Los Angeles County Grand Jury
2014-2015
Findings & Recommendations
15 findings
F1:
The Office of the Inspector General needs access to Los Angeles County Sheriff’s Department confidential and employee records.
F2:
The Office of the Inspector General needs to maintain independence from political pressure.
F3:
A Los Angeles County Board of Supervisors 2013 resolution releases county general funds, to the Community Development Commission for affordable housing, over five years.
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
R1:
Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
R2:
5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
R3:
When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
R4:
Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
R5:
Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
Los Angeles County funding for affordable housing expires in 2017.
F2:
The Community Development Commission’s 20 percent administration fee for affordable housing projects may not be sufficient to cover long-term monitoring costs of those projects.
F3:
A Los Angeles County Board of Supervisors 2013 resolution releases county general funds, to the Community Development Commission for affordable housing, over five years.
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
R1:
Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
R2:
5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
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When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
Los Angeles County funding for affordable housing expires in 2017.
F2:
The Community Development Commission’s 20 percent administration fee for affordable housing projects may not be sufficient to cover long-term monitoring costs of those projects.
F3:
A Los Angeles County Board of Supervisors 2013 resolution releases county general funds, to the Community Development Commission for affordable housing, over five years.
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
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Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
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3 (2009–2010) LADWP should continue maximum efforts to obtain United States Environmental Protection Agency (USEPA) funding for the cleanup of the San Fernando Basin Aquifer. LADWP’s Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT LADWP’s written response to the Los Angeles County 2009–2010 Civil Grand Jury on November 22, 2010 LADWP agrees with the finding. LADWP agrees and continues to work with and engage the USEPA to effect cleanup of the San Fernando Basin (SFB). CGJ’s written questions to LADWP on February 10, 2015 What progress has LADWP made in obtaining funding from the United States Environmental Protection Agency (USEPA) to effect cleanup of the SFB? Please indicate the funding amounts received from the potentially responsible parties since 2010. Please indicate the status of the North Hollywood Operable Unit (NHOU) Second Interim Remedy (RI2) and monitoring wells including their location, construction, and operational dates. LADWP’s written response to the 2014–2015 CGJ on March 3, 2015 USEPA has designated three Superfund areas in the easterly portion of the SFB; a fourth SuperFund area was also designated within the Verdugo Basin, a neighboring sub-basin within the Upper Los Angeles River Area watershed.8 USEPA have implemented three groundwater remediation facilities—the NHOU, the Burbank Operable Unit, and the Glendale North and South Operable Units. Our response is limited to the NHOU, since this facility is located within the city of Los Angeles (city) and primarily affects solely LADWP’s use of its water rights in SFB. LADWP continues to work closely with USEPA on SFB remediation, and our ongoing collaboration is currently focused on NHOU remediation facility, which began operating in 1989 and now requires replacement. USEPA issued a Record of Decision for RI2 in 2009, requiring a new remediation facility. The responsible parties have submitted work plans to USEPA and are currently conducting its remedial design investigation to determine the appropriate size and scope of the replacement facility. Expected construction and operational dates for the RI2 facility is 8 The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), commonly known as the Superfund, was enacted by congress on Dec. 11, 1980. This law created a tax on the chemical and petroleum industries and provided broad federal authority to respond directly to releases or threatened releases of hazardous substances that may endanger public health or the environment. Over five years, $1.6 billion was collected, and the tax went to a trust fund for cleaning up abandoned or uncontrolled hazardous waste sites. http://www.epa.gov/superfund/policy/cercla.htm. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT subject to completing their investigation and are undetermined at this time. Responsible parties have also completed installation of 33 groundwater monitoring wells in 2013, and they use these wells to collect samples of groundwater for laboratory analysis. Funding for the NHOU is provided through the USEPA Superfund Program, which reimburses 90 percent of the operating costs. Funds are provided by the responsible parties to USEPA, which then reimburses LADWP based on actual expenditures. Since January 1, 2010, responsible parties have provided $2,082,283 in reimbursements through December 31, 2014. Notes taken from 2014–2015 CGJ’s telephonic conversation on April 17, 2015, clarifying LADWP’s March 3, 2015, response NHOU needs to be replaced—it will be replaced by RI2. USEPA issued a Record of Decision for RI2 in 2009, requiring a new remediation facility. The responsible parties have submitted work plans to USEPA and are currently conducting a remedial design investigation to determine the appropriate size and scope of the replacement facility. Expected construction and operational dates for the RI2 facility are subject to completing the investigation and are undetermined at this time. The Potentially Responsible Parties (PRP) are Honeywell, Lockheed, and minor PRPs. The PRPs have installed 33 groundwater monitoring wells in 2013. Some are inside and around Home Depot, and others are near NHOU at 11845 Vose in North Hollywood. The PRPs send the groundwater samples for laboratory analysis. LADWP operates NHOU. LADWP agrees upon a work plan budget for NHOU operating costs for the year (personnel, electricity—direct and indirect costs). The PRPs give 100 percent of the budget to USEPA, and USEPA reimburses LADWP 90 percent. LADWP received $2,082,283 in reimbursements through December 31, 2014 from USEPA. The RI2 will clean up four primary contaminants—1.44 Dioxane, Hexavalent Chromium, Trichloroethylene, and Tetrachloroethylene. The City Attorney is coordinating with the USEPA and the engineers.
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When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
Los Angeles County funding for affordable housing expires in 2017.
F2:
The Community Development Commission’s 20 percent administration fee for affordable housing projects may not be sufficient to cover long-term monitoring costs of those projects.
F3:
A Los Angeles County Board of Supervisors 2013 resolution releases county general funds, to the Community Development Commission for affordable housing, over five years.
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
2
Not linked to specific findings.
R2:
5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
R9:
1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
Currently, the decision to institute a PAD program is within the discretion of individual county departments.
F2:
Although no one interviewed disputed the usefulness of AEDs, on balance the costs to Los Angeles County in expanding installation of the devices, as well as the time needed for training government personnel on the use of AEDS, do not justify countywide installation of AEDs. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F3:
Educating the public on the purpose of AEDs, including training in the use of existing AEDs, is economically feasible and would help make better use of already installed AEDs.
F4:
The city of Los Angeles PAD program is understaffed. Its existing devices are in need of maintenance and may currently be a liability.
F5:
The Los Angeles Department of City Planning does not keep a copy of notices mailed.
F6:
The Los Angeles Department of City Planning keeps copies of affidavits of mailings but could not locate that affidavit in this instance.
F7:
The City of Los Angeles Department of Public Works does not have access to information about its mailing of notices.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
R1:
Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
R2:
5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
R3:
When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
Production systems are fragmented over 64 Los Angeles County data centers plus three private out-of-state data centers.
F2:
Development and hosting are going out of Los Angeles County hands. This means jobs and county funds are moving out of the county.
F3:
Software development industrywide has such a high failure rate that extra oversight is warranted.
F4:
Los Angeles County has no method to determine to what degree completed software development programs have been a success, and there is no permanent record of lessons learned from the experience of developing new systems.
F5:
There appears to be no standard system development methodology for Los Angeles County.
F6:
There appears to be no standard project management methodology for Los Angeles County.
F7:
Data security is constantly being challenged, so the Los Angeles County chief information officer has been working to upgrade and standardize security.
F8:
Data are not standardized within Los Angeles County chief information officer–defined clusters of departments, except within the justice (ISAB) group.
F9:
Some departments worry about Information Technology Services (ITS) responsiveness and ITS’s ability provide a high level of service.
F10:
Some Los Angeles County data centers inadequately conduct backup. The most- comprehensive backup operation appears to be that of the ITS Data Center at Downey. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F11:
Many Los Angeles County departments worry about the disaster survivability of the ITS Data Center and the Orange County backup site. Three departments worry so much that they run their mission critical systems on private data centers outside of the county, in fact, even outside of California.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
R1:
Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
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5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
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When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
R4:
Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
R5:
Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
The Department of Health Services responded to all 16 questions put to it by the committee. Its responding document is reproduced in full as Attachment A to this report. The questions are listed and DHS’s responses are summarized on the following table.
F2:
The table lists the committee’s questions on the left and categorizes the DHS responses as either implemented, in progress, no progress, or decline to implement. Of the 16 2 Online Real-Time Centralized Health Information Database. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F3:
With 15 out of 16 recommendations either completed or underway, clearly a good faith effort is being made by DHS. The department is to be complimented on its rapid progress. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Summary of Responses to Civil Grand Jury questions by the Department of Health Services In No Questions to DHS Implemented Progress Progress Decline Comments 2.1 Have both the new ORCHID system and the current system incorporated codes on all accounts for classifying and explaining reasons for denial? X 2.2 Has DHS updated the procedure to include new Reason for denial codes? X 2.3 Has the availability of Patient Financial Services worker staff been increased at all hospitals? X 2.4 What method, if any, has DHS Replaced with implemented to replace the new process discontinued method of (see Attachment identifying write-offs for denied or A) late claims that are billed by the DHS Consolidated Business Office? X 2.5 Has DHS determined the staffing required to review Medi- Cal fee-for-service accounts for patients still in DHS hospitals? X 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? X 2.7 What is the projected date by Target date is which DHS expects to fully July 1, 2015 implement the original
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
R1:
Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
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5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
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Licensure/contract requirements
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Facility and environment
F3:
Maintenance of required documentation and service delivery
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Education and workforce readiness
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Health and medical needs
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Psychotropic medication
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Personal rights and social/emotional well-being
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Personal needs/survival and economic well-being
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Personnel records Department of Children and Family Services (DCFS) Group Home Compliance Monitoring5 GH compliance monitoring is a component of the Performance Monitoring Section in the Out of Home Care Management Division. Annual reviews of those GHs servicing DCFS-placed children are conducted, which include program contract compliance. The reviews determined whether homes meet the requirements set forth in the Foster Care Agreement, the homes’ program statements, and DCFS policies. The reviews assess the homes’ service delivery to ensure that these homes are providing children with quality care and services in a safe environment, inclusive of physical care, emotional support, and other services to protect and enhance their growth and development. Copies of DCFS Compliance Monitoring Reports can be accessed through the DCFS website at: http://dcfs.lacounty.gov. Information obtained from the DCFS website. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Contract Monitoring Process6 The goals of the monitoring process are to improve child safety, increase provider services, and strengthen networking among the homes. DCFS’s rating system assesses home performance and incorporates Corrective Action Plans (CAPs) and follow-up to ensure compliance:
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Fiscal Compliance—assesses home’s fiscal internal controls that will ensure that the CAP, if any, is implemented.
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Contract Compliance—assesses contract deliverables on safety, service needs, and administrative compliance, and follows up on implementation by the agency CAP as necessary. Ensures that homes are in compliance with contract terms and conditions, Community Care Licensing Division approved Program Statements, Statement of Work, and Title 22 regulations.
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Quality Assurance—assesses the quality of performance and service delivery by homes to ensure children are provided with quality care and services in a safe environment. Los Angeles County Probation Department Office of the Ombudsman7 The Probation Department Office of the Ombudsman is a confidential, informational, and neutral resource where probation clients, their families, and the community can seek assistance with their concerns related to GH service delivery, policies, and/or procedures. The role of the ombudsman for GHs is twofold: 1) to ensure that the voice of youth under the care and custody of Probation is heard and 2) to provide an avenue for the Probation youth to express concerns about their GH experience without fear of retaliation from the GH provider and/or Probation officer and to get resolutions that are reasonable. Placement Permanency and Quality Assurance Unit (PPQA)8 The PPQA serves Probation foster children and their families, group home providers, and the Placement Bureau as a whole. The primary purpose of the group home monitoring/investigations unit is to conduct annual monitoring inspections of group homes that have multiple sites throughout Los Angeles County; investigate GHs related to noncompliance with the county contract; conduct follow-up investigations on minor infractions; refer investigations to Probation from the DCFS Child Abuse Hotline; and develop and monitor the CAP for accuracy and compliance. GHs have 30 days to make the noted corrections; safety issues must be dealt with immediately. At the end of 30 days the PPQA makes another visit to ensure all corrective actions have been addressed. Correspondence received from DCFS. Information received from the Probation Department. Correspondence received from the Probation Department. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Group Home Compliance monitoring reports can be accessed through Los Angeles County Probation at http://probation.lacounty.gov. Department of Auditor-Controller Group Home Ombudsman9 The Office of the Children’s Group Home Ombudsman, within the Department of Auditor- Controller, is an independent advocate for children placed in group homes by DCFS. The ombudsman’s responsibilities include: maintaining a toll-free telephone number for DCFS GH residents to call from anywhere to express their concerns and complaints; informing children of their rights when placed in a GH; providing a voice to speak and act on behalf of GH residents; establishing an avenue for children to discuss their concerns and complaints without fear of retaliation; offering recommendations that are reasonable and feasible; and working with the county and service providers to benefit GH residents. Although primarily for DCFS GH residents, the GH ombudsman will contact the Probation ombudsman on behalf of any Probation resident who has issues to be resolved. Even though the ombudsman’s policy is to maintain confidentiality to the extent possible, callers are informed that, by law, child endangerment, abuse, and/or neglect must be reported. Fiscal Review of Group Homes10 According to the Auditor-Controller’s Contract Monitoring Division, at the beginning of each fiscal year (July 1), the Auditor-Controller completes a Risk Home Assessment of GHs and Foster Family Agencies to determine those homes that will be included in its list of audits to be conducted for the year. In addition, both DCFS and Probation can request a fiscal audit if, during a GH program review, fiscal improprieties are noted. Fiscal reviews can also be initiated by allegations received through the Auditor-Controller’s fraud hotline or a Board of Supervisor’s office’s referral. The Auditor-Controller provides fiscal training upon request to the DCFS Fiscal Compliance section, Foster Family Agencies, and GHs. The Auditor-Controller also collaborates and consults with DCFS’s Fiscal Compliance section on results of DCFS’s Internal Controls Questionnaire and Fiscal Compliance Assessment Tool. Fiscal Review Reports can be reviewed at http://auditorcontroller.lacounty.gov. Information received from the Group Home Ombudsman. Information received from the Auditor-Controller. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Note: All group homes in Los Angeles County are licensed by the Community Care Licensing (CCL) Division of the California Department of Social Services under Title 22 Regulations and as such are subject to annual reviews by CCL to ensure licensing compliance. CCL’s complete Policy and Procedures Manual can be accessed at http://cdss.ca.gov. SUMMARY The focus of the Group Home Committee was to determine if the basic needs of the minors— including but not limited to food, housing, clothing, education, and psychological services— were met. Overall, the group homes inspected appeared to meet these needs. Most of the group homes housed both DCFS and Probation youths but followed different requirements based on the respective department’s regulations. Although the majority of minors interviewed were satisfied with their placement, more than one youth stated that the group home did not replace being with family. Due to the decline in the number of group homes, it would appear that the court and departments have changed their focus from group home placement to family reunification or relative placement whenever possible. According to an email sent by DCFS to The Chronicle of Social Change, dated Sept. 30, 2014, Los Angeles County submitted a nonbinding letter to opt into the Approved Relative Caregiver Funding Program (ARC) effective Jan. 1, 2015. The new funding (initially a $30 million budget allocation) is intended to provide relative caregivers with the same level of funding as other nonrelative foster caregivers. Currently, many relative caregivers receive about half of what other caregivers receive monthly.11 On March 3, 2015, Los Angeles County Board of Supervisors passed a motion instructing DCFS to opt into the ARC program by March 15, 2015.12 COMMENDATION Based on observations of the group homes visited, the committee commends the efforts of these group home providers in delivering services and promoting the safety and well-being of the home residents. Information obtained from http://ChronicleofSocialChange.org. Board of Supervisors Statement of Proceedings, March 3, 2015. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT The committee also applauds the Los Angeles County Board of Supervisors’ decision to participate in the Approved Relative Caregiver Funding Program. It will be a tremendous savings for the county and a win-win situation for all parties. ACRONYMS ARC Approved Relative Caregiver Funding Program CAP Corrective Action Plan CCL Community Care Licensing Division DCFS Department of Children and Family Services GH Group Home RCL Rate Classification Level PPQA Placement Permanency and Quality Assurance unit COMMITTEE MEMBERS Wesley C. Thompson, chair Larry Lyman, vice chair Earline Parker, secretary Doris K. Reed Joyce Simily Margaret Yasuda 107 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT METRO RIDERSHIP Jim Contreras, chair Simeon Zano, vice chair Shari E. Pearce, secretary METRO RIDERSHIP TOPIC The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) formed the Metro Ridership Committee (committee) to look into increasing the ridership within the Los Angeles County Metropolitan Transportation Authority (Metro) system and investigate the efforts of Metro to do the same. The committee also looked into whether Metro would receive maximum funding from federal sources based on achieving the farebox recovery goal of 33 percent.1
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Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
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There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
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In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
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Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
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5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
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When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
R5:
Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
15 findings
F1:
A bill has been introduced in the California State Senate that would allow Los Angeles County Metropolitan Transportation Authority (Metro) to seek a new sales tax via the ballot.
F2:
The Orange Line Bus Rapid Transit is congested during peak times.
F3:
Metro used the goal of achieving a 33 percent farebox recovery rate as a reason to raise fares in 2014 and increase enforcement of fare collection.
F4:
Metro uses armed and unarmed personnel to cite fare evaders.
F5:
Metro safety signage is ineffective. Metro 52, Executive Management Committee, March 19, 2015, Subject: Metro Parking Ordinance, Metro Parking Rates and Permit Fee Resolution. Los Angeles County Metropolitan Transportation Authority Administrative Code, Title 8. Metro Parking management, San Gabriel Valley Service Council Minutes, March 9, 2015. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
6
Not linked to specific findings.
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Who: Your Name: _______________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip, Code: _______________________________________________________________ Telephone: ( ) Extension: ______________
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5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ QUESTION 2.8 Is DHS monitoring the processing of Medicare claims by the new ORCHID system? 1/30/15 RESPONSE Not Implemented – The ORCHID system was successfully implementation at Harbor-UCLA Medical Center on November 1, 2014, however, the interface between ORCHID and the Affinity system has resulted in new challenges impacting the usage of itemize billing from the system. As a result, we have postponed usage of itemize detail coming from the system to generate Medicare claims until a full assessment of the process is completed. The assessment will start in April and is expected to be completed by July 2015. In the interim, we have developed alternative plans to ensure the billing process is resumed. RECOMMENDATION No. 2.9 Track the backlog for coding at all facilities through regular reports, similar to those produced by Los Angeles County’s LAC+USC Medical Center. Aggregate and analyze coding backlog data at all facilities for resulting trends and to identify any problem areas. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will standardize Health Information Management (HIM) reports to monitor coding backlogs as part of its implementation of ORCHID. ORCHID implementation at DHS’ first facility is anticipated to be completed by November 1, 2014. CGJ QUESTION 2.9 Has DHS standardized Health Information Reports to monitor coding backlogs? 1/30/15 RESPONSE Implemented - DHS has developed an inventory status report to identify and prioritize accounts that need medical record coding. This report is provided to DHS facilities on a weekly basis. Additionally, current monitoring reports (e.g., staffing model, Dashboard report, Coder Output Productivity) used by LAC+USC Medical Center have been expanded to other facilities for identifying coding issues to prevent backlog. RECOMMENDATION No. 2.10 Perform a staffing analysis in Health Information Management (HIM) divisions at all DHS facilities to assess whether additional staff might ameliorate the current HIM backlogs and delays in coding. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease HIM backlogs and delays in coding. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.10 Has DHS conducted a staff analysis to determine if additional staff will decrease the HIM backlogs and delays in coding? 1/30/15 RESPONSE Implemented - HIM completed a staffing analysis in October 2014. Based on anticipated production standards, current staffing level was sufficient to handle existing coding volume. However, staffing resource and work volume are not evenly distributed. HIM will work to reallocate staffing needs across all areas to prevent future backlogs. RECOMMENDATION No. 2.11 Implement an electronic notification method for alerting physicians of the patients' required authorization from third party payers when follow-up services are required. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will study the feasibility of utilizing an electronic notification to alert physicians, utilization review nurses, etc., when third party payer authorization is required for follow-up services as part of its implementation of ORCHID. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.11 Has an electronic notification method been implemented to alert physicians of patients requiring authorization from third party payers for services? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.11 as of 02/19/2015 What is the method by which DHS will ensure that a patient is identified as requiring third party authorization for follow-up services prior to such services being provided – and – when will that method be fully implemented? 3/20/2015 Response DHS will use the new ORCHID electronic health care system to identify admissions and visits that require third party authorizations. The First Net module/solution in ORCHID will enable the facilities to use an indicator (icon) on the patient's record that will alert providers and staff that an authorization is required. This indicator has been fully implemented at Harbor\UCLA Medical Center and MLK Jr. Outpatient Center and will be implemented at remaining facilities according to the ORCHID install schedule established for the Department. The schedule for the remaining hospitals is: May 1, 2015 for LAC+USC Medical Center, August 1, 2015 High Desert Regional Health Center, October 1, 2015 for Rancho Los Amigos National Rehabilitation Center and February 1, 2016 for Olive View/UCLA Medical Center. In addition, the Department is working on standardizing procedures to ensure facilities refer patients to their appropriate third party plans for follow-up care. RECOMMENDATION No. 2.12 All physicians must be trained on the new electronic notification system and accountability measures should be implemented to ensure that physicians schedule follow-up services appropriately. 7/18/14 RESPONSE DHS agrees with this recommendation. Based upon the outcome of feasibility study conducted on Recommendation 2.11, training will be provided to appropriate staff, e.g., physicians, utilization review nurses, etc., on the electronic notification system. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014, and training will be subsequently scheduled as necessary. CGJ QUESTION 2.12 Are there plans to train physicians on the electronic notification system? 1/30/15 RESPONSE Partial Implementation - DHS has created an icon in First Net (the ORCHID ED module) to indicate that a patient has private insurance or is a managed care, assigned to a non-DHS provider. DHS is exploring the possibility of this icon auto- populating based on the insurance type, rather than being manually added by the registration staff. Once the assessment is completed, training will be provided to the appropriate staff. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CGJ Question 2.12 as of 02/19/2015 Please identify the classifications or groupings of staff who will receive training on the electronic notification system. What is the status of the training on the electronic notification system and what is the target date for full implementation of the training? 3/20/2015 Response Classifications who have received training include physicians, nursing staff, Utilization Review nurses, clerical support staff and registration staff. These same classifications will receive training within 60 days of their scheduled ORCHID implementation date. RECOMMENDATION No. 2.13 Require all DHS facilities to regularly pre-screen scheduled outpatient appointments to ensure that authorization is obtained or the patient is referred to a more appropriate provider. 7/18/14 RESPONSE DHS partially agrees with this recommendation. DHS will evaluate facility staffing for pre-screening outpatient appointments (excludes Emergency Room, Urgent Care, and Walk-in Clinics). If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.13 Has DHS evaluated how to pre-screen outpatient appointments to ensure authorization has been obtained? 1/30/15 RESPONSE Partially implemented - DHS has implemented a streamlined model at one facility that has resulted in improvements in the prescreening and outpatient appointment process and is implementing a similar model at all facilities. This effort will ensure patients are appropriately prescreened for eligibility and authorization prior to their appointment and ensure patients are redirected to their appropriate provider. In addition, DHS is working with Human Resources to fill all available registration positions dedicated to the prescreening process and is working with technology staff on improving the eligibility verification system. RECOMMENDATION No. 2.14 Evaluate effective and efficient staffing models to support the need for obtaining authorization from third party payers for inpatient services; such as a designated unit, a centralized staff, or an independent utilization review unit. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will evaluate the feasibility of inpatient staffing to determine the organizational structure and staffing needs in order to effectively obtain authorization from third party payers for inpatient services. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.14 Has DHS selected a staffing model to expedite service authorization from third party payers? 1/30/15 RESPONSE Implemented - DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.15 Determine the cost-effectiveness of implementing third party payers' online authorization tools to ensure timely authorization for inpatient services. 7/18/14 RESPONSE DHS agrees with this recommendation. A study will be conducted to determine the feasibility of obtaining an electronic tool for online third party payer authorization for DHS’ largest payers. If necessary, DHS will submit a budget request for additional staffing, and associated Services and Supplies (S&S) needed to fully implement this recommendation. Completion of the study is anticipated by December 31, 2014. CGJ QUESTION 2.15 Has DHS selected an electronic tool to expedite service authorization from third party payers? 96 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Partially Implemented - DHS has approached the software vendor, Provider Advantage, to obtain an online tool for processing prior authorization and "278" referral transactions. An assessment is being completed to determine feasibility. RECOMMENDATION No. 2.16 Collaborate with Cerner, the Department's vendor for its new electronic medical record system, ORCHID, to determine if enhancements in the new system could facilitate online processing of health care plan authorizations for DHS services. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will collaborate with Cerner to determine the feasibility of using standard functionality or enhancing ORCHID to facilitate electronic online processing of health care plan authorizations for DHS services. If necessary, DHS will submit a budget request needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.16 Has DHS ensured that the new ORCHID system facilitates online processing of health care plan treatment authorizations? 1/30/15 RESPONSE Partially Implemented - ORCHID is built to automate the faxing of key documentation required for authorized inpatient admissions. This includes the initial clinical review done by the utilization review nurse and additional care management information, including progress notes, labs, clinical updates, and additional medical record information. UR nurses at Harbor are now able to enter a fax number into ORCHID, which then generates and sends the selected paperwork. This has eliminated some of the manual work previously done by UR nurses and improved efficiency. ORCHID will be fully implemented DHS-wide by February 2016. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT GROUP HOME Wesley C. Thompson, c hair Larry Lyman, vice chair Earline C. Parker, secretary Doris K. Reed Joyce Simily Margaret M. Yasuda GROUP HOME TOPIC Based on a review of past Los Angeles County Civil Grand Jury final reports, the Los Angeles County 2014–2015 Civil Grand Jury (CGJ) noted that group homes in the County of Los Angeles had not been inspected by a Los Angeles County Civil Grand Jury for the prior eight years. Due to concern for the well-being of minors in group homes, the Group Home Committee (committee) was formed, consisting of six members of the CGJ. The committee’s focus was to determine if the basic needs of the minors—including but not limited to food, housing, clothing, education, and psychological services—were being met.
R3:
When: Date(s) of incident: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 165 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
R4:
Where: Names and addresses of other departments, agencies or officials involved in this complaint. Include dates and types of contact, i.e. phone, letter, personal. Use additional sheets if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
R5:
Why/How: Attach pertinent documents and correspondence with dates. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 166 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Complaint Guidelines Communications from the public can provide valuable information to the Civil Grand Jury. Any private citizen, government employee, or officer may submit a completed complaint form to request that the Civil Grand Jury conduct an investigation. This complaint must be in writing and is treated as confidential. Prior to submitting the Complaint Form to the Grand Jury office, please retain a copy for your records if needed. Receipt of all complaints will be acknowledged. If the Civil Grand Jury determines that a matter is within the legally permissible scope of its investigative powers and would warrant further inquiry, additional information may be requested. If a matter does not fall within the Civil Grand Jury's investigative authority, or the jury determines not to investigate a complaint, no action will be taken and there will be no further contact from the Civil Grand Jury. The findings of any investigation conducted by the Civil Grand Jury can be communicated only in a formal final report published at the conclusion of the Grand Jury's term, June 30th. Some complaints are not suitable for civil grand jury action. For example, the Civil Grand Jury has no jurisdiction over judicial performance, actions of the court, or cases that are pending in the courts. Grievances of this nature must be resolved through the established judicial appeal system. The Civil Grand Jury has no jurisdiction or authority to investigate federal or state agencies. Only causes of action occurring within the County of Los Angeles are eligible for review. The jurisdiction of the Civil Grand Jury includes the following: • Consideration of evidence of misconduct against public officials within Los Angeles County. • Inquiry into the condition and management of the jails within the county. • Investigation and report on the operations, accounts, and records of the officers, departments or functions of the county including those operations, accounts, and records of any special legislative district or other district in the county created pursuant to state law for which the officers of the county are serving in their ex officio capacity as officers of the districts. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT • Investigation of the books and records of any incorporated city or joint powers agency located in the county. Mail complaint form to: Los Angeles County Civil Grand Jury Clara Shortridge Foltz Criminal Justice Center 210 W. Temple Street, 11th Floor, Room 11-506 Los Angeles, CA 90012 168 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT CONTINUITY COMMITTEE Ken Star, chair Jim Contreras, vice chair Simeon Zano, secretary Shari E. Pearce John A. Rangel Wesley C. Thompson Margaret M. Yasuda CONTINUITY COMMITTEE The Continuity Committee serves a statutory function of the Los Angeles County Civil Grand Jury: to archive and organize responses to the previous year’s Final Report. The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) also ensured continued retention of CGJ materials and changed the method of indexing that information. California Penal Code Section 933(c) mandates responses, within 90 days, to the previous year’s reports by the public agencies to whom recommendations were made by the Final Report. The CGJ followed up to ensure reasonably timely compliance by the agencies addressed in the 2013–2014 Final Report. Penal Code Section 933.05 requires that agency responses be specific to each individual finding and recommendation. The committee reviewed the responses and found they substantially complied with the legal requirements. Please take note that the responses filed by the agencies are much more extensive than indicated in the following pages and were placed with the custodians set forth in Penal Code Section 933(c) and also on the CGJ website at http://grandjury.co.la.ca.us/gjreports.html. ARCHIVAL/ORGANIZATIONAL ROLE The committee has continued the actions of its predecessors in maintaining copies of previous reports and responses, both hard copy and electronic. Past Continuity committees have also prepared tables of reports and recommendations for the following year’s jury to use as a
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1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
14 findings
F1:
During the course of the CGJ’s inspection of municipal police jails. CGJ noted that Los Angeles Police Department (LAPD) had closed six jails: Devonshire, Foothill, Harbor, Southwest, Wilshire, and Southeast jails. The closure of these facilities required arresting officers to transport arrestees to a centrally located jail. This created a strain on police manpower in the field. Based on information received from LAPD, the closure of the above- mentioned jails was due to a lack of detention officers. To reopen the temporarily closed jails would require 62 additional detention officers; in addition, 75 police officer IIs currently back- fill for the vacant detention officer positions at other stations. LAPD’s jail division is currently holding a detention officer academy class, and a second class was planned for June 2015.
F2:
At one Los Angeles County Sheriff’s Department courthouse lockup inspected by the committee, deputies described the process of handling prisoners in a manner that would prevent the spread of staph bacteria called Methicillin-resistant Staphylococcus aureus (MRSA). When prisoners arrive, they are attached to a chain by individual handcuffs. Wearing gloves, the deputies detach prisoners from their handcuffs and chain. The deputies apply and clean the hardware with a specially designed disinfectant spray to kill MRSA.1
F3:
Staff at Northeast (LA/Eagle Rock) Station stated that there are potential environmental issues in the soil of the Northeast Police Station. A new facility will be built on the same site.
F4:
Some of the jails/holding areas the committee inspected were unsatisfactory: Bell Gardens Police Department: The inspection revealed peeling paint. There were locks on cabinets holding detainees’ belongings, but there were no keys. One cell was not useable because of broken plumbing pipes. Bellflower Courthouse Jail: Radio dead zones exist in some areas within the courthouse. The refrigerator registered at an unsafe temperature. Staff stated the gun lockup needed to be upgraded and the sally port needed to be enhanced. Alarm systems for exit doors were not operable. Compton Courthouse Jail: The building was very old. There were scratches throughout the facility. The walls and ceilings in the cells were in poor condition. There was low water pressure in cells and in the lock-up area. Walls and ceilings throughout 1 According to research by the Mayo Clinic, MRSA is spread by skin contact. It affects healthy people in settings where skin contact is likely, such as contact sports, or groups living in crowded and unsanitary conditions. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT the facility needed to be painted. Food for inmates was left unrefrigerated and out in the open. East Los Angeles Courthouse Jail: The turn-out gear does not fit staff and had never been used. There was graffiti all over floor of holding cells. The staffing level was in flux due to court consolidation. There were no defibrillators at this facility. Inglewood Juvenile Courthouse Jail: The facility was built in 1976 and had not been properly maintained (graffiti and peeled paint on the wall, and the floor tile needed to be repaired). The sally port was inadequate, having a narrow path from outside of the building to the courthouse. Packaged food for inmates was delivered and stored in a portable cooler rather than refrigerated. The health inspection was done roughly five months ago, and the facility did not pass. In case of an emergency, a deputy at the detention facility needed to call the dispatcher first before connecting to the 911 Call Center. Men’s Central Jail: The facility was old but was clean. The old section was built in 1963 and the new section was built in 1973. There were ongoing plumbing problems. The kitchen operation was running well and it was clean. It serviced roughly 20,000 meals per day—mainly packaged food for Central Jail and Twin Towers. A chapel on- site performs services multiple times daily. Staff stated pest control and plumbing were the major issues. The facility was overcrowded. Redondo Beach Police Department: Cameras within the facility were installed but were not yet operational. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
Additional Recommendations
1
Not linked to specific findings.
R9:
1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Findings & Recommendations
2 findings
F1:
The Office of the Inspector General needs access to Los Angeles County Sheriff’s Department confidential and employee records.
F2:
The Office of the Inspector General needs to maintain independence from political pressure.
Additional Recommendations
1
Not linked to specific findings.
R2:
3 (2009–2010) LADWP should continue maximum efforts to obtain United States Environmental Protection Agency (USEPA) funding for the cleanup of the San Fernando Basin Aquifer. LADWP’s Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT LADWP’s written response to the Los Angeles County 2009–2010 Civil Grand Jury on November 22, 2010 LADWP agrees with the finding. LADWP agrees and continues to work with and engage the USEPA to effect cleanup of the San Fernando Basin (SFB). CGJ’s written questions to LADWP on February 10, 2015 What progress has LADWP made in obtaining funding from the United States Environmental Protection Agency (USEPA) to effect cleanup of the SFB? Please indicate the funding amounts received from the potentially responsible parties since 2010. Please indicate the status of the North Hollywood Operable Unit (NHOU) Second Interim Remedy (RI2) and monitoring wells including their location, construction, and operational dates. LADWP’s written response to the 2014–2015 CGJ on March 3, 2015 USEPA has designated three Superfund areas in the easterly portion of the SFB; a fourth SuperFund area was also designated within the Verdugo Basin, a neighboring sub-basin within the Upper Los Angeles River Area watershed.8 USEPA have implemented three groundwater remediation facilities—the NHOU, the Burbank Operable Unit, and the Glendale North and South Operable Units. Our response is limited to the NHOU, since this facility is located within the city of Los Angeles (city) and primarily affects solely LADWP’s use of its water rights in SFB. LADWP continues to work closely with USEPA on SFB remediation, and our ongoing collaboration is currently focused on NHOU remediation facility, which began operating in 1989 and now requires replacement. USEPA issued a Record of Decision for RI2 in 2009, requiring a new remediation facility. The responsible parties have submitted work plans to USEPA and are currently conducting its remedial design investigation to determine the appropriate size and scope of the replacement facility. Expected construction and operational dates for the RI2 facility is 8 The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), commonly known as the Superfund, was enacted by congress on Dec. 11, 1980. This law created a tax on the chemical and petroleum industries and provided broad federal authority to respond directly to releases or threatened releases of hazardous substances that may endanger public health or the environment. Over five years, $1.6 billion was collected, and the tax went to a trust fund for cleaning up abandoned or uncontrolled hazardous waste sites. http://www.epa.gov/superfund/policy/cercla.htm. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT subject to completing their investigation and are undetermined at this time. Responsible parties have also completed installation of 33 groundwater monitoring wells in 2013, and they use these wells to collect samples of groundwater for laboratory analysis. Funding for the NHOU is provided through the USEPA Superfund Program, which reimburses 90 percent of the operating costs. Funds are provided by the responsible parties to USEPA, which then reimburses LADWP based on actual expenditures. Since January 1, 2010, responsible parties have provided $2,082,283 in reimbursements through December 31, 2014. Notes taken from 2014–2015 CGJ’s telephonic conversation on April 17, 2015, clarifying LADWP’s March 3, 2015, response NHOU needs to be replaced—it will be replaced by RI2. USEPA issued a Record of Decision for RI2 in 2009, requiring a new remediation facility. The responsible parties have submitted work plans to USEPA and are currently conducting a remedial design investigation to determine the appropriate size and scope of the replacement facility. Expected construction and operational dates for the RI2 facility are subject to completing the investigation and are undetermined at this time. The Potentially Responsible Parties (PRP) are Honeywell, Lockheed, and minor PRPs. The PRPs have installed 33 groundwater monitoring wells in 2013. Some are inside and around Home Depot, and others are near NHOU at 11845 Vose in North Hollywood. The PRPs send the groundwater samples for laboratory analysis. LADWP operates NHOU. LADWP agrees upon a work plan budget for NHOU operating costs for the year (personnel, electricity—direct and indirect costs). The PRPs give 100 percent of the budget to USEPA, and USEPA reimburses LADWP 90 percent. LADWP received $2,082,283 in reimbursements through December 31, 2014 from USEPA. The RI2 will clean up four primary contaminants—1.44 Dioxane, Hexavalent Chromium, Trichloroethylene, and Tetrachloroethylene. The City Attorney is coordinating with the USEPA and the engineers.
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Findings & Recommendations
5 findings
F1:
North Hollywood Operable Unit needs to be replaced. It will be replaced by the North Hollywood Operable Unit Second Interim Remedy. The completion date is as yet undetermined.
F2:
The potentially responsible parties have installed 33 groundwater monitoring wells in and around Home Depot and near the North Hollywood Operable Unit at 11845 Vose Street in North Hollywood.
F3:
Los Angeles Department of Water and Power operates the North Hollywood Operable Unit. Potentially responsible parties give funds to United States Environmental Protective Agency. The agency pays the Los Angeles Department of Water and Power 90 percent of North Hollywood Operable Unit’s operating costs.
F4:
The Los Angeles Department of Water and Power has 26 new groundwater monitoring wells—25 were constructed by the Los Angeles Department of Water and Power and one by the United States Environmental Protective Agency. The Los Angeles Department of Water and Power’s 25 monitoring wells have three elevations/zones (shallow, middle, and deep pipes) and the United States Environmental Protective Agency’s one monitoring well has two elevations/ zones (two pipes).
F5:
It will take many decades to clean up the contaminants in the aquifer. The Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus’s Los Angeles Clean Tech Incubator will need additional help to create new methods to clean up the groundwater.10
Additional Recommendations
2
Not linked to specific findings.
R2:
5 (2009–2010) LADWP should have a new review made of the amount of water that can be pumped from the San Fernando Basin Aquifer. Due to the future increased demand for water and possible reductions in water sources, the San Fernando Basin Aquifer may be a major source of potable water. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT LADWP’s written response to the Los Angeles County 2009–2010 Civil Grand Jury on November 22, 2010 LADWP agrees with the finding. LADWP has already been working with the cities of Glendale and Burbank as well as the Upper Los Angeles River Area (ULARA) Watermaster to develop a plan to determine a thorough and accurate “Re-evaluation of the Safe Yield of the San Fernando Basin.” The ULARA Watermaster recommended to the Superior Court on April 30, 2010, that a number of critical data-gathering activities need to take place before undertaking such a study. It is anticipated that a study would likely be initiated within 3 to 5 years. CGJ’s written questions on February 10, 2015 Did the Upper Los Angeles River Area (ULARA) Watermaster complete the study of the amount of potable water that can be pumped from the SFB within the three- to five-year timeline as promised? What was the result, and can we have a hard copy of the study or can you point us to an online version on your website? LADWP’s written response to the 2014–2015 CGJ on March 3, 2015 First, LADWP would like to clarify that the ULARA Watermaster did not promise to study the amount of potable water that could be pumped from SFB within three to five years. The ULARA Watermaster has determined that SFB is not in a condition of overdraft and that current operations do not pose an imminent threat to water supplies.9 This affords time to complete improvements to the stormwater capture facilities while also compiling the necessary data for a future reevaluation of the safe yield. LADWP and the cities of Burbank and Glendale are working proactively towards preserving the SFB water supply, including an agreement to reevaluate the SFB safe yield. This reevaluation will be supported by the ULARA Watermaster’s continuing compilation of data and information about the SFB hydrogeology and his evaluation of the viability of Los Angeles River tributary flow measurement devices. LADWP has also partnered with the Los Angeles County Flood Control District on a program to improve and expand the system of stormwater capture facilities. This program will substantially increase the natural recharge of stormwater into SFB and provide the greatest benefit to protecting the SFB water supply. Groundwater overdraft occurs when water removal exceeds water recharge. The slow natural recharge rate of most aquifers and high rate of pumping has led to groundwater overdrafts in most irrigated areas of the U.S. over the past century. Impacts associated with groundwater overdraft are the results of falling water levels as the water stored in an aquifer is depleted. http://wingolog.org/projects/water/html/node35.html. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
R9:
1 Los Angeles Department of Water and Power’s research and development lab at the La Kretz Innovation Campus should work with the UCLA La Kretz Center for California Conservation Science to request academic research into groundwater remediation in the San Fernando Basin to help speed the cleanup of the San Fernando Basin Aquifer. As described in the committee’s interview report with LADWP’s Chief Sustainability and Economic Development Officer. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Findings & Recommendations
4 findings
F1:
During the course of the CGJ’s inspection of municipal police jails. CGJ noted that Los Angeles Police Department (LAPD) had closed six jails: Devonshire, Foothill, Harbor, Southwest, Wilshire, and Southeast jails. The closure of these facilities required arresting officers to transport arrestees to a centrally located jail. This created a strain on police manpower in the field. Based on information received from LAPD, the closure of the above- mentioned jails was due to a lack of detention officers. To reopen the temporarily closed jails would require 62 additional detention officers; in addition, 75 police officer IIs currently back- fill for the vacant detention officer positions at other stations. LAPD’s jail division is currently holding a detention officer academy class, and a second class was planned for June 2015.
F2:
At one Los Angeles County Sheriff’s Department courthouse lockup inspected by the committee, deputies described the process of handling prisoners in a manner that would prevent the spread of staph bacteria called Methicillin-resistant Staphylococcus aureus (MRSA). When prisoners arrive, they are attached to a chain by individual handcuffs. Wearing gloves, the deputies detach prisoners from their handcuffs and chain. The deputies apply and clean the hardware with a specially designed disinfectant spray to kill MRSA.1
F3:
Staff at Northeast (LA/Eagle Rock) Station stated that there are potential environmental issues in the soil of the Northeast Police Station. A new facility will be built on the same site.
F4:
Some of the jails/holding areas the committee inspected were unsatisfactory: Bell Gardens Police Department: The inspection revealed peeling paint. There were locks on cabinets holding detainees’ belongings, but there were no keys. One cell was not useable because of broken plumbing pipes. Bellflower Courthouse Jail: Radio dead zones exist in some areas within the courthouse. The refrigerator registered at an unsafe temperature. Staff stated the gun lockup needed to be upgraded and the sally port needed to be enhanced. Alarm systems for exit doors were not operable. Compton Courthouse Jail: The building was very old. There were scratches throughout the facility. The walls and ceilings in the cells were in poor condition. There was low water pressure in cells and in the lock-up area. Walls and ceilings throughout 1 According to research by the Mayo Clinic, MRSA is spread by skin contact. It affects healthy people in settings where skin contact is likely, such as contact sports, or groups living in crowded and unsanitary conditions. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT the facility needed to be painted. Food for inmates was left unrefrigerated and out in the open. East Los Angeles Courthouse Jail: The turn-out gear does not fit staff and had never been used. There was graffiti all over floor of holding cells. The staffing level was in flux due to court consolidation. There were no defibrillators at this facility. Inglewood Juvenile Courthouse Jail: The facility was built in 1976 and had not been properly maintained (graffiti and peeled paint on the wall, and the floor tile needed to be repaired). The sally port was inadequate, having a narrow path from outside of the building to the courthouse. Packaged food for inmates was delivered and stored in a portable cooler rather than refrigerated. The health inspection was done roughly five months ago, and the facility did not pass. In case of an emergency, a deputy at the detention facility needed to call the dispatcher first before connecting to the 911 Call Center. Men’s Central Jail: The facility was old but was clean. The old section was built in 1963 and the new section was built in 1973. There were ongoing plumbing problems. The kitchen operation was running well and it was clean. It serviced roughly 20,000 meals per day—mainly packaged food for Central Jail and Twin Towers. A chapel on- site performs services multiple times daily. Staff stated pest control and plumbing were the major issues. The facility was overcrowded. Redondo Beach Police Department: Cameras within the facility were installed but were not yet operational. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
Findings & Recommendations
7 findings
F1:
Los Angeles County funding for affordable housing expires in 2017.
F2:
The Community Development Commission’s 20 percent administration fee for affordable housing projects may not be sufficient to cover long-term monitoring costs of those projects.
F3:
A Los Angeles County Board of Supervisors 2013 resolution releases county general funds, to the Community Development Commission for affordable housing, over five years.
F4:
The Community Development Commission Tracker project management reports in their current format do not provide the Board of Supervisors with sufficient information needed to perform ongoing oversight, particularly original budget vs. actual expenditures and original vs. revised timelines by project.
F5:
The Board of Supervisors, sitting as the commissioners of the Community Development Commission, has not taken a sufficiently active role in providing comprehensive oversight of all projects after funding allocations are made.
F6:
The Board of Supervisors has not fully adopted the 2012 Affordable Housing and Economic Development Framework and Implementation Strategy and has underfunded the affordable housing development goals by $98,196,500.
F7:
Staffing levels may be insufficient if Notices of Funding Availability of a higher value are released.
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Findings & Recommendations
11 findings
F1:
Currently, the decision to institute a PAD program is within the discretion of individual county departments.
F2:
Although no one interviewed disputed the usefulness of AEDs, on balance the costs to Los Angeles County in expanding installation of the devices, as well as the time needed for training government personnel on the use of AEDS, do not justify countywide installation of AEDs. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F3:
Educating the public on the purpose of AEDs, including training in the use of existing AEDs, is economically feasible and would help make better use of already installed AEDs.
F4:
The city of Los Angeles PAD program is understaffed. Its existing devices are in need of maintenance and may currently be a liability.
F5:
The Los Angeles Department of City Planning does not keep a copy of notices mailed.
F6:
The Los Angeles Department of City Planning keeps copies of affidavits of mailings but could not locate that affidavit in this instance.
F7:
The City of Los Angeles Department of Public Works does not have access to information about its mailing of notices.
F8:
Without public access to city identifier numbers, city staff cannot respond to public inquiries.
F9:
After the public hearing, data is confidential, available to the property owner and the city only, until the project is approved.
F10:
The City of Los Angeles Department of Public Works’ website is not organized to help the public register disputes.
F11:
The City of Los Angeles Department of Public Works has no dedicated phone number that the public can use to register disputes.
Findings & Recommendations
15 findings
F1:
Production systems are fragmented over 64 Los Angeles County data centers plus three private out-of-state data centers.
F2:
Development and hosting are going out of Los Angeles County hands. This means jobs and county funds are moving out of the county.
F3:
Software development industrywide has such a high failure rate that extra oversight is warranted.
F4:
Los Angeles County has no method to determine to what degree completed software development programs have been a success, and there is no permanent record of lessons learned from the experience of developing new systems.
F5:
There appears to be no standard system development methodology for Los Angeles County.
F6:
There appears to be no standard project management methodology for Los Angeles County.
F7:
Data security is constantly being challenged, so the Los Angeles County chief information officer has been working to upgrade and standardize security.
F8:
Data are not standardized within Los Angeles County chief information officer–defined clusters of departments, except within the justice (ISAB) group.
F9:
Some departments worry about Information Technology Services (ITS) responsiveness and ITS’s ability provide a high level of service.
F10:
Some Los Angeles County data centers inadequately conduct backup. The most- comprehensive backup operation appears to be that of the ITS Data Center at Downey. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F11:
Many Los Angeles County departments worry about the disaster survivability of the ITS Data Center and the Orange County backup site. Three departments worry so much that they run their mission critical systems on private data centers outside of the county, in fact, even outside of California.
F12:
The Los Angeles County Board of Supervisors is moving toward consolidating most of Los Angeles County data centers into one disaster-resistant facility.
F13:
Los Angeles County information systems use many different programming languages. The county has no standard or guideline on how to select a programming language for use on its development projects.
F14:
There are no enterprise-wide programming standards for the languages that are used. There is no central guide to good programming practices.
F15:
In Los Angeles County, there is a countywide tendency to replace existing systems rather than modernize them, in part because COBOL is unjustifiably considered obsolete, and lack of expertise in COBOL contributes to this tendency.
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Findings & Recommendations
3 findings
F1:
The Department of Health Services responded to all 16 questions put to it by the committee. Its responding document is reproduced in full as Attachment A to this report. The questions are listed and DHS’s responses are summarized on the following table.
F2:
The table lists the committee’s questions on the left and categorizes the DHS responses as either implemented, in progress, no progress, or decline to implement. Of the 16 2 Online Real-Time Centralized Health Information Database. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
F3:
With 15 out of 16 recommendations either completed or underway, clearly a good faith effort is being made by DHS. The department is to be complimented on its rapid progress. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Summary of Responses to Civil Grand Jury questions by the Department of Health Services In No Questions to DHS Implemented Progress Progress Decline Comments 2.1 Have both the new ORCHID system and the current system incorporated codes on all accounts for classifying and explaining reasons for denial? X 2.2 Has DHS updated the procedure to include new Reason for denial codes? X 2.3 Has the availability of Patient Financial Services worker staff been increased at all hospitals? X 2.4 What method, if any, has DHS Replaced with implemented to replace the new process discontinued method of (see Attachment identifying write-offs for denied or A) late claims that are billed by the DHS Consolidated Business Office? X 2.5 Has DHS determined the staffing required to review Medi- Cal fee-for-service accounts for patients still in DHS hospitals? X 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? X 2.7 What is the projected date by Target date is which DHS expects to fully July 1, 2015 implement the original
Additional Recommendations
1
Not linked to specific findings.
R2:
5 below; as a result, the Utilization Review Units in the hospitals have been able to timely review accounts to enable timely billing. Also, DHS has developed an inventory status report to identify and prioritize accounts that need a TAR in order to be billed for stronger control. DHS does not bill any accounts that do not have a TAR. RECOMMENDATION No. 2.5 Formalize the point at which Medi-Cal fee-for-service accounts are retrospectively reviewed for patients still in the Department hospitals. 7/18/14 RESPONSE DHS agrees with this recommendation. An assessment will be conducted to determine the staffing needs to perform the concurrent reviews recommended. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.5 Has DHS determined the staffing required to review Medi-Cal fee-for-service accounts for patients still in DHS hospitals? 89 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 1/30/15 RESPONSE Implemented - Currently Medi-Cal Fee-for-Service patients are reviewed on a daily basis when receiving acute care. DHS utilizes a State approved evidence based proprietary software program (InterQual) for determination of medical necessity. A second level review of the account is completed by a physician to evaluate the medical necessity if InterQual criteria are not met. DHS Utilization Review (UR) Committee has implemented an action plan; where UR nurses are reassigned from other County hospitals should a backlog develop at a DHS facility, to assist in the reviews using approved overtime. Also, additional Physician Advisors are recruited to complete second level reviews. Based on this strategy and assessment, DHS has been able to mitigate the effect of staff shortage at its facilities. RECOMMENDATION No. 2.6 Conduct a Utilization Review staffing analysis at county hospitals as an increase in staff may substantially increase Department cash flow by decreasing backlogs and increasing the timeliness of billings. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will conduct a staffing analysis to determine if additional staffing will decrease backlogs and increase billing timeliness. If necessary, DHS will submit a budget request for additional staffing needed to fully implement this recommendation. Completion of the evaluation is anticipated by December 31, 2014. CGJ QUESTION 2.6 Has DHS conducted a staffing analysis to determine if additional staffing will reduce backlogs and reduce billing time? 1/30/15 RESPONSE Implemented - In the spring of 2014, DHS performed a comprehensive assessment of staffing needs within inpatient Utilization Review departments with the goal of ensuring sufficient staff are available to complete all inpatient UR related duties which would decrease backlogs and increase billing timeliness. DHS calculated the additional staff needed for each hospital to achieve full staffing levels. These items were included in DHS’ 2014-15 supplemental budget request, approved by the Board of Supervisors on September 30, 2014. Approximately half of the newly added items have been filled to date, with interviews ongoing. RECOMMENDATION No. 2.7 Utilize available systems and tools, and require DHS physicians to report their National Provider Identifier (NPI) number and complete the 855R form linking the NPI number to DHS, as required for Medicare billing purposes, prior to commencing work at a DHS facility. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will assess available systems, tools, and processes to determine how best to implement this recommendation. Completion of the assessment is anticipated by December 31, 2014. CGJ QUESTION 2.7 Does DHS require physicians to report their National Provider Identifier (NPI) number and enter it into the system prior to commencing work at a DHS site? 1/30/15 RESPONSE Partially Implemented - DHS is evaluating the licensed practitioner credentialing process and the utilization of the new Cactus credentialing software to enable improved accountability and control. In the interim, Medical Administration and Finance are working together to initiate enrollment applications for practitioners who provide care to Medicare members. CGJ Question 2.7 as of 02/19/2015 What is the projected date by which DHS expects to fully implement the original recommendation to require DHS physicians to report their NPI number and complete the 855R form linking the NPI number to DHS prior to commencing work at a DHS facility? 3/20/2015 Response The target date is July 1, 2015. On this date, the credentialing process will include initiation of NPIs and enrollment of physicians into the Medicare program for the facilities where it is a requirement (Comprehensive Health Centers and Health Centers). RECOMMENDATION No. 2.8 Monitor the processing of Medicare claims to ensure that the implementation of ORCHID, the Department's new electronic health record system is aiding and providing Medicare itemized claims. 7/18/14 RESPONSE DHS agrees with this recommendation. DHS will monitor the processing of Medicare claims and ensure itemized billing is accommodated within the Online Real-Time Centralized Health Information Database (ORCHID), Affinity Patient Accounting, Billing Clearinghouse, etc., as each DHS facility implements ORCHID. ORCHID implementation and associated interfaces for billing is anticipated to be completed prior to December 31, 2014. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT
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Findings & Recommendations
12 findings
F1:
Licensure/contract requirements
F2:
Facility and environment
F3:
Maintenance of required documentation and service delivery
F4:
Education and workforce readiness
F5:
Health and medical needs
F6:
Psychotropic medication
F7:
Personal rights and social/emotional well-being
F8:
Personal needs/survival and economic well-being
F9:
Personnel records Department of Children and Family Services (DCFS) Group Home Compliance Monitoring5 GH compliance monitoring is a component of the Performance Monitoring Section in the Out of Home Care Management Division. Annual reviews of those GHs servicing DCFS-placed children are conducted, which include program contract compliance. The reviews determined whether homes meet the requirements set forth in the Foster Care Agreement, the homes’ program statements, and DCFS policies. The reviews assess the homes’ service delivery to ensure that these homes are providing children with quality care and services in a safe environment, inclusive of physical care, emotional support, and other services to protect and enhance their growth and development. Copies of DCFS Compliance Monitoring Reports can be accessed through the DCFS website at: http://dcfs.lacounty.gov. Information obtained from the DCFS website. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Contract Monitoring Process6 The goals of the monitoring process are to improve child safety, increase provider services, and strengthen networking among the homes. DCFS’s rating system assesses home performance and incorporates Corrective Action Plans (CAPs) and follow-up to ensure compliance:
F10:
Fiscal Compliance—assesses home’s fiscal internal controls that will ensure that the CAP, if any, is implemented.
F11:
Contract Compliance—assesses contract deliverables on safety, service needs, and administrative compliance, and follows up on implementation by the agency CAP as necessary. Ensures that homes are in compliance with contract terms and conditions, Community Care Licensing Division approved Program Statements, Statement of Work, and Title 22 regulations.
F12:
Quality Assurance—assesses the quality of performance and service delivery by homes to ensure children are provided with quality care and services in a safe environment. Los Angeles County Probation Department Office of the Ombudsman7 The Probation Department Office of the Ombudsman is a confidential, informational, and neutral resource where probation clients, their families, and the community can seek assistance with their concerns related to GH service delivery, policies, and/or procedures. The role of the ombudsman for GHs is twofold: 1) to ensure that the voice of youth under the care and custody of Probation is heard and 2) to provide an avenue for the Probation youth to express concerns about their GH experience without fear of retaliation from the GH provider and/or Probation officer and to get resolutions that are reasonable. Placement Permanency and Quality Assurance Unit (PPQA)8 The PPQA serves Probation foster children and their families, group home providers, and the Placement Bureau as a whole. The primary purpose of the group home monitoring/investigations unit is to conduct annual monitoring inspections of group homes that have multiple sites throughout Los Angeles County; investigate GHs related to noncompliance with the county contract; conduct follow-up investigations on minor infractions; refer investigations to Probation from the DCFS Child Abuse Hotline; and develop and monitor the CAP for accuracy and compliance. GHs have 30 days to make the noted corrections; safety issues must be dealt with immediately. At the end of 30 days the PPQA makes another visit to ensure all corrective actions have been addressed. Correspondence received from DCFS. Information received from the Probation Department. Correspondence received from the Probation Department. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Group Home Compliance monitoring reports can be accessed through Los Angeles County Probation at http://probation.lacounty.gov. Department of Auditor-Controller Group Home Ombudsman9 The Office of the Children’s Group Home Ombudsman, within the Department of Auditor- Controller, is an independent advocate for children placed in group homes by DCFS. The ombudsman’s responsibilities include: maintaining a toll-free telephone number for DCFS GH residents to call from anywhere to express their concerns and complaints; informing children of their rights when placed in a GH; providing a voice to speak and act on behalf of GH residents; establishing an avenue for children to discuss their concerns and complaints without fear of retaliation; offering recommendations that are reasonable and feasible; and working with the county and service providers to benefit GH residents. Although primarily for DCFS GH residents, the GH ombudsman will contact the Probation ombudsman on behalf of any Probation resident who has issues to be resolved. Even though the ombudsman’s policy is to maintain confidentiality to the extent possible, callers are informed that, by law, child endangerment, abuse, and/or neglect must be reported. Fiscal Review of Group Homes10 According to the Auditor-Controller’s Contract Monitoring Division, at the beginning of each fiscal year (July 1), the Auditor-Controller completes a Risk Home Assessment of GHs and Foster Family Agencies to determine those homes that will be included in its list of audits to be conducted for the year. In addition, both DCFS and Probation can request a fiscal audit if, during a GH program review, fiscal improprieties are noted. Fiscal reviews can also be initiated by allegations received through the Auditor-Controller’s fraud hotline or a Board of Supervisor’s office’s referral. The Auditor-Controller provides fiscal training upon request to the DCFS Fiscal Compliance section, Foster Family Agencies, and GHs. The Auditor-Controller also collaborates and consults with DCFS’s Fiscal Compliance section on results of DCFS’s Internal Controls Questionnaire and Fiscal Compliance Assessment Tool. Fiscal Review Reports can be reviewed at http://auditorcontroller.lacounty.gov. Information received from the Group Home Ombudsman. Information received from the Auditor-Controller. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT Note: All group homes in Los Angeles County are licensed by the Community Care Licensing (CCL) Division of the California Department of Social Services under Title 22 Regulations and as such are subject to annual reviews by CCL to ensure licensing compliance. CCL’s complete Policy and Procedures Manual can be accessed at http://cdss.ca.gov. SUMMARY The focus of the Group Home Committee was to determine if the basic needs of the minors— including but not limited to food, housing, clothing, education, and psychological services— were met. Overall, the group homes inspected appeared to meet these needs. Most of the group homes housed both DCFS and Probation youths but followed different requirements based on the respective department’s regulations. Although the majority of minors interviewed were satisfied with their placement, more than one youth stated that the group home did not replace being with family. Due to the decline in the number of group homes, it would appear that the court and departments have changed their focus from group home placement to family reunification or relative placement whenever possible. According to an email sent by DCFS to The Chronicle of Social Change, dated Sept. 30, 2014, Los Angeles County submitted a nonbinding letter to opt into the Approved Relative Caregiver Funding Program (ARC) effective Jan. 1, 2015. The new funding (initially a $30 million budget allocation) is intended to provide relative caregivers with the same level of funding as other nonrelative foster caregivers. Currently, many relative caregivers receive about half of what other caregivers receive monthly.11 On March 3, 2015, Los Angeles County Board of Supervisors passed a motion instructing DCFS to opt into the ARC program by March 15, 2015.12 COMMENDATION Based on observations of the group homes visited, the committee commends the efforts of these group home providers in delivering services and promoting the safety and well-being of the home residents. Information obtained from http://ChronicleofSocialChange.org. Board of Supervisors Statement of Proceedings, March 3, 2015. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT The committee also applauds the Los Angeles County Board of Supervisors’ decision to participate in the Approved Relative Caregiver Funding Program. It will be a tremendous savings for the county and a win-win situation for all parties. ACRONYMS ARC Approved Relative Caregiver Funding Program CAP Corrective Action Plan CCL Community Care Licensing Division DCFS Department of Children and Family Services GH Group Home RCL Rate Classification Level PPQA Placement Permanency and Quality Assurance unit COMMITTEE MEMBERS Wesley C. Thompson, chair Larry Lyman, vice chair Earline Parker, secretary Doris K. Reed Joyce Simily Margaret Yasuda 107 LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT This page intentionally left blank. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT METRO RIDERSHIP Jim Contreras, chair Simeon Zano, vice chair Shari E. Pearce, secretary METRO RIDERSHIP TOPIC The Los Angeles County 2014–2015 Civil Grand Jury (CGJ) formed the Metro Ridership Committee (committee) to look into increasing the ridership within the Los Angeles County Metropolitan Transportation Authority (Metro) system and investigate the efforts of Metro to do the same. The committee also looked into whether Metro would receive maximum funding from federal sources based on achieving the farebox recovery goal of 33 percent.1
Findings & Recommendations
5 findings
F1:
A bill has been introduced in the California State Senate that would allow Los Angeles County Metropolitan Transportation Authority (Metro) to seek a new sales tax via the ballot.
F2:
The Orange Line Bus Rapid Transit is congested during peak times.
F3:
Metro used the goal of achieving a 33 percent farebox recovery rate as a reason to raise fares in 2014 and increase enforcement of fare collection.
F4:
Metro uses armed and unarmed personnel to cite fare evaders.
F5:
Metro safety signage is ineffective. Metro 52, Executive Management Committee, March 19, 2015, Subject: Metro Parking Ordinance, Metro Parking Rates and Permit Fee Resolution. Los Angeles County Metropolitan Transportation Authority Administrative Code, Title 8. Metro Parking management, San Gabriel Valley Service Council Minutes, March 9, 2015. LOS ANGELES COUNTY 2014–2015 CIVIL GRAND JURY FINAL REPORT