Under an interagency agreement between the Department of Health Care Services (DHCS) and the California Department of Aging (CDA), CDA administers the CBAS Program and certifies providers for participation in CBAS. Prior to participation as CBAS Medi-Cal waiver providers, CBAS providers must be licensed to operate adult day health care (ADHC) centers by the California Department of Public Health (CDPH).
The information below illustrates the types of onsite surveys conducted by CDA in Fiscal Year 2017-18, and the types and frequency of citations from those visits.
CDA conducts the following types of onsite certification surveys:
FY 2017-18
CBAS Onsite Survey
|
| Certification Renewal
|
133
|
| Follow-Up
|
2
|
| Reconsideration
|
0
|
| 1st Quarter
|
0
|
|
Total Surveys
|
135
|
- Certification Renewal - at least every 24 months
- Follow-Up - between renewal visits to ensure a plan to correct deficiencies is implemented
- Reconsideration - revisit post Certification Renewal where significant non-compliance is identified
- First Quarter - visit within 90 days of certifying a new provider
Citations are based on record reviews, observations, and/or interviews during onsite surveys and are categorized as follows:
- Repeat - counted if the same citation was recorded during the previous onsite survey.
- Health and Safety - findings that demonstrate non-compliance with specified laws and regulations, the scope and severity of which demonstrate harm or potential harm to a participant and/or are at a pattern level across multiple disciplines and/or participants.
- Administrative - findings that demonstrate non-compliance with specified laws and regulations, but that do not rise in scope or severity to a Health and Safety level. For example, isolated and/or less consequential instances such as failures to provide complete documentation.
| FY 2017-18
|
|
Types of Citations
|
#
|
As Percentage of Total Citations
|
| Repeat
|
145
|
21%
|
| Health and Safety
|
260
|
40%
|
| Administrative
|
431
|
60%
|
FY 2017-18
Most Frequently Cited Findings
|
| # |
Citation |
Explanation |
# of
Times
Cited |
| 1 |
Title 22, CCR,Section 14529(d)(2) |
IPC not developed to meet participant need |
82 |
| 2 |
W&I Code,Section 54425(a)(4) |
Failure to maintain complete participant records |
72 |
| 3 |
W&I Code,Section 14552(a) |
Failure to meet licensing requirements |
64 |
| 4 |
W&I Code,Section 14530(a) |
Services not provided |
59 |
| 5 |
Title 22, CCR,Section 54323(a)(8) |
Failure to liaison with PHCP |
57 |
| 6 |
W&I Code, Section 54323(a)(6)(A)(B)(C)(D) |
Failure to monitor, administer, and record medication |
35 |
| 7 |
Title 22, CCR,Section 54329(a)(7) |
Social worker failed to liaison with family |
25 |
| 8 |
Title 22, CCR,Section 54401(b) |
Failure to establish Policies and Procedures |
23 |
| 9 |
Title 22, CCR,Section 54439(b) |
Confidentiality of participant data |
23 |
| 10 |
Title 22, CCR,Section 14529(d)(1)(3) |
Failure to reassess for necessary adjustments to care plan |
22 |
Source: CDA CBAS Database, Citation Statistics and Post-Survey Statistics Reports, 07/01/17-06/30/18, run date 07/08/19.