COUNTY OF LOS ANGELES DEPARTMENT OF AUDITOR.CONTROLLER

Transcription

1 COUNTY OF LOS ANGELES DEPARTMENT OF AUDITOR.CONTROLLER KENNETH HAHN HALL OF ADMINISTRATION 5OO WEST TEMPLE STREET, ROOM 525 LOS ANGELES, CALIFORNIA 9OO PHONE: (213) FAX: (213) JOHN NAIMO ACTING AUDITOR-CONTROLLER August 27,2014 TO FROM: Supervisor Don Knbe, Chirmn Supervisor Glori Molin Supervisor Mrk Rid ley-thoms Superviso r Zev Yroslvsky Supervisor Michel D. Antonovich John Nimo Acting Aud itor-controller SUBJECT: DEPARTMENT OF PUBLIC HEALTH NURSING HOME INVESTIGATION FOLLOW-UP REVIEW (Bord Agend ltem 49-4, Mrch 4,20141 We hve completed follow-up review of the Deprtment of Public Helth's (DPH or Deprtment) nursing home investigtions. The follow-up review evluted the qulity nd integrity of selected smple of nursing home investigtions. Bckqround On Mrch 4, 2014, your Bord instructed the Auditor-Controller, in coordintion with County Counsel nd with the coopertion of DPH, to conduct n udit of the qulity nd integrity of nursing home investigtions in Los Angeles County nd report bck to the Bord of Supervisors in writing, in 30 dys. The report shll include informtion on: 1. The current bcklog of nursing home complint investigtions; 2. The resons for the bcklog; 3. The resources tht would be needed to timely ddress the bcklog; nd, 4. The corrective ction pln to timely ddress the bcklog. On April 4, 2014, we issued report tht focused on the current bcklog of nursing home investigtions, the resons for the bcklog, nd DPH's pln to ddress the bcklog. We lso reported tht federl privcy lws prevented us from ccessing the cse files nd s such, we were unble to evlute the qulity nd integrity of the nursing home investigtions. Help Conserve Pper - Print Double-Srded "To Enrich Lives Through Effective nd Cring Service"

2 Bord of Supervisors August 27,2014 Pge 2 County Counsel worked on our behlf nd on April 2, 2014, we were grnted ccess to the nursing home investigtion cse files. As result, we reviewed selected smple of cse files to evlute the qulity nd integrity of the nursing home investigtions. Scope of Review DPH's Helth Fcilities lnspection Division (HFID) investigtes complints involving 385 nursing homes operting in Los Angeles County. Our review focused on evluting the qulity nd integrity of nursing home investigtions nd whether HFID is in complince with pplicble guidelines covering the following res: o lnititing the investigtions. Conducting the investigtions o Reviewing nd closing the investigtions As prt of our review, we interviewed HFID mngement nd stff nd reviewed 30 (3%) of the 1,124 cses files tht were closed between July 1,2012 nd April 16,2014. We lso reviewed cse files for 20 (1o/o) of the 3,044 investigtions tht were open s of Mrch 14, At the time of our review, HF D mngement could not locte two dditionl closed cse files requested for review. Results of Review Overll, DPH needs to improve their communiction between stff conductíng the investigtions (surveyors), their supervisors/mngers, nd Consultnt Unit Physicins to ensure the qulity nd integrity of their investigtions. For exmple, we noted instnces where HFID's supervisors downgrded defíciencies nd cittions recommended by the surveyors without documenting their justifiction for the downgrde or discussing the chnges with the surveyors. The qulity nd integrity of investigtions is impired when surveyors' conclusions re chnged without their knowledge. ln ddition, HFID did not lwys prioritize complints nd/or Entity Reported Incidents (ERls) in ccordnce with Stte guidelines resulting in delys in inititing investigtíons. Following re some of the issues we noted: For six (12o/o) of the 50 complinverl cse files reviewed, HFID did not document the justifiction for designting priority less severe thn the priority recommended by the Stte. Three (50%) of the six cses involved complints/erls tht could be considered "lmmedite Jeoprdy" to the nursing home residents which would hve required the surveyors to initite the complints/erls investigtions within 24 hours. However, sínce the HFID mngers selected lower priority, the surveyors hd up to ten dys to initite the complints/erls investigtions.

3 Bord of Supervisors August 27,2014 Pge 3 DPH's ttched response indictes tht the Deprtment grees with the recommendtíon, nd tht HFID supervisors nd stff received trining regrding the Stte guidelines for prioritizing complinfslerls. o For 12 (40%) of the 30 closed cse files reviewed, the surveyors' supervisors or the HFID's Consultnt Unit's Physicins chnged the surveyors' recommended deficiencies nd cittions. Nine (75%) of the 12 cse files lcked documenttion to support the supervisors or physicins justifiction to downgrde nd/or delete the surveyors' recommended deficiencies nd cittions. We lso noted tht for four (33%) of the 12 downgrded cses, the supervisors did not discuss the chnges with the surveyors s required. DPH's ttched response indictes tht the Deprtment grees with the recommendtion. HFID worked with the Sffe to develop new form tht requires superuisors to document their justifiction for pproving or chnging the surueyors' recommended deficiencres nd cittions. DPH lso cknowledged tht they re in the process of developing comprehensive udit review process to ensure superuisors nd surveyors re using the new form. As indicted in our report, chnges to recommended deficiencies nd cittions re lso mde by HFID mngers nd Consultnt Unit Physicins. DPH needs fo ensure their corrective ction ddresses ll chnges to surueyors' recommended defi cíe n ci e s nd cittion s. For five (17%) of the 30 closed cse files reviewed, HFID inppropritely closed the cses without conducting or completing the investigtions when n onsite investigtion ws required. DPH's ttched response indictes tht the Deprtment grees with the recommendtion. However, their response does not indicte how they pln to ensure ll investigtions re ppropritely completed before they re closed. For one (5%) of the 20 open cses reviewed, HFID did not ressign the investigtion when the surveyor retired in Jnury As of \Ay 2014, HFID hd not ressigned this cse or ny of this surveyor's other open cses. DPH's ttched response indictes tht the Deprtment grees with the recommendtion, but believes fhrs ws one-time occurrence. However, fhls lssue ws identified when we requesfed fo review n open cse /sf ssþned to the retired surveyor. At tht time, we lerned tht none of the retired surveyor's open cses were ressigned upon her retirement. We did not perform dditionlsfeps fo confirm this ws one-time occurrence.

4 Bord of Supervisors August 27,2014 Pge 4 For one (20o/o) of the five closed cses reviewed, HFID closed the cse before it ws investigted. According to HFID, the cse ws closed becuse the complint ws withdrwn. However, the cse file did not contin documenttion to show who withdrew the complint or when the complint ws withdrwn. DPH's ttched response indictes tht the Deprtment drsgrees with the recommendtion. DPH believes the level of documenttion in the cse file complied with Stte policy. However, DPH mngement hs responsibility to ensure the County operted progrm is properly mnged. Although Sfúe policy does not expressly require such documenttion, we believe it ppropritely ugments the Sffe's policies. Additionlly, due to the incresing bcklog of open investigtions nd significnt concerns we identified in our two recent reports, we recommended tht DPH hire n independent consultnt to ssist them in vlídting the Stte's stffing model nd to help them ensure ll recommendtions from recent udit reports re ddressed. DPH disgreed with our recommendtion, stting tht they hve n executive oversight tem responsible for ensuring recommendtions move fonrurd. Review of Report We discussed the results of our review with DPH nd County Counsel. The Deprtment's ttched response (Attchment lv) indictes they gree with eight of our ten recommendtions. We thnk DPH nd County Counsel mngement nd stff for their coopertion nd ssistnce during our review. Plese cll me if you hve ny questions, or your stff my contct Don Chdwick t (213) JN:AB:DC:EB:yP Attchments c: Willim T Fujiok, Chief Executive Officer Schi A. Hmi, Executive Officer, Bord of Supervisors Jonthn E. Fielding, M.D., M.P.H., Director, Deprtment of Public Helth Richrd D. Weiss, Acting County Counsel Public lnformtion Office Audit Committee Helth Deputies

5 Attchment I DEPARTMENT OF PUBLIC HEALTH NURSING HOME INVESTIGATION FOLLOW.UP Bckground The Deprtment of Public Heth's (DPH or Deprtment) Helth Fcilities lnspection Division (HFID) hs 146 stff responsible for re-licensing, certifiction, inspections, nd investigting complints nd Entity Reported lncidents (ERls) t the 2,525 helth fcilities in Los Angeles County, including:. Skilled nursing fcilities (nursing homes); o Acute cre hospitls; o Homes for the intellectully impired;. Hospice progrms; o Ambultory surgicl centers;. Dilysis clinics; o Home helth gencies; o Community cre clinics; nd. Congregted living fcilities (i.e., for the ctstrophic nd severely disbled, ventiltor dependent, nd terminlly ill). HFID hs pproximtely 56 stff locted t four district offices responsible for investigting complints/erls relting to the pproximte 385 nursing homes tht operte within Los Angeles County. Complints/ERls re reported by the nursing homes, ptients, reltives, etc., to HFID vi phone, fx, mil, e-mil, or in-person. Complints/ERls re logged into the Automtic Survey Processing Environment (ASPEN) Complint Trcking System (ACTS), federl system used to trck complints/erls involving ll helth cre providers (including nursing homes). District supervisors review the complints/erls reported, designte priority level for ech complinuerl, nd ssign cses to stff who investigte the complints/erls (surveyors). Surveyors re responsible for conducting investigtions, which includes site visits nd interviews with complinnts nd/or other relevnt individuls. For "lmmedite Jeoprdy" complints/erls, in which the fcilities' noncomplince with one or more requirements hs cused, or is likely to cuse serious injury, hrm, impirment, or deth to resident, surveyors re required to initite the investigtion by contcting the helth cre fcility within 24 hours. For ll other complints/erls, surveyors re required to initite n investigtion within ten working dys of notifiction of the incident. Surveyors document the results of their complintsierls investigtions in cse files nd prepre drft reports summrizing their findings nd recommendtions regrding penlties/fines to be ssessed to the nursing homes. Attchment lll lists the fines nd penlties tht correspond to the deficiencies nd the cittions tht the surveyors my recommend. AU DITOR.CONTROLLER COUNTY OF OS ANGELES

6 District supervisors nd ssistnt supervisors re required to review the surveyors' findings nd drft reports to confirm the ccurcy of the findings nd determine if the evidence supports the regultory requirements. Supervisors must concur with the conclusions or discuss their concerns with the surveyors, t which time the supervisors my require the surveyors to obtin dditionl informtion to ensure ll issues re properly investigted nd supported by evidence. Supervisors nd surveyors must come to consensus on the recommended deficiencies nd cittions. Surveyors re clled to testify when litigtion occurs; therefore, it is criticl tht they re included in ll discussions regrding their investigtions, especilly if their conclusions re chnged. When surveyors conclude the complinverl is unsubstntited nd the district supervisors or ssistnt supervisors concur, the cse is fonryrded to clericl stff to uplod the conclusion nd close the cse in ACTS. When surveyors conclude the complinverl is substntited, they document the findings in the complinuerl cse file nd my recommend deficiencies nd/or cittions. The surveyors' recommended deficiencies nd/or cittions my lso be reviewed by the district mngers (district supervisors' supervisor). A deficiency is defined s nursing home's filure to meet prticiption requirement specified in the Socil Security Act or in 42 Code of Federl Regultions Prt 483 Subprt B (42 CFR ). A cittion is n imposition of prompt nd effective civil snctions ginst long{erm helth cre fcilities in víoltion of Stte nd federl lws nd regultions relting to ptient cre estblished by the Cliforni Helth nd Sfety Code Sectíon For deficiencies nd cittions involving deth, physicin from HFID's Consultnt Unit is required to review nd pprove the completed investigtions before deficiencies nd cittions cn be issued. lf the physicin does not gree with the surveyor's recommended deficiencies nd cittions, nd consensus could not be reched with the surveyor, the cse is then referred to the Stte's Chief Medicl Consultnt for finl determintion. The finl recommended deficiencies nd cittions re then submitted to the Stte of Cliforni's Office of Legl Services for review nd to the HFID's Division Chief for review nd pprovl. The report of the deficiencies nd the cittions (s pplicble) re then sent to the nursing home. Nursing homes re required to complete Pln of Correction whenever surveyors note deficiencies. Once the completed Pln of Correction hs been reviewed nd pproved by the surveyor, clericl stff will uplod the Pln of Correction nd close the cse in ACTS. Cittions cn impct the overll rting of the nursing home, nd in certin sítutions cn result in the nursing home losing its license. Scope of Review Our review focused on evluting the qulity nd integrity of nursing home investigtions nd whether HFID is in complince with pplicble guidelines covering the following res: AU DITOR.CONTROLLER COUNTY OF LOS A'VGE ES

7 Nursino Home Investiotion Follow-uo Pqe 3. lnititing the investigtions o Conducting the investigtions o Reviewing nd closing the investigtíons As prt of our review, we interviewed HFID mngement nd stff, nd reviewed the cse files for 30 (3%) of the 1,124 cses tht were closed between July 1, 2012 nd April 16, We lso reviewed cse files for 20 (1o/o) of the 3,044 complints/erls investigtions tht were open s of Mrch 14,2014. At the time of our review, HFID mngement could not locte two dditionl closed cse files requested for review. Nursinq Home lnvestigtions Overll, DPH needs to improve their communiction between surveyors, their supervisors/mngers, nd Consultnt Unit Physicins to ensure the qulity nd integrity of their investigtions. For exmple, we noted instnces where HFID's supervisors downgrded deficiencies nd cittions recommended by the surveyors without documenting their justifiction for the downgrdes or discussing the chnges with the surveyors. The qulity nd integrity of investigtions is impired when surveyors' conclusions re chnged without their knowledge. We lso noted tht HFID did not lwys prioritize complints/erls in ccordnce with Stte guidelines, resulting in delys in inititing investigtions. Lstly, we noted tht HFID closed cses s u nsubst ntited without co nd ucti ng onsite i nvestigtions o r interviews. Updtinq ACTS Inititing the lnvestiqtions According to the Cliforni Deprtment of Public Helth's (Stte) Licensing nd Certifiction Policy nd Procedure Mnul (Mnul), "ll complints/erls will be entered into ACTS upon receipt." Complince with this policy is criticl to ensure tht ll complints/erls investigtions re initited within the Stte required timefrmes. However, ccording to HFID mngement, complints/erls re entered into ACTS fter they re "reviewed" by the ssistnt or district supervisors rther thn upon receipt. For the 50 open nd closed complinuerl cse files we reviewed, we noted four (8%) were entered into ACTS up to four workdys fter receipt of the complints/erls. The four complints/erls were not prioritized s "lmmedite Jeoprdy," however, since they were ll received on County business dys, they should hve been entered into ACTS on the dy they were received. HFID mngement should ensure ll complints/erls re entered into ACTS upon receipt. Recommendtion 1 HFID mngement ensure ll complints/eris re entered into ACTS upon receipt. AU DITOR.CONTROLLER COUNTY OF LOS A'VGELES

8 Nursinq Home lnvestiqtion Follow-up Pse 4 Prioritizinq Complints/ERls nd lnititinq lnvestígtions Bsed on documenttion contined in the complinuerl cse files nd ACTS, HFID surveyors ppropritely responded within 24 hours forthe 12 cses reviewed tht were prioritized s "lmmedite Jeoprdy" nd within ten dys for the 38 "Non-lmmedite Jeoprdy" cses we reviewed. However, we noted tht HFID supervisors did not lwys prioritize complints/erls in complince with the Mnul (Attchment ll). We reviewed 50 complints/erls nd noted six (12o/o) where HFID designted the incident s lower priority thn the priority recommended by the Stte. In ddition, HFID did not document why they ssigned lower priority to the complints/erls. Three (50%) of the six complints/erls involved llegtions tht could be considered imminent dnger to the nursing home residents, requiring the surveyors to initite contct with the nursing home within 24 hours. For exmple, HFID prioritized one complinuerl involving deth s "Non-lmmedite Jeoprdy High." According to the Mnul, the complinuerl met the definition of "lmmedite Jeoprdy" which would require the investigtion to be initited within 24 hours. Due to the lower priority designted to this cse, the surveyor did not initite their investigtion until ten dys fter the complinuerl ws logged. HFID needs to ensure tht complints/erls re prioritized in ccordnce with the Stte guidelines nd the justifiction for prioritizing the complints/erls is documented. Recommendtion 2 HFID mngement ensure tht complints/erls re prioritized in ccordnce with the Stte guidelines nd the justifiction for prioritizing the complints/erls is documented. Completinq the lnvestiqtions Conductinq the lnvestiqtions As noted in our Nursing Home Investigtion Audit report dted April 4, 2014,945 (31%) of HFID's 3,044 open cses hd been opened for more thn two yers. The report noted tht insufficient stffing nd lck of n effective cse mngement system were resons tht contributed to the bcklog. During our current review, we reviewed 30 closed cses nd 20 open cses. We noted tht the 30 closed cses reviewed were opened for n verge of 17 months nd tht 19 (95%) of the 20 open cses reviewed hve been opened for more thn six months. We lso noted tht for one (5%) of the 20 open cses reviewed, HFID did not ressign the investigtion when the surveyor retired in Jnury The cse involved n incident tht occurred in August 2012 nd prior to her retirement, the surveyor noted in the cse file tht she would recommend tht cittion be issued to the fcility for AU DITOR-CONTROLLER COUNTY OF LOS A'VGELES

9 Nursing Home lnvestigtion Follow-up Pqe 5 multiple violtions. However, s of My 2014, HFID hd not ressigned this cse or ny of this surveyors' other open cses. To ensure tht ll complints/erls investigtions re completed timely, HFID mngement needs to ressign open investigtions timely when surveyors retire or re trnsferred. Recommendtion 3. HF D mngement ressign open investigtions timely when surveyors retire or re trnsferred. Reviewinq the lnvestiqtions Reviewing nd Glosing the lnvestigtions As previously mentioned, once the surveyors complete investigtions, the districts' supervisors or ssistnt supervisors review the surveyors' findings nd recommended deficiencíes nd cittions. The district mnger, the Consultnt Unit's Physícin, nd Division Chief re lso requíred to review nd pprove the investigtions when deficiencies nd/or cittions re recommended on substntited complints/erls involving the deth of the resident. According to HFID's Assistnt Divisíon Chief, the supervisors, district mngers, nd the HFID's Consulting Unit Physicin my mke chnges to the surveyors' recommended deficiencies nd cittions; however, ech of the chnges must be discussed wíth the surveyors for consensus on the outcome of the investigtions. lt is criticl for consensus to be reched becuse certin cittions cn led to fines of up to $100,000 or nursing home losing their license. lf consensus cnnot be reched, the cse is referred to the Stte's Chief Medicl Consultnt for finl determintion. The finl recommended deficiencies nd cittions re then submitted to the Stte's Offíce of Legl Services for review nd to the HFID's Division Chief for review nd pprovl. We noted tht for 12 (40%) of the 30 closed cse files reviewed, the surveyors' recommended deficiencies nd cittions were deleted or downgrded. Five (42o/o) of the 12 cses involved the deths of residents s young s three yers old. Relting to the 12 cses, we noted: Nine (75%) of the 12 cses lcked documenttion to support the downgrding nd/or deletions of the deficiencies nd cittions by the supervisors or HFID's Consultnt Unit's Physicins. Four (33%) of the 12 cses, the supervisors did not discuss the chnges with the surveyors, s required. Five (42o/o) of the 12 cses, the district mnger, who deleted or downgrded the cittions/deficiencies, could not provide justifiction for the chnges. For two AU DITOR.CONTROLLER COUNTY OF OS AIVGELES

10 Nursinq Home lnvestiqtion Follow-up Pge 6 cses, the district mnger nnotted "unble to support," however, when questioned, he could not explin wht dditionl informtion ws necessry to substntite the cse. Exmples of surveyor conclusions in the cses we reviewed included issues such s the nursing homes did not comply with doctor's orders, check to see if ptient hd dverse rections to mediction bsed on theír medicl condition, or tht the deth could hve been prevented if the pln of cre (preventive mesures to reduce injury) hd been implemented. Stte policy does not require HFID district offices to provide Consultnt Unit Physicins with the entire cse file for investigtions tht re referred to their Unit. The district offices only provide the physicins with the "District Office Approvl nd Civil Penlty Dte Sheet" nd the "Sttement of Deficiencies nd Pln of Correction" forms for review. However, physicins my request HFID district offices to provide dditionl documenttion, including the entire cse file for their review. One Consultnt Unit Physicin we interviewed indicted tht he cn generlly complete his review without reviewing the cse file nd tht he generlly does not document the results of his review. As result, this physicin ws unble to provide documenttion to support his decisions to downgrde severl deficiencies/cittions in the cses we reviewed, including cses involving deths of ptients. Without dequte documenttion, it is very difficult to ensure tht deficiencies nd cittions re hndled in consistent, thorough nd equitble mnner. ln ddition, Consultnt Unit Physicins my be clled to testify when litigtion occurs, nd they need to document the bsis for their decisions. HFID supervisory stff, mngers, nd physicins re responsible for ensuring the qulity of the investigtion by ensuring cittions nd/or deficiencies re supported by the evidence in the cse file. According to HFID mngement, there re pproprite resons why deficiencies nd/or cittions should be downgrded, including lck of evidence to support the proposed deficiencies nd/or cittions, or need for the surveyor to conduct further investigtion. We hve expressed concern to DPH mngement tht they need to ensure better communiction between surveyors, supervisors, mngers, nd physicins to ensure proposed deficiencies nd cittions re only downgrded when the evidence does not support the surveyors' conclusion. lf surveyors need to gther dditionl informtion necessry to support their recommended deficiencies nd/or cittions, they should be given n opportunity to gther dditionl support before downgrdes re mde nd cses re closed. Due to the lck of vilble documenttion, we were unble to determine why the deficiencies nd/or cittions were downgrded for the 12 cses reviewed. HFID mngement needs to ensure tht individuls reviewing nd pproving the surveyors' recommended deficiencies nd cittions ppropritely document the justifictions for pproving or chnging the surveyors' results. ln ddition, HFID mngement needs to ensure tht chnges to the surveyors' recommended deficiencies nd cittions re AU DITOR-CONTROLLER COUNTY OF IOS A'VGELES

11 Nursing Home lnvestigtion Follow-up Pqe 7 pproprite nd discussed wíth the surveyors nd other pplicble personnel s required. Recommendtions HFID mngement: 4. Ensure tht ll stff who review nd pprove the suleyors' recommended deficiencies nd cittions ppropritely document the justifiction for pproving or chnging the surveyors' results. 5. Ensure tht ll chnges to the surveyors' recommended deficiencies nd cittions re discussed nd, s pproprite, surueyors gther missing evidence to support their results before downgrdes re mde nd cses re closed. Reportino the Outcomes of the Investiqtions According to the Stte's Licensing nd Certifiction Policy nd Procedure Mnul, HFID is required to notify the complinnt on the outcome of the investigtion within ten business dys of the forml exit regrdless of whether deficiency ws cited or not. Of the 30 closed cse files reviewed, 20 (660/0) complints required HFID to notify the complinnt of the outcome of the investigtions. Ten closed cses were ERl, which do not require HFID to notify the results to complinnts. HFID did not issue the Results of Complint Investigtion Letter (Letter) to three (15%) of the 20 complinnts, s required. HFID lso did not issue Letters to two (10%) complinnts within the required timefrme. HFID mngement needs to comply wíth Stte requirements nd issue the Letter to the complinnts within ten business dys of the forml exit s required. Recommendtion 6. HFID mngement comply with Stte requirements nd issue the Results of Complint lnvestigtion Letter to the complinnts within ten business dys of the forml exit s required. Closinq Complints/ERls With No lnvestiqtion HFID inppropritely closed five (17%) of the 30 closed cse files reviewed without conductíng or completing the investigtions when n onsite investigtion ws required. Specificlly: o One of the five cses ws inppropritely closed s prt of the "Complint-Worklod Clen-Up Project" tht llowed surveyors to close cses without conducting AUDITOR.CONTROLLER COUNTY OF LOS AA'GELES

12 Nursinq Home lnvestiqtion Follow-up Pqe I investigtions. According to HFID, the prctice of llowing surveyors to close cses without conducting investigtions lsted from August 2013 to Februry One of the five cses ws closed before it ws investigted becuse, ccording to HFID, the complint ws withdrwn. However, bsed on our review of the cse file, we could not verify whether the person withdrwing the complint ws the sme person who initilly reported it. According to HFID, the Stte hs not estblished guidelines relting to complint withdrwls; therefore, HFID stff re not required to verify the ppropriteness of withdrwn complints. HFID could not explin why the remining three cses were closed HFID should estblish policy requiring stff to vlidte tht complint withdrwls re pproprite before closing cses. ln ddition, HFID mngement needs to ensure onsite investigtions re ppropritely completed for ll complints in ccordnce with the Stte contrct. Recommendtions HFID mngement: 7 Estblish policy for stff to vlidte nd document withdrwls of complints nd incidents. 8. Ensure onsite investigtions re ppropritely completed for ll complints/erls in ccordnce with the Stte contrct. Mintininq Closed Cse File lnventorv We noted tht HFID did not mintin n inventory of closed cses in ccordnce with the Stte requirements. Specificlly, HFID could not locte two (6%) of the 32 closed cse files tht we originlly requested. According to HFID stff, one of the two missing cse files, which ws prioritized s "No Action Necessry," ws purged bsed on the dte tht the incident ws received. According to the Stte's Licensing nd Certifiction Policy nd Procedures Mnul, cse files re to be purged (destroyed) four yers from the djudiction dte or the investigtion close dte. The second missing cse file, prioritized s n "lmmedite Jeoprdy," could not be locted. DPH mngement indicted tht they subsequently locted the "lmmedite Jeoprdy" cse. HF D mngement needs to ensure closed cse files re mintined in ccordnce with the Stte requirements. AU DITOR-CONTROLLER COUNTY OF OS ANGE ES

13 Follow-u Recommendtion I HFID mngement ensure tht n inventory of closed cses is mintined nd closed cses re purged in ccordnce with the Stte requirements. Additionl Concerns Since the 1960's, the Stte hs contrcted with DPH to provide re-licensing, certifiction, surveys (inspections), nd investigtions of the 2,525 helth fcilities in Los Angeles County. DPH's HFID provides the contrcted services which includes investigtions nd inspections of cute cre hospitls, nursing homes, homes for the intellectully impired, hospice progrms, mbultory surgicl centers, dilysis clinics, home helth gencíes, community cre clinics, nd congregted living fcilities (i.e., for the ctstrophic nd severely disbled, ventiltor dependent, nd terminlly ill). The scope of our review ws limited to reviewing the qulity of nursing home investigtions. We did not review HFID's bilities to effectively mnge nd oversee the inspections, investigtions, nd licensing of the other helth cre fcilities. Currently, HFf D hs 146 stff responsible for overseeing the 2,525 helth fcilities. DPH recently reported to the Stte tht to dequtely ddress the worklod to oversee the 2,525 helth fcilities, including ensuring investigtions cn be completed timely, HFID will require 306 stff. DPH nticipted tht it will tke pproximtely 52,000 hours to complete the bcklog of pproximtely 3,400 nursing home investigtions nd pproximtely 41,000 hours to complete the bcklog of 3,384 complints/erls investigtions of other helth cre fcilities. DPH mngement indictes they re using stffing model developed by the Stte to request Stte fundíng tht will ensure pproprite stffing levels re mintined to perform nursing home investigtions. We recommend tht the Deprtment hire n independent consultnt tht cn ssist them in vlidting the Stte's stffing model nd help them to ensure ll recommendtions from recent udit reports re ddressed. Recommendtion 10. DPH mngement hire n independent consultnt tht cn ssist them in vlidting the Stte's stffing model nd help them ensure ll recommendtions from recent udit reports re ddressed. AU DITOR-CONTROLLER COUNTY OF T-OS AA'GE ES

14 PRtORtTYl Attchment ll A - IMMEDIATE JEOPARDY PRIORITY DEFINED AS EXAMPLES Noncomplince hs cused, or is likely to cuse, serious injury, hrm, impirment, or deth to resident.. lnjury or incident involving deth or potentil criminl ctiviç. o Unexplined or unexpected deth with circumstnces indicting tht there ws buse or neglect.. Abuse. Sexul ssult. Environmentlhzrds. Elopement of resident from the fcility. B - NON-IMMEDIATE JEOPARDY HIGH C - NON-IMMEDIATE JEOPARDY MEDIUM D - NON.IMMEDIATE JEOPARDY LOW E - ADMINISTRATIVE REVIEW - OFFSITE INVESTIGATION F - REFERRAL - IMMEDIATE G - REFERRAL - OTHER Noncomplince my hve cused hrm tht negtively impcts the individul's mentl, physicl nd/or psychosocil sttus nd re of such consequence to the person's well-being tht rpid response by the Stte Agency is indicted. Noncomplince cused or my cuse hrm tht is limited consequence nd does not significntly impir the individul's mentl, physicl nd/or psychosocil sttus or function. Noncomplince my hve cused physicl, mentl ndlor psychosocil discomfort tht does not constitute injury or dmge. Onsite investigtion is not necessry. An offsite dministrtive review of written/verbl communiction or documenttion to determine if further ction is necessry. Requires referrl or reporting to nother gency, bord, or End Stge Renl Disese (ESRD) network without dely for investigtion Referred to nother gency, bord or ESRD Network for investigtion or informtionl purposes.. A resident is intimidted or thretened.. Physiclly bused (condition no longer present nd ongoing). Flls resulting in frcture.. lnpproprite use of restrints resulting in injury.. Filure to provide pproprite cre or medicl services (e.9., filure to respond to signifícnt chnge in resident's condition). o Refusl to redmit resident.. Elopement of resident (subsequently found) resulting in hrm, but not serious injury. NONE PROVIDED NONE PROVIDED NONE PROVIDED NONE PROVIDED NONE PROVIDED H - NO ACTION NECESSARY Determintion with certinty tht the lleged noncomplince requires no further investigtion, nlysis, or ction. No llegtion of lmmedite Jeoprdy. Previous survey investigted the sme event. Previous survey evluted the pproprite individuls, including those identified in the intke. Sitution did not worsen. t Source: Stte of Cliforni's Licensing nd Certifiction Policy nd Procedure Mnul, Publiction No. P&P 14-01, Section

15 DEFICIENCY AND CITATION CLASSIFICATIONS Attchment lll CATEGORY DEFINITION CLASS DEFINED AS FINES AND PENALTIES D,E,F DEFICIENCY2 Skilled nursing fcility's or nursing fcility's filure to meet prticiption requirement specified in the Act (SocilSecuriÇ Act) or in 42 CFR Prt 483 Subprt B. (42 CFR ) G,H,I The fcility is not in substntil complince. More thn miniml physicl, mentl nd/or psychosocil discomfort nd:. D=lsoltedlncident. E = Pftem. F = Widespred The fciliç is not in substntil complince. Actul hrm tht is not lmmedite Jeoprdy nd:. G=lsoltedlncident H = Pttem I = Widespred J K L The fcilíty is not in substntil complince. lmmedite Jeoprdy to resident helth or sfety nd:. J=lsoltedlncident K = Pttem. L=Widespred(most serious) o No revisit is required.. The fcility must submit n cceptble pln of correction nd provide evidence of complince; othenryise there is n imposition of denil of pyment for new dmissions.. Possible civil money penlty between $50 nd $3,000 per dy or "per instnce" civil money penlty between $1,000 nd $10,000 for ech deficiency. A revisit is required within dys.. Denil of pyment for new dmissions.. Possible civil money penlty between $50 nd $3,000 per dy or "per instnce" civil money penlty between $1,000 nd $10,000 for ech deficiency A revisit is required within dys to verifi7 demonstrted removl of lmmedite Jeoprdy. Acceptble pln of correction. Possible civil money penlty between $3,050 nd $10,000 per dy of lmmedite Jeoprdy or "per instnce" civil money penlty from $1,000 to $10,000 for ech deficiency. Denil of pyment for new dmissions. AA Violtions tht meet the criteri for clss "A" violtion nd tht the Stte determines to hve been direct proximte cuse of deth of ptient or resident of long-term helth cre fcility.. Not less thn $25,000 nd not exceeding $100,000 for ech cittion.. For ech clss "AA" cittion within 24- month period, the Stte deprtment shll commence ction to suspend or revoke the fcility's license. CITATION3 lmposition (under the uthority of the Clifomi Helth nd Sfety Code) of civil snctions ginst skilled nursing fcilities in violtion of Stte nd federl lws nd regultions relting to ptient cre. A B Violtions which the Stte deprtment determines present either (1) imminent dnger tht deth or serious hrm to the ptients or residents of the longterm helth cre fciliç would result therefrom, or (2) substntil probbility tht deth or serious physicl hrm to ptients or residents of the longterm helth cre fcility would result there from. Violtions tht the Stte deprtment determines hve direct or imminent reltionship to the helth, sfety, or security of long-term helth cre fcility ptients or residents, other thn clss "AA" or "A" violtions. Not less thn $2,000 nd not exceeding $20,000 for ech nd every cittion. Not less thn $100 nd not exceeding $2,000 for ech cittion. t source: 3 source: Centers for Medicre nd Medicid Services'(CMS) Stte Opertions Mnul, Chpter 7, nd the Stte of Cliforni's Licensing nd Certifiction Policy nd Procedure Mnul, Publiction No. P&P 14-01, Section Clifomi Helth nd Sfety Code Section

16 Attchment IV Pge 1 of 9

17 Attchment IV Pge 2 of 9 Attchment I LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH RESPONSE TO AUDITOR-CONTROLLER NURSING HOME INVESTIGATION FOLLOW-UP Introduction This is the Deprtment of Public Helth s (DPH) response to the Auditor-Controller s follow-up review of the Helth Fcilities Inspection Division s (HFID) nursing home investigtions. The initil report ws issued by the Auditor-Controller on April 4, In this second phse of the udit, the Auditor-Controller reviewed very smll smple of cse files: 3% of the cses closed between July 1, 2012 nd April 16, 2014, nd 1% of cses tht were open s of Mrch 14, Their review focused on cse file documenttion to demonstrte the initition, review nd closure of these cses. Seven of the ten recommendtions in this current udit hve lredy been implemented, s is noted below in our response to ech recommendtion. The Auditor-Controller s findings were not bsed on clinicl review of the nursing home investigtion files which, we believe, hindered their reviewers bility to comprehensively understnd the medicl context of the ctions tken. DPH Audit nd Investigtion Division (AID) conducted n internl review of the sme cse files, using reviewers with clinicl bckgrounds. DPH AID uditors nd Auditor-Controller s stff did not rech the sme conclusions bout HFID s complince with cse file documenttion. While DPH grees tht cse file documenttion ws lcking in some instnces, the Auditor-Controller stted documenttion ws not sufficient for some cse files, where DPH AID found documenttion in support of complince with Stte prctices nd policies. It should be noted tht for ny A or AA cittion cse, HFID consulted with both the Stte's dministrtion nd Office of Legl Services to determine the finl level of cittion. In most cses, this consulttion ws conducted vi emil or orlly nd documenttion in the cse files ws not mintined, s it should hve been. The Auditor-Controller s report of their follow-up review, completed t the end of June 2014, does not mention tht since Mrch 2014, HFID hs, nd is in the progress of, implementing numerous opertionl improvements. On My 28, 2014, July 8, 2014, July 22, 2014, nd August 21, 2014, DPH provided to the Bord of Supervisors updtes on ctions tken to improve the overll functioning of HFID. Additionlly, HFID hs developed n updted stffing model identifying the need for n dditionl 183 positions. DPH worked with the Stte on the development of this model,

18 which is bsed on the sme stffing model tht the Stte uses in offices outside of Los Angeles County. The model clerly demonstrtes tht the Los Angeles County HFID is severely understffed. As the jurisdiction responsible for 33% of licensed helth fcilities tht require inspections in the Stte, the County of Los Angeles receives only 15% of the CDPH Licensing & Certifiction budget. In My 2014, Los Angeles County submitted request for dditionl resources to the Stte in order to dequtely mnge the worklod. While we concur with the Auditor-Controller tht cse file documenttion ws sometimes lcking nd tht opertionl improvements were necessry, it must be reiterted tht HFID s chronic lck of funding nd subsequent understffing hve led to less thn optiml progrm opertions nd overburdened stff. HFID hs implemented numerous opertionl nd dministrtive chnges tht hve mesurbly improved the progrm, yet without dditionl funding, HFID will not hve the cpcity to complete the nnul worklod without dding to the current bcklog. DPH hs been working with both the Stte nd the U.S. Centers for Medicid & Medicre Services to resolve the worklod nd funding issues to ensure the highest qulity of fcility inspections going forwrd. If we re unble to resolve these issues, we will be forced to recommend tht the Bord terminte the contrct with the Stte. Recommendtion 1 HFID mngement ensure ll complints/eris re entered into ACTS upon receipt. DPH Response to Recommendtion 1: Attchment IV Pge 3 of 9 Agree. Recommendtion ws implemented prior to the completion of this udit. The CDPH Licensing nd Certifiction Policy nd Procedure No 14-01, Abbrevited Stndrd Survey (Federl Complint Process) in Skilled Nursing/Nursing Fcilities, Section ws discussed with ll supervisors on June 25, 2014, nd ll Senior Nurses nd support stff on July 1, On July 1, 2014, new Complint Trcking Log ws implemented in ll District Offices. The newly developed trcking log identifies the fcility nme, complint intke number, nme of the complinnt, resident nme, ssigned evlutor; dte complint ws received, dte due, complint investigtion initition/strt dte, exit dte, nd supervisor review dte. To ensure ll complints nd entity relted incidents (ERIs) re entered into the Automted Survey Processing Environment (ASPEN) Complint Trcking System (ACTS) upon receipt, on dily bsis, supervisors compre the receipt dte on the new Complint Trcking Log with the dte the complint/eri ws entered into ACTS. The Progrm Mnger genertes n ACTs report for ll

19 complints/eris received during the week, compres the Complint Trcking Log with the ACTs report, nd discusses the findings in the weekly Progrm Mnger meeting. A comprehensive udit review process is in the development stge nd will be implemented by December 31, This udit review process will include component to verify tht ll complints/eris re entered into ACTS upon receipt. Recommendtion 2 HFID mngement ensure tht complints/eris re prioritized in ccordnce with the Stte guidelines nd the justifiction for prioritizing the complints/eris is documented. DPH Response to Recommendtion 2: Agree. Recommendtion ws implemented prior to the completion of this udit. By July 1, 2014, ll HFID supervisors reviewed the CDPH Licensing nd Certifiction Policy nd Procedure No 14-01, Abbrevited Stndrd Survey (Federl Complint Process) in Skilled Nursing/Nursing Fcilities, with emphsis on procedures relted to intke, prioritiztion, nd ssignment of complints nd ERIs with support stff. Acknowledgement Sheets were signed by support stff in ech district office, cknowledging tht the policy ws distributed, reviewed, nd discussed with them. This policy nd procedure will be reviewed nnully with support stff. In ddition, on June 25, 2014, the HFID trining coordintor provided trining to ll HFID supervisors, nd on July 1, 2014, to ll Senior Nurses nd support stff. Both of these trining sessions covered the prioritiztion nd ssignment of ll complint/entity reported incidents t intke including complints nd entity reported incidents tht constitute n immedite jeoprdy sitution. The comprehensive udit review process currently being developed includes verifiction component tht will ensure ll complints/eris re prioritized correctly. Recommendtion 3 HFID mngement ressign open investigtions timely when surveyors retire or re trnsferred. DPH Response to Recommendtion 3: Attchment IV Pge 4 of 9 Agree. It should be noted tht the specific cse in the Auditor-Controller s review refers to one-time occurrence. However, in HFID s own investigtion into this mtter it becme pprent tht HFID does not hve uniform prctice regrding

20 ressignment of investigtions. Therefore, effective September 1, 2014, ll surveyor ressignments will be included in the new Complint Trcking Log. This log is updted dily by supervisors to closely monitor the sttus of ll complints received. Recommendtion 4 HFID mngement ensure tht ll stff who review nd pprove the surveyors recommended deficiencies nd cittions ppropritely document the justifiction for pproving or chnging the surveyors results. DPH Response to Recommendtion 4: Agree. Recommendtion ws implemented prior to the completion of this udit. On June 5, 2014, supervisors were directed to use documenttion verifiction form titled, Supervisor Worksheet for Survey nd Complint/ERI Investigtion by Surveyor. DPH ssisted the Stte with revising the form which will now be used sttewide. The previous form did not require signtures indicting consensus fter discussions took plce between the surveyor nd the supervisor. The new form requires supervisors to ppropritely document the justifiction for pproving or chnging the surveyor s results. This form verifies tht supervisors re conferring with the surveyors before ny chnges re implemented. The Supervisors Worksheet contins the following informtion: components of deficient prctice sttement; findings tht ddress ll fctul spects of the investigtion; sources of evidence (observtion/interview/record review); sufficient supporting evidence; correct regultions cited; supportive documenttion for violtions; impct on the residents involved; nd the pproprite scope nd severity. The comprehensive udit review process currently in development includes verifiction component to ensure tht supervisors nd mngers re ppropritely using this worksheet. Recommendtion 5 HFID mngement ensure tht ll chnges to the surveyors recommended deficiencies nd cittions re discussed nd, s pproprite, surveyors gther missing evidence to support their results before downgrdes re mde nd cses re closed. DPH Response to Recommendtion 5: Attchment IV Pge 5 of 9 Agree. Recommendtion ws implemented prior to the completion of this udit. See DPH response to Recommendtion 4. When mnger or supervisor documents nd recommends chnge to the surveyor s

21 recommended deficiencies nd cittions, the Supervisor Worksheet for Survey nd Complint/ERI Investigtion by Surveyor form is completed nd discussed with the surveyor. The form is signed by both the surveyor nd Supervisor/Mnger to verify discussion. When further evidence is required to support finding, the following survey evidence is requested by the supervisor to support the deficiency/cittion nd supervisor determintion s indicted on the complince determintion worksheet for Supervisors: ) Survey Field Notes (observtions nd interviews) b) Residentil Medicl Records c) Fcility Policies nd Procedures Recommendtion 6 HFID mngement comply with Stte requirements nd issue the Results of Complint Investigtion Letter to the complinnts within ten business dys of the forml exit s required. DPH Response to Recommendtion 6: Agree. Recommendtion ws implemented prior to the completion of this udit. HFID Supervisors, Senior Nurses, nd support stff prticipted in trining on June 25, 2014, nd July 1, The trining ddressed ll components of the CDPH complint policy nd procedure with emphsis on the timely issunce of the finl complint notifiction letter no lter thn ten business dys. Refresher trining will be conducted on n nnul bsis. The comprehensive udit review process currently in development includes verifiction component regrding the timely issunce of the finl complint notifiction letter. Recommendtion 7 HFID mngement estblish policy for stff to vlidte nd document withdrwls of complints nd incidents. DPH Response to Recommendtion 7: Attchment IV Pge 6 of 9 Disgree. The specific cse the Auditor Controller is referring to contined documenttion within the file tht the cse hd been withdrwn, which is in ccordnce with Stte policy. The HFID progrm is implemented s contrct with the Stte nd therefore, stff must follow the existing Stte policies nd procedures. A seprte policy for hndling withdrwls is not necessry t this

22 time. In ddition, the newly developed Complint Trcking Log will be used to improve trcking of complints nd ERIs tht hve been withdrwn. Recommendtion 8 HFID mngement ensure onsite investigtions re ppropritely completed for ll complints/eris in ccordnce with the Stte contrct. DPH Response to Recommendtion 8: Agree. Recommendtion ws implemented prior to the completion of this udit. On June 27, 2014, HFID submitted to the Stte three-month worklod pln describing HFID s pln for ppropritely completing complints nd ERIs. The worklod pln exmines the mount of work tht cn be completed given the current stffing levels. HFID will complete ll complints nd ERIs ccording to the worklod pln greed upon by the Stte. HFID continues to request dditionl resources to be ble to complete ll mndted work nd will continue to collborte with the Stte on future worklod plns. The Complint Trcking Log will be used to ensure tht ll complints nd ERIs re initited nd completed timely in ccordnce with the worklod pln. The comprehensive udit review process currently in development includes verifiction component to ensure tht complints/eris re investigted nd completed ccording to the worklod pln. Recommendtion 9 HFID mngement ensure tht n inventory of closed cses is mintined nd closed cse re purged in ccordnce with the Stte requirements. DPH Response to Recommendtion 9: Attchment IV Pge 7 of 9 Agree. Recommendtion ws implemented prior to the completion of this udit. HFID will mintin current inventory of ll closed cses utilizing the ACTS system. According to the Stte s Licensing nd Certifiction Policy nd Procedure Mnul, cse files re to be purged four yers from the djudiction dte or the investigtion close dte. HFID stff prticipted in CDPH trining on June 25, 2014, nd July 1, 2014, which included trining on the record retention policy. Refresher trining will be provided on n nnul bsis. The comprehensive udit review process currently in development includes verifiction component to ensure tht the retention policy is being correctly enforced.

23 Attchment IV Pge 8 of 9 Recommendtion 10 DPH mngement hire n independent consultnt tht cn ssist them in vlidting the Stte s stffing model nd help them ensure ll recommendtions from recent udit reports re ddressed. Tble I DPH Response to Recommendtion 10: Disgree. DPH worked closely with the Stte using the stffing model they provided to us nd tht they currently use to llocte resources sttewide. DPH rrived t the recommended stffing level by pplying the Stte stffing fctors to the nnul projected DPH worklod. The request for dditionl funding ws submitted in ccordnce with Stte budget request dedlines for FY , including n urgent request for dditionl funding for FY Los Angeles County is responsible for 33% of ll fcilities in the Stte, yet is llocted only 15% of the sttewide funding lloction (See Tble I). The Stte is currently providing stffing ssistnce to complete the mndted worklod while they review nd process our request for dditionl funding. LAC HFID vs. Stte: Fcility nd Budget Comprison Fcility Comprison* HFID Shre of CDPH Budget** Fcilities % of Fcilities FY % of Budget FY % of Budget LAC HFID 2, % $26,951, % $26,951, % CDPH L&C 7, % $182,636, % $186,902, % * Dt provided by the Stte ** Dt obtined from CDPH L&C website