Health Care Department Operations Manual

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Chapter 5 – Administrative

Article 1 – General Administration

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5.1.8 Compliance and Support Team

  • Policy

    • The Health Care Correspondence and Appeals Branch (HCCAB) shall maintain a Compliance and Support Team (CAST) to assist Health Care Grievance Offices (HCGO) statewide to ensure compliance with California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 5, Health Care Grievances; court mandates; and departmental policies and procedures related to the health care grievance (grievance) process; efficient grievance processing at the institutional and headquarters’ levels; and a meaningful administrative remedy process for patients. 

  • Purpose

    • To maintain the integrity of the grievance process by promoting accountability through compliance reviews and provision of assistance and/or training; tracking and monitoring of action items, Corrective Action Plans (CAP), and recommendations; identifying and implementing processes to increase efficiencies and mitigate risk; and compiling and reporting compliance review findings, CAST activities, and key performance metrics and trends.

  • Responsibilities

    • The Chief, HCCAB, and the Deputy Director, Policy and Risk Management Services (PRMS), are responsible for:

      • The oversight and management of the statewide grievance program and implementation of this policy and procedure, and the Health Care Grievances Operating Standards, Section 4.1, Compliance and Support Team.

      • Approving requests and referrals for CAST Support.

      • Issuing Compliance Review Exit Memorandums.

      • Compiling and issuing CAST metrics as appropriate.

    • The Chief Executive Officer (CEO) is responsible for:

      • Compliance with this policy and procedure at the institution level.

      • Responding to the Compliance Review Exit Memorandum and taking corrective action to resolve identified non-compliance issues.

    • All California Correctional Health Care Services and Division of Health Care Services staff involved in the grievance process are responsible for the efficient operation of the grievance process and supporting CAST activities to ensure compliance with applicable regulations, court mandates, and departmental policies and procedures.

  • Procedure

    • Compliance Review

      • Prior to a compliance review site visit, CAST shall utilize the Compliance Review Tool to conduct a preliminary assessment consisting of a review of grievances and staff complaints closed in the Health Care Appeals and Risk Tracking System (HCARTS) in the most recent three months to identify applicable areas of non-compliance and general grievance processing issues.

      • During the site visit, CAST shall discuss the results of the preliminary assessment, interview HCGO staff to complete the questions in the Compliance Review Tool that require on-site responses, and review hard copies of staff complaint packages selected during the preliminary assessment.

      • Upon return from the site visit, CAST shall draft a Compliance Review Exit Memorandum, which shall:

        • Be addressed to the CEO, with copies to the appropriate headquarters and institution chain of command.

        • Outline the observations, compliance ratings for the quantifiable indicators, action items, and/or CAP, if applicable.

        • Be routed for HCCAB management review within ten business days.

        • Be emailed with the completed Compliance Review Tool to the addressees within 15 business days.

        • Request a response from the CEO to address the action items and/or CAP within 25 business days of receipt.

      • Within 25 business days of receipt of the Compliance Review Exit Memorandum, the CEO shall prepare a memorandum confirming each action item has been implemented and/or completed, including a CAP, if applicable, and email the signed response to CAST.

    • CAST Support

      • CAST shall assist in the development and implementation of effective training curriculum and utilize appropriate training methods to deliver onboarding and ad-hoc training to institution and headquarters staff involved in the health care grievance process.

      • HCGO Support

        • Upon identifying the need for CAST Support, the HCGO or HCCAB staff shall complete and submit a CAST Support Request and Referral Form to HCCAB management for approval.

        • The Chief, HCCAB, and the Deputy Director, PRMS, shall review requests and referrals for approval within ten business days of receipt.

        • Upon approval of a request or referral for CAST Support, CAST shall review monitoring data and may use applicable sections of the Compliance Review Tool to conduct a spot check consisting of review of grievances and staff complaints closed in HCARTS in the most recent three months to identify risks, trends, training needs, and process improvement opportunities.

        • While on-site in the HCGO, CAST shall:

          • Observe HCGO operations to analyze training needs, develop customized training plans, identify process improvement opportunities, and provide guidance in the development of local operating procedures.

          • Provide assistance and/or training and recommendations to HCGO staff and other institutional staff, as necessary.

        • CAST shall provide ongoing support to HCGO staff as deemed necessary by CAST management and the Chief, HCCAB.

  • CAST Reporting

    • Metrics Report

      • CAST management shall generate the Metrics Report by the tenth day of the month after the end of the reporting period for issuance to the Chief, HCCAB.  The Metrics Report shall consolidate the previous month’s CAST activities and performance information across key areas of the grievance process.

    • Regional Report

      • CAST management shall generate the Regional Report by the tenth day of the month after the end of the fiscal year for issuance to headquarters executives and the Regional Health Care Executives.  The Regional Report shall consolidate CAST activities and performance trends identified in the previous fiscal year’s Metrics Reports.

  • References

    • California Code of Regulations, Title 15, Division 3, Section 2, Subsection 2, Article 5, Health Care Grievances

    • Armstrong Remedial Plan, Armstrong v. Newsom, U.S. District Court of Northern California, Case No. C94-2307 CW, Amended January 3, 2001

    • Clark Remedial Plan, Clark v. California, United States District Court of Northern California, March 1, 2002

    • Plata v. Newsom, et al., U.S. District Court of the Northern District of California, Case No. C01-1351 TEH

    • Health Care Grievances Operating Standards, Section 4.1, Compliance and Support Team

  • Revision History

    • Effective: 08/2019