Audit
Division
Audit Summary
Health
Division
Bureau of Licensure and Certification
The Bureau of Licensure and Certification needs to improve its data collection and reporting systems. We found the current management information systems do not produce or provide complete, accurate, or reliable information. Poor quality management information increases the risk that complaint investigations and facility inspections are not always performed timely. Complete and accurate management information will help ensure complaints are accurately tracked and recorded, and routine facility inspections are conducted timely.
The programs’ databases contained duplicate and incomplete information, and did not always track significant events. The Bureau also manually compiled program and performance information resulting in inaccurate information being reported. In addition, the Bureau prepared reports based on information gathered through inadequate management information systems. Furthermore, we found reports were not readily supported by complete, accurate, and reliable data.
· The BLC is responsible for investigating complaints received
against facilities and personnel it regulates.
Our analysis of the Bureau’s complaint database showed some complaint
investigations may not have occurred. We
found approximately 100 complaints from 1995, and 530 complaints from 1998 that
did not have investigation dates recorded in the database. (page 7)
· Based on information in the Bureau’s database, some
complaint investigations may not have been initiated within the required time
period. We found complaint
investigations exceeding initiation time requirements in approximately half of
priority 1, 2, and 3 complaints filed against skilled nursing facilities and
adult group care facilities. (page 9)
· The BLC’s controls over the complaint database do not ensure
accurate, reliable, and consistent data.
We found the information on 17 of 51 complaints did not agree with the
information contained in the database.
The database had numerous errors including duplicate records, incomplete
information, inconsistent information, and input errors. (page 10)
· The current management information systems do not provide management with information for monitoring activities. The BLC needs to improve its systems to track on-site inspections of medical and health facilities and ambulances, and prepare routine activity reports. Based upon review of facility files, we found 37 of 100 medical and health facilities and 7 of 29 ambulances did not receive an inspection this past year. Furthermore, several facility inspection intervals exceeded 5 years. Division management indicates annual on-site inspections are not always required but are the preferred monitoring procedure. (page 12)
·
Reports are provided to the public and management based on
information that is not always complete, accurate, or reliable. Some reports were prepared by manually
counting information in the complaint database and complaints in the facility
files. For example, consumers are provided information through “report cards”
on skilled nursing facilities. Based on
comparing complaint information in these reports to the complaint database, we
found discrepancies. For instance, the
1997 report identified a facility with 1 valid complaint in 1997, but the
database listed 9 valid complaints for this facility. (page 16)
Department
of Human Resources
Health
Division
Bureau of
Licensure and Certification
Agency
Response
To Audit Recommendations
|
Recommendation
Number |
|
Accepted |
Rejected |
|
1 |
Develop controls to ensure accurate,
reliable, and complete information is maintained for all programs
administered by the Bureau |
x |
|
|
2 |
Review criteria for priority 3 and 4
complaints and determine if they are appropriate. Revise the written policy if needed and implement appropriate
procedures |
x |
|
|
3 |
Establish uniform controls to ensure
complaints are properly tracked to ensure timely investigations |
x |
|
|
4 |
Establish formal policy for
frequency of on-site inspections of medical and health facilities |
x |
|
|
5 |
Define the terms, “survey”,
“investigate”, and “inspect”, and incorporate changes in the agency’s policy
and procedures manual |
x |
|
|
6 |
Ensure the information systems
accurately track inspections of medical and health facilities, ambulances,
and medical laboratories |
x |
|
|
7 |
Prepare program activity reports to monitor
complaint investigations, medical and health facilities, EMS program, and
medical laboratories |
x |
|
|
TOTALS |
|
7 |
0 |