California Department Of Public Health
Licensing and Certification Division
Carol Littler,
Annual RAP Session
April 26, 2012
CENTER FOR HEALTH CARE QUALITY
OVERVIEW
• Patient safety protection through:
• Licensing & Certification (L&C): Evaluate
facilities, agencies, and professionals for
compliance with state and federal laws and
regulations in order to license/certify them to
operate in California.
• Laboratory Field Services: Enforce quality
standards in clinical and public health
laboratories, and blood and tissue banks both
within and outside California serving
Californians.
• Healthcare Associated Infection Program:
Conduct surveillance, prevention and public
reporting of infection rates.
LICENSING &
CERTIFICATION PROGRAM
VISION AND MISSION
•Vision:
• L&C strives to operate a responsive, uniform
enforcement program in accordance with
state licensing and federal certification
requirements, to encourage provider-initiated
compliance and quality of care improvement
activities, and to assure quality of care.
•Mission:
• Promote the highest quality of care in
community settings and health facilities,
improve access to care and assure quality of
care.
MAJOR ACTIVITIES
 Ensure quality health care delivery by nearly 8,000
facilities in 30 different facility and agency types.
 Certify facility and agency compliance with
federal requirements.
 Conduct approximately 27,000 complaint
investigations and 7,000 licensing surveys annually.
 Certify over 160,000 nurse assistants, home health
aides and hemodialysis technicians.
 License over 3,000 Nursing Home Administrators.
 Train, inspect, drill, and educate facilities in
emergency preparedness response and recovery
efforts.
LICENSING AND CERTIFICATION
MAJOR ACTIVITIES, CONT.
• Field Operations Branch:
• Employs approximately 600 dedicated, highly
skilled and qualified Registered Nurses,
Medical, Pharmaceutical and Nutritional
Consultants.
• Conducts approximate 1,350 on-site
inspections of nursing homes, annually.
LICENSING & CERTIFICATION
STAFFING AND BUDGET
Staffing
 1,111.45 positions in 14 district offices, statewide:
• Survey Staff – 556.00
• Professional Certification Branch – 87
• Administrative Staff – 468.45
 Los Angeles County Department of Public
Health
 200 staff under contract
 Conducts licensing and certification activities
within LA County.
COMPLAINTS & ENTITY REPORTED
INCIDENTS
Fiscal
Year
Entity
Total
Complaints Reported Complaints
Incidents
+ ERIs
Change
from
Baseline
2004/05
9,007
14,778
23,785
Baseline
2005/06
8,900
19,701
28,601
20.2%
2006/07
9,155
21,705
30,860
2007/08
10,544
24,046
2008/09
9,643
2009/10
Annual
Increase
Closed
Closed
Entity
Complaints Reported
Incidents
99.2%
99.6%
20.2%
98.5%
99.5%
29.7%
7.9%
98.0%
99.5%
34,590
45.4%
12.1%
96.3%
98.9%
26,217
35,860
50.8%
3.7%
90.3%
95.6%
9,452
28,533
37,985
59.7%
5.9%
82.9%
91.5%
2010/11
9,586
28,676
38,262
60.9%
0.7%
69.5%
82.6%
2011/12
projection
9,830
*29,633
39,463
65.9%
3.1%
64.6%
79.8%
COMPLAINTS COMPLETED WITHIN 45 AND 90 DAYS
07/01/10-06/30/11
# Complaints to # Complaints
% Complaints
# Complaints
% Complaints
Facility Type
Investigate done in 45 days done in 45 Days done in 90 days done in 90 days
SNFs
5063
2879
56.86%
3415
67.75%
GACHs
2872
764
26.60%
1113
38.75%
IMRs
435
256
58.85%
309
71.1%
HHAs
217
63
29.03%
86
39.63%
ESRDs
132
36
27.27%
75
56.82%
Hospice
79
25
31.65%
46
58.22%
FQHCs
59
29
49.15%
42
71.18%
ASCs
40
6
15.00%
16
40.0%
RHCs
8
2
25.00%
3
37.5%
11
ERIS COMPLETED WITHIN 45 AND 90 DAYS
07/01/10-06/30/11
Facility Type
# ERIs to
Investigate
# ERIs done in % ERIs done
45 days
in 45 Days
# ERIs done
in 90 days
% ERIs done
in 90 days
SNFs
7468
3933
52.66%
4730
63.33%
GACHs
6618
1909
28.85%
2546
38.47%
IMRs
2919
1014
34.74%
1587
54.37%
HHAs
85
19
22.35%
26
30.59%
FQHCs
37
10
27.03%
16
43.24%
Hospice
36
9
25.00%
12
36.33%
ESRDs
35
18
51.43%
21
60.00%
ASCs
4
1
25.00%
RHCs
4
2
50.00%
COMPLAINT/ERI & POC CHALLENGES
Implementation of LTC Federal complaint process
• Phased in approach
• Development of Complaint P&P and retraining of staff
• Impact on Federal Grant Allocation
Timely initiation of backlog and closure of initiated investigations
OIG Plan of Correction Audit Findings
• Reinforce CMS requirements that each POC include the 5
elements for an acceptable POC (OIG audit report)
• Reinforce the need to on-site visits to determine if facility is
implementing its POC
Solutions
• Implementation of SOM Chapter 5, Section 5070
• (Closure of LTC ERIs if received and not initiated before
recertification survey.) Would like this for non-LTC as well
• Preparing All Facility Letter and District Office Memo
QUALITY AND
ACCOUNTABILITY PROGRAM
For SKILLED NURSING FACILITIES
QUALITY AND ACCOUNTABILITY
PROGRAM
• Collaborative effort between Departments of
Public Health and Health Care Services.
• Implement Skilled Nursing Facility Quality and
Accountability Program.
• Provide incentive payments to facilities for
achieving minimum scores on Quality Measures.
QUALITY AND ACCOUNTABILITY
PROGRAM
• Quality Measures
• Staffing
• Physical Restraints
• Facility-acquired Pressure Ulcers
• Immunizations
• Influenza
• Pneumococcal
• Patient/Family Satisfaction Survey
• Other measures added in subsequent years
QUALITY AND ACCOUNTABILITY
PROGRAM
• All Facility Letter 11-19 for compliance audits:
• In-depth accounting of facility compliance
with 3.2 nurse-staffing requirements.
• Helps determine whether program yields
staffing rates that are instrumental to changes
in health care outcomes.
• Audit all SNFs every year
• Administrative Penalties
• $15,000 non-compliant 5-49% of audited days
• $30,000 non-compliant >49% of audited days
EMERGENCY PREPAREDNESS/
DISASTER RESPONSE BRANCH
EMERGENCY PREPAREDNESS/
DISASTER RESPONSE
• Core Responsibilities/Activities
• Life Safety Code
• Emergency Preparedness/Disaster Response
• State Facilities Unit
• Background:
• Created in 1998 following Northridge Earthquake.
• Assists licensed facilities to prepare for, respond to,
and recover from disasters/emergencies.
• Ensure patient health and safety during extreme
events.
• Educate and train response partners including:
facilities, counties, provider associations, and
state/federal agencies and departments.
OPEN ISSUES
•
•
•
•
•
•
3.2 NHPPD Audit Process
High Profile Facility Closures
LA County Contract Renewal
CMS Grant Compliance
Medical Breaches
Health Facility Consumer Information System
ADMINISTRATIVE SERVICES
BRANCH
ADMINISTRATIVE SERVICES BRANCH
• Personnel and Business Services Section
• Ensures timely processing of hiring and benefit
documents and related personnel requests.
• Provides effective, efficient business services and
operational support to internal & external customers.
• Liaisons with CDPH Human Resources, Program
Support and Contracts Management, as well as
Department of Personnel Administration.
• Fiscal Operations& Grant Administration Section
• Program fiscal liaison with CDPH Budget and
Accounting, Centers for Medicaid and Medicare
Services, Department of Finance, Health and Human
Services Agency, Legislature, Legislative Analyst's
Office and public.
ADMINISTRATIVE SERVICES BRANCH
HEALTH CARE FACILITY FEES
• Annual Fees
• H&S Code 1266(d) requires by Feb. 1:
• Budget Year Health Facility License Fees;
• Based on L&C Program activity costs;
• Staffing and system analysis data includes,
but not limited to:
• Surveyors and other personnel devoted to
licensing & certification activities.
• Facilities receiving full surveys.
• Timeliness of complaint investigations.
• Citation review conferences and
arbitration hearings.
• Data on deficiencies and citations issued.
SYSTEMS, TECHNOLOGY AND
RESEARCH BRANCH
SYSTEMS, TECHNOLOGY,
AND RESEARCH BRANCH
• Research Section
• Conduct research on quality of health care
provided by California's health professionals,
health facilities, and laboratories.
• Staffing Audits Section
• Monitor, enforce, and report on nursing staff
levels in long-term care facilities.
• Program Applications Support Section
• Support and oversee information
technology needs for staff and health
services providers.
POLICY & ENFORCEMENT
BRANCH
POLICY & ENFORCEMENT
• Policy Section:
• promotes program-wide consistency and
standardization; communicate Department
position on legislation impacting Program;
assess need for new/revised field policies
and procedures.
• Provider Certification Section:
• Process certification requests and monitor
enforcement actions against Title 19
certified providers.
POLICY & ENFORCEMENT
• Registered Nurse Section:
• Assists in legislative analysis, writing
regulations, providing technical assistance
to headquarters and L&C Field staff on
survey issues, monitoring regulatory
compliance of providers enrolled in waiver
programs, and assisting in handling appeals
of L&C investigations.
REGULATIONS IN PROCESS
• ICF DD-N Regulations—
• Health and Safety Code 1275.3 mandates that
the Department of Public Health and the
Department of Developmental Services jointly
develop and implement licensing and Medi-Cal
regulations appropriate for ICF DD-N regulations.
• Tuberculosis Testing Regulation
• Allows for use of a broader choice of TB
screening test.
• Medical Information Breach Regulation
• Clarify and specify statutory language related
breach violations in all affected facility types.
REGULATIONS IN PROCESS
• General Acute Care Infection Control Revision
• Revises Title 22 Section 70739 Infection Control
Program to reflect changes in current infection
control statutes.
• General Acute Care & Special Hospitals
Regulations
• Reviews and revises Title 22 Division 5 Chapter 1General Acute Care Hospital regulations in order
to modernize an increasingly obsolete regulation
set.
PROFESSIONAL
CERTIFICATION BRANCH
PROFESSIONAL CERTIFICATION
BRANCH
• Aide and Technician Certification Section
• Certifies Nurse Assistants (CNA), Home Health
Aides (HHA), and Hemodialysis Technicians
(CHT); maintains State Registry; and has
oversight of Training Programs.
• Criminal Background Section
• Grants/denies criminal record clearances for
CNAs, HHAs; deny applications,
revoke/suspend certificate; represents
Department at administrative appeal
hearings.
PROFESSIONAL CERTIFICATION
BRANCH
• Investigation Section
• Investigates allegations/complaints against CNAs, HHAs,
and CHTs; initiates administrative actions (denying an
application, revoking/suspending a certificate/placing
the certificate holder on a diversion program); and
represents Department at administrative appeal hearings.
• Nursing Home Administrator Program
• Licenses Nursing Home Administrators; administers Nursing
Home Administrator State Examination; investigates
allegations/ complaints; oversees Administrator-in-Training
Program and Preceptors; and approves/denies
continuing education providers and courses for Nursing
Home Administrators.
PROFESSIONAL CERTIFICATION
BRANCH ADP TRANSITION
• Department of Alcohol and Drug Programs
transferring into Center for Health Care Quality
effective July 1, 2012:
• Driving Under the Influence Program
• Narcotic Treatment Program
• Counselor Certification
CDPH/DHCS ANTIPSYCHOTIC
COLLABORATIVE
• Goal: Identify facilities where inappropriate
antipsychotic medication is being used; and once
identified corrective action is implemented—
ultimately improving patient care and reducing
health care costs.
• Resident Selection
• Polypharmacy: those who are older than 55 y/o
(with diagnosis of SMI or dementia);
• Monopharmacy: with dementia, no SMI, and
greater than 65 y/o
• Serious Mental Issues (SMI) includes for example major
depression, scizophrenia, bi-polar disorder, etc.
DHCS – Department of Health Care Services
ISSUES
• Independent Information Dispute Resolution
• Standard Admission Agreement
• Retail Food Requirements
• Other issues