Report 2017-109 Recommendation 9 Responses

Report 2017-109: Skilled Nursing Facilities: Absent Effective State Oversight, Substandard Quality of Care Has Continued (Release Date: May 2018)

Recommendation #9 To: Public Health, Department of

As the Legislature considers changes to state law, Public Health should take the steps necessary to ensure that its oversight results in nursing facilities improving their quality of care by ensuring that it issues citations in a timely manner, especially for immediate jeopardy deficiencies.

Annual Follow-Up Agency Response From October 2023

Fiscal Year 2022-23 Q3 data shows that CHCQ issued 92% of state citations on time. This percentage been at least 86% for every quarter in the last year, which is a significant improvement from the past few years. Timely issuance of citations is a continuing priority for CHCQ. As part of our ongoing effort to improve complaint investigation timelines for long term care facilities, we are making a concerted effort to issue citations on time.

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

Annual Follow-Up Agency Response From September 2022

Fiscal Year 2020-21 Q2 data shows that CHCQ issued 84% of state citations on time. In Fiscal Year 2021-22 Q2 data shows that 76% of citations we released timely. This increased to 97% in Fiscal Year 2021-22 Q3. The timeliness percentage reduction was due to a decrease of utilized resources and competing priorities. CHCQ is committed to eliminating its backlog of open complaints and has reprioritized its complaint reduction project, with direction given to staff in the District Offices to focus on these goals and expectations including timeliness of issuing citations. CHCQ is actively tracking and monitoring citation issuance as part of this initiative, and will continue to prioritize the timely release of citations.

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

We are rating this recommendation as partially implemented. As we noted in our May 2021 assessment, Public Health has taken steps to improve its processes for issuing citations. However, Public Health's response indicates that additional steps are necessary to reduce its complaint backlog and issue citations in a timely manner.

Annual Follow-Up Agency Response From September 2021

Fiscal Year 2020-21 Q2 data shows that CHCQ issued 84% of state citations on time. Even during the COVID-19 pandemic response, CHCQ maintained a high level of on-time compliance for issuing citations. Since Q2 in FY 2018-19 when CSA 2017-109 findings were released, CHCQ improved its on-time issuance by 24%. CHCQ is committed to reducing its backlog of open complaints and has publicly announced and initiated a complaint reduction project and given direction to staff to district offices on goals and expectations. CHCQ is actively tracking and monitoring citation issuance as part of this initiative.

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

We are rating this recommendation as partially implemented because, as we noted in our May 2021 assessment, Public Health has taken steps to improve its processes for issuing citations. However, as Public Health noted in its prior response, it deferred some oversight activities due to COVID-19 and issued fewer citations during the past year. Overall, it is unclear to what extent a reduction in the number of citations—as opposed to improvements in Public Health's processes—affected its ability to issue citations in a timely manner.

Annual Follow-Up Agency Response From May 2021

This past year, 2020, was an unprecedented year as it relates to surveys, investigations, and performance due to the COVID-19 pandemic. To mitigate the spread of the virus and to reduce unnecessary exposure for our examiners, health care facility staff, and patients, lower risk priority workload was deferred. However, during this period, high-risk complaints and outbreaks remained a priority, and staff continued to be redirected for these events. As a result, fewer citations were written due to these risk mitigation factors since regular inspections and lower priority investigations were deferred, thus the associated enforcement activities did not continue through the end of 2020. On April 1, 2021, state surveys reconvened and survey activity and investigations will increase accordingly. Annual training of District Office Supervisors was given in February and March 2021 in a special academy focused on survey activity, updates to the citation procedure and policy, and use of the citation template to enhance and improve citation processes. A new process using an RSS application to streamline complaint investigations is planned to launch May 17, 2021. Determining efficacy of this process will follow 6 months post-implementation.

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

We are rating this recommendation as partially implemented because, as we noted in our June 2020 assessment, Public Health has taken steps to improve its processes for issuing citations; however, as Public Health noted in its response, it deferred some oversight activities due to COVID-19 and issued fewer citations during the past year. Overall, it is unclear to what extent a reduction in the number of citations—as opposed to improvements in Public Health's processes—affected its ability to issue citations in a timely manner. Further, Public Health planned to add a new process for streamlining complaint investigations. Thus, we will be unable to determine the efficacy of this process until at least six months after the new process has been implemented.

Annual Follow-Up Agency Response From October 2020

Our previous response submitted on 6/29/20 is still current.

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

Annual Follow-Up Agency Response From June 2020

The new Policy and Procedure for Citations was completed in October of 2019 and was used in the New Surveyor Academy curriculum for the training academy in early in 2020. The training is based on the updated policy and procedure including the citation template. As of March 31, 2020 93% percent of IJ citations are issued in a timely manner.

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

We are rating this recommendation as partially implemented because while Public Health has taken steps to improve its processes for issuing citations, we identified concerns when we assessed its data. Although Public Health's publicly available data shows improvements to the timeliness of citation issuance, in fiscal year 2019-20 about 15 percent of citations were not issued timely. Public Health's data also shows it issued 93 percent of immediate jeopardy citations in a timely manner in the second quarter of fiscal year 2019-20. However, the data from fiscal years 2016-17 through 2019-20 causes us to question whether Public Health will sustain this level of performance. Finally, according to Public Health's data, it will likely issue significantly fewer citations in fiscal year 2019-20 as compared to fiscal years 2016-17 through 2018-19. Overall, it is unclear to what extent a reduction in the number of citations— as opposed to improvements in Public Health's processes— affected its ability to issue citations in a timely manner.

1-Year Agency Response

CDPH has completed a draft citation template and accompanying policy and procedure for issuing citations. The template, the policy and procedures are under management review. Once CDPH approves these documents, the CDPH training team will train staff on the new process. CDPH anticipates approving the documents in May of 2019. In addition, CHCQ's Performance Improvement Management (PIM) office has a current work stream for ELMS and Dashboard Enhancements. This work stream is to enhance the way CHCQ is currently collecting and reporting data from the ELMS database in the effort to timely process applications, surveys, citations, etc. CHCQ continues to work towards improving our data for workflow efficiencies and timeliness.

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

This recommendation is pending Public Health's implementation of its draft citation template, policies, and procedures as well as related training.

6-Month Agency Response

California Department of Public Health (CDPH) continues to improve compliance with the citation issuance timeline requirement and reached 87% compliance in the most recent quarter of 2018, up from 65% and 51% year over year in FY 17 and 16, respectively. The data is refreshed quarterly and the most current metrics are displayed on the public site at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/FieldOperationsComplaints_ERIs.aspx. The citation issuance metric is the top chart of the Disposition Dashboard tab, titled "Citations: Percent Completed Timely."

The draft of the citation template is under management review. Once CDPH approves this template, the CDPH training team will produce a webinar to train staff on using the template. The webinar will be followed by in-person, in-service training in each district to further clarify usage of the template. This training will begin November 2018.

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

This recommendation is pending Public Health's implementation of its draft citation template and related training.

60-Day Agency Response

California Department of Public Health trains new surveyors during new surveyor academy presentations that include writing skills needed for defensible citations. Supervisors receive training from the Office of Legal Services on writing citations and deficiencies. California Department of Public Health is developing a webinar for an all-state rollout of a new citation template. After the webinar, training specialists will visit each District Office to provide in-service training to further clarify usage of the template. This training will begin September 2018. California Department of Public Health revised its internal policy and procedure on citation development and issued the guidance on June 11, 2018. These steps create the foundation for efficiently processing documents so that citations and immediate jeopardy citations are issued in a timely manner.

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

This recommendation is pending further actions by Public Health to ensure that it issues citations in a timely manner.

All Recommendations in 2017-109

Agency responses received are posted verbatim.