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DPH Had Inadequate Documentation to Track Intakes Designated for On-Site Investigation Surveys.

DPH does not have controls in place to ensure staff completes Complaint Processing Summary forms for case intakes.

Table of Contents

Overview

In a nonstatistical sample of 94 intakes designated for on-site investigation surveys, 24 intakes lacked Complaint Processing Summary forms to track the intakes and document a manager’s review of work performed by surveyors. In addition, DPH tracked and reviewed 16 of those 24 intakes on a different form from the one outlined in its stated procedures, and there was no documentation to track, and document manager review of, the remaining 8 intakes. As a result, there is a higher-than-acceptable risk that DPH staff members might not take the required actions described on the form. Furthermore, there is a higher-than-acceptable risk that DPH staff members may lose track of an intake altogether after it is designated for on-site survey.

Authoritative Guidance

DPH’s Complaint Unit Intake Process Manual states,

Once a decision has been made to conduct an On-Site investigation it is the responsibility of the Intake Surveyor to create the On-Site Cover Sheet, “Complaint Processing Summary.” . . . This tracking form reflects the administrative life of the case and is the key information resource which documents proper review.

DPH staff members told us that managers use the Complaint Processing Summary form to document their review of work performed by surveyors on on-site investigations.

Reasons for Issues

DPH does not have monitoring controls in place that ensure that its staff completes Complaint Processing Summary forms for all intakes that require on-site investigation surveys.

Recommendation

DPH should establish monitoring controls to ensure that its staff completes Complaint Processing Summary forms for all intakes that require on-site investigation surveys.

Auditee’s Response

The audit report notes that 16 out of 24 of the intake cases that were identified as non-IJ high on-site investigations had a different form other than the on-site cover sheet with them. In a review of these intake cases, DPH found that the form referenced in the draft report is the tracking sheet for the Recertification Unit as these 16 intake cases were investigated as part of a recertification survey.

DPH acknowledges that the Complaint Unit Manual requires that intake cases prioritized as requiring on-site investigations have an on-site cover sheet with them. However, the on-site cover sheet serves as a visual trigger for tracking an on-site investigation through the stages of completion including investigation, writing, review and mailing but it is not a replacement for the work performed in ACTS. The draft audit report states that “DPH staff members may lose track of an intake altogether after it is designated for on-site survey.” However, ACTS serves as the tracking system, and the on-site cover sheet augments the process. As a result, while having the on-site cover sheet is a quality assurance tool for tracking an on-site investigation through the completion stages, its absence does not preclude an on-site investigation from being completed. The absence of this form in no way influences or increases the risk of an on-site investigation not being performed.

Auditor’s Reply

As noted above, we found a number of problems with the documentation related to 24 out of 94 intakes reviewed: 16 of the 24 were processed using a different form from the one prescribed by DPH policy, and there was no documentation to track the remaining 8 and document their manager review. In its response, DPH does not address the 8 intakes that had no Complaint Processing Summary forms completed and suggests that the other 16 were processed using a different but acceptable intake form. However, DPH’s Complaint Unit Intake Process Manual requires the generation of a specific Complaint Processing Summary form for all intakes that require on-site investigation and states, “This tracking form reflects the administrative life of the case and is the key information resource which documents proper review.” For 16 intakes, DPH staff members used an alternate form from the one outlined in its stated procedures, and for 8 intakes, there was no documentation that could be used for tracking and for documenting the manager review. In OSA’s opinion, these conditions create a higher-than-acceptable risk that DPH staff members may lose track of an intake altogether after it is designated for on-site survey, and we therefore urge DPH to implement our recommendation to address this problem.

Date published: September 11, 2019
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