritization level and timely onsite visits through by a quarterly lookback review of a sample of complaints and ERIs. We began this review with Los Angeles County and expanded it to all district offices beginning with the first quarter of FY 2015/16.

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

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

As we noted in our public reasoning for recommendation #6, Public Health has not yet provided documentation to support that it has issued guidance to district offices on best practices. Until it issues such guidance, it cannot review periodically a sample of the priorities that district offices assign to ERIs to ensure compliance with best practices.

  • 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.

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

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


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: 10/31/2015
  • Response Date: December 2014

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


All Recommendations in 2014-111

Agency responses received are posted verbatim.


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