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Health Professions Quality Assurance
Performance Audit Issued August 2007

Agency Action Plan

Link the full audit report.
Link to a summary of the findings and the agency's response.
Link to the briefing to the State Legislature.

Action plan legend
 

 Action Plan

Sort by AttachmentsUse SHIFT+ENTER to open the menu (new window).
Agency Action StepFilterNotesFilter
F1Use SHIFT+ENTER to open the menu (new window).
R1
We will follow any legislative direction regarding changes to operating agreements between HPQA and the boards and commissions.
Legislature7/1/2008CompletedNoNoYes
Operating agreements negotiated in 2011 are in place for 16 boards and commissions.  One board is still considering the agreement.
F2Use SHIFT+ENTER to open the menu (new window).
L1
We are conducting a second study of the registered counselors' profession.
Bob Nicoloff, LegislatureCompletedYesNoYes
Completed 11/20/2007
F2Use SHIFT+ENTER to open the menu (new window).
L2
We will follow legislative direction regarding registered professions.
Patti LatschCompletedNoNoYes

Legislation re counseling professions implemented 7/1/2009; legislature has not acted on the other registered professions.

F2Use SHIFT+ENTER to open the menu (new window).
R1
We are replacing desk manuals with online procedures.
Sam Marshall6/30/2008CompletedYesNoNo
Desk manuals and business practices are now available online for staff access
F2Use SHIFT+ENTER to open the menu (new window).
R2
The new computer system will have checks against errors.
Sam Marshall2/19/2008CompletedYesNoNo
Completed 2/19/2008
F2Use SHIFT+ENTER to open the menu (new window).
R2
We will centralize our credentialing work units to promote standard business practices.
Karen Jensen6/18/2008CompletedYesNoNo
Functions were centralized in June 2008.  Physical moves completed 10/6/08.
F2Use SHIFT+ENTER to open the menu (new window).
R2
We will include audit suggestions and quality assurance pilot project results in revised procedures.
Patti Latsch9/30/2008CompletedYesNoNo
CSO procedures 4-3-11 (8/2009)and 4-3-13  (4/2009) adopted; ILRS workflow documents requirements – in place 2/19/2008
F2Use SHIFT+ENTER to open the menu (new window).
R3
We will work with the boards to change the administration of the exams for the three professions mentioned in the report.
Bonnie King/Steve Saxe12/31/2007CompletedYesNoNo
Completed 12/31/2007
F2Use SHIFT+ENTER to open the menu (new window).
R3
We will review the administration of jurisprudence exams with other boards and commissions in the context of their rules and policies.
Steve Saxe, Melissa Turner, Executive Directors, Program Managers3/31/2008CompletedYesNoNo
Completed 3/14/2008
F2Use SHIFT+ENTER to open the menu (new window).
R4
We will follow legislative direction regarding establishing a minimum age for health care professions.
Steve SaxeCompletedNoNoYes
DOH completed study indicating that it was not appropriate to set a minimum age limit for individual professions.
F2Use SHIFT+ENTER to open the menu (new window).
R1
We will identify necessary resources for a formal training program
Sam MarshallDeferredNoYesNo
DOH completed work 12/12/2007; need budget authority from legislature.  Further work deferred pending budget authority.  Working on issue within current resources.
F6Use SHIFT+ENTER to open the menu (new window).
R6
We will identify necessary resources for a formal training program
Sam MarshallDeferredNoYesNo
DOH completed work 12/12/2007; need budget authority from legislature.  Further work deferred pending budget authority.  Working on issue within current resources.
F8Use SHIFT+ENTER to open the menu (new window).
R4
We will identify necessary resources for a formal training program
Sam MarshallDeferredNoYesNo
DOH completed work 12/12/2007; need budget authority from legislature.  Further work deferred pending budget authority.  Working on issue within current resources.
F3Use SHIFT+ENTER to open the menu (new window).
L1
We will follow legislative direction regarding additional authority to conduct background checks.
Julie Miracle, Steve Hodgson, Dave Magby, Patti Latsch, Shannon Beigert, Joel EmeryCompletedNoNoYes
Legislation implemented 7/1/2008. 
F3Use SHIFT+ENTER to open the menu (new window).
R2
We are developing mandatory reporting rules that will include the timeline for reporting unprofessional conduct.
Margaret Gilbert, Tami Thompson5/31/2008CompletedYesNoNo
Completed 3/31/2008
F3Use SHIFT+ENTER to open the menu (new window).
R3
We will develop a quality assurance sampling process to audit completed background checks.
Patti Latsch7/31/2007CompletedYesNoNo
Completed 9/30/07
F3Use SHIFT+ENTER to open the menu (new window).
R5
We are testing a national search service for public criminal conviction records.  If it is useful, we will assess costs and consider expanding to all applicants. 
Patti Latsch7/31/2008CompletedYesYesNo
Completed 8/1/08
F4Use SHIFT+ENTER to open the menu (new window).
R1
We will provide the threshold list used for Secretary-regulated professions to all boards and commissions for their adoption and use. (Develop check list as part of Procedure 205).
Patti Latsch7/31/2008CompletedYesNoNo
Completed 5/29/2008
F4Use SHIFT+ENTER to open the menu (new window).
R10
We will continue to send notification letters when we assess the complaint. We will look into the cost of additional notifications.
Kristi Weeks6/30/2008CompletedYesYesNo
Implementation of RCW 18.130.057 addressed this recommendation.
F4Use SHIFT+ENTER to open the menu (new window).
R2
We will develop specific criteria for imminent danger.  (Procedure 212 to be expanded with examples).
Patti Latsch, Executive Directors2/29/2008CompletedYesNoNo
Completed 11/1/2007
F4Use SHIFT+ENTER to open the menu (new window).
R3
We will evaluate the success of other states’ use of multiple complaints to identify incompetent practitioners.  We will adopt practice review procedures if there is evidence that they are effective.
Patti Latsch, Melissa Turner5/31/2008CompletedYesNoNo
Completed 5/31/2008
F4Use SHIFT+ENTER to open the menu (new window).
R4
We will evaluate the success of other jurisdictions’ experience with long-term behavioral indicators.  If they are shown effective, we will adopt new procedures.
Patti Latsch, Melissa Turner5/31/2008CompletedYesNoNo
Completed 5/30/2008
F4Use SHIFT+ENTER to open the menu (new window).
R5
We will update training related to disciplinary case tracking after the first internal quality review.
Patti Latsch, Kirby Putscher11/30/2007CompletedYesNoNo
Completed 12/07/2007
F4Use SHIFT+ENTER to open the menu (new window).
R8
We will develop a common case assessment worksheet for use in all Secretary-regulated professions and recommend its use in board/commission-regulated professions.
Patti Latsch11/30/2007CompletedYesNoNo
Completed 11/30/2007
F4Use SHIFT+ENTER to open the menu (new window).
R9
The database complaint types and closure codes are defined in manuals for the obsolete computer system, ASI.  We have reduced the number of complaint types and closure codes for the new system. We have clear definitions for each. The ILRS system will be fully implemented in June 2008.
Sam Marshall6/30/2008CompletedYesNoNo
Completed 2/19/2008
F4Use SHIFT+ENTER to open the menu (new window).
R6
We will seek funds to study the feasibility of electronic document management.  It will include imaging of complaint files.
Sam Marshall, DIRM10/31/2007DeferredNoYesNo

Doing what we can within current resources.  Regular discipline panel calls ensure prompt intake and assessment of complaints. DOH work on imaging system funding request complete 12/12/2007.  Further action on imaging system is deferred as funding is needed to implement an imaging system.

F13Use SHIFT+ENTER to open the menu (new window).
R3
We will seek funds to study the feasibility of electronic document management.  It will include imaging of complaint files.
Sam Marshall, DIRM10/31/2007DeferredNoYesNo
DOH completed funds request 12/12/2007.  Funding was not available.  Deferred pending budget authority.
F4Use SHIFT+ENTER to open the menu (new window).
R7
We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records.
Patti Latsch9/30/2008CompletedYesNoNo
Completed 08/2011
Procedure adopted May 2009.  Training is complete as of 12/15/2009.  Policy effective 01/01/2010 and  implementation under way.
F6Use SHIFT+ENTER to open the menu (new window).
R10
We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records.
Patti Latsch9/30/2008CompletedYesNoNo
Completed: 08/2011
 
Procedure adopted May 2009. Training is complete as of 12/15/2009.  Policy effective 01/01/2010 and implementation under way.
F7Use SHIFT+ENTER to open the menu (new window).
R3
We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records.
Patti Latsch9/30/2008CompletedYesNoNo
Completed 08/2011
Procedure adopted May 2009.  Training is complete as of 12/15/2009.  Policy effective 01/01/2010 and implementation under way.
F5Use SHIFT+ENTER to open the menu (new window).
R1
We are developing a public awareness strategy and will identify its costs for the Legislature.
Michael WilsonDeferredNoYesNo
 DOH work on funds completed 12/12/2007; Broad public awareness strategy deferred pending funds needed for next step. Doing what we can within current resources.
F4Use SHIFT+ENTER to open the menu (new window).
R2
We are developing a public awareness strategy and will identify its costs for the Legislature.
Michael Wilson6/30/2008DeferredNoYesNo
DOH work on funds completed 12/12/2007; Broad public awareness strategy deferred pending funds needed for next step. Doing what we can within current resources.
F5Use SHIFT+ENTER to open the menu (new window).
R3
We will calculate the cost to redevelop our Web site to focus on customer needs.
Michael Wilson10/31/2007DeferredNoYesNo
DOH work requesting funding completed 12/12/2007; Full website redesign deferred pending Funds needed for further development  Substantial progress made within current resources.
F5Use SHIFT+ENTER to open the menu (new window).
R4
We are testing outreach to vulnerable populations, particularly the elderly, based on the results of the Elway Poll. 
Michael Wilson, Meghan Young12/31/2007CompletedYesNoNo
Completed 8/30/2007
F6Use SHIFT+ENTER to open the menu (new window).
L1
We will follow legislative direction regarding additional investigative tools.
Patti Latsch, Karen JensenCompletedNoNoYes
Implemented legislation; Oct 2009
F6Use SHIFT+ENTER to open the menu (new window).
R8
We already have these practices in place requiring supervisors to officially sign off on all investigations.
Patti LatschCompletedYesNoNo
Completed prior to audit; 3/1/05
F6Use SHIFT+ENTER to open the menu (new window).
R1
We will propose improvements to the process to authorize an investigation
Patti Latsch, Executive Directors, Program Managers5/31/2008CompletedYesNoNo
Completed 6/1/2008
F6Use SHIFT+ENTER to open the menu (new window).
R2
We have state-approved guidelines in place.
Patti LatschCompletedNoNoNo
Completed prior to audit
F6Use SHIFT+ENTER to open the menu (new window).
R4
We will complete the contract process for expert review of standard of care cases. 
Blake Maresh12/31/2007CompletedYesNoNo
Completed 3/10/2008
F6Use SHIFT+ENTER to open the menu (new window).
R6
We already have these practices in place to ensure all investigators receive appropriate training.
Patti LatschCompletedYesNoNo
Completed prior to audit
F6Use SHIFT+ENTER to open the menu (new window).
R7
We already have these practices in place to ensure all investigators receive appropriate training.
Patti LatschCompletedNoNoNo
Completed prior to audit
F6Use SHIFT+ENTER to open the menu (new window).
R9
We will have a single caseload report available for each investigator in the new licensing system.
Sam Marshall6/30/2008CompletedYesNoNo
Completed 2/19/08
F6Use SHIFT+ENTER to open the menu (new window).
R3
A workload standards study is now underway to identify appropriate staffing levels.  We will provide the report to the Legislature when it is completed.
Patti Latsch12/31/2007DeferredNoYesNo
Staffing study was completed by November 2007, was revised in 2008 and in December 2009 was validated by JLARC audit.  The study provided a model that is in use to assess fiscal impacts of legislation and to prepare decision packages for staff and funding. Staffing to the level suggested by the model is deferred pending funding.
F8Use SHIFT+ENTER to open the menu (new window).
R3
A workload standards study is now underway to identify appropriate staffing levels.  We will provide the report to the Legislature when it is completed.
Patti Latsch12/31/2007DeferredNoYesNo
Staffing study was completed by November 2007, was revised in 2008 and in December 2009 was validated by JLARC audit.  The study provided a model that is in use to assess fiscal impacts of legislation and to prepare decision packages for staff and funding. Staffing to the level suggested by the model is deferred pending funding.
F7Use SHIFT+ENTER to open the menu (new window).
L1
We will follow legislative direction regarding requiring a deadline for adoption of sanction guidelines.
Margaret Gilbert, Kristi WeeksCompletedNoNoYes
Legislation has been implemented.  Emergency rules effective 01/01/09.
F7Use SHIFT+ENTER to open the menu (new window).
L2
We will follow legislative direction regarding shift of authority for misconduct cases; Secretary disciplines for misconduct, while boards/ commissions continue to discipline standard of care violations.
LegislatureCompletedNoNoYes

Legislation implemented July 2008.  Procedure adopted 5/5/2009.

F7Use SHIFT+ENTER to open the menu (new window).
L3
We will follow legislative direction regarding sanction guidelines. (Loss of disciplinary authority if sanction guidelines not adopted).
LegislatureCompletedNoNoYes
Disciplinary authorities all adopted sanction guidelines by 10/18/2007. 
F7Use SHIFT+ENTER to open the menu (new window).
R1
We will work with OFM to see whether further action is appropriate to require all boards and commissions to adopt the sanctioning guidelines.
Laurie Jinkins, Karen Jensen12/31/2007CompletedYesNoNo

All boards and commissions adopted the sanction guidelines as of 10/18/2007.

F7Use SHIFT+ENTER to open the menu (new window).
R2
We will continue to enter default orders according to the law.
Patti LatschCompletedNoNoNo
Completed and ongoing
F7Use SHIFT+ENTER to open the menu (new window).
R4
We will review our options to assure accuracy in reporting disciplinary actions. (basis of action)
Patti Latsch6/30/2008CompletedYesNoNo
Ongoing quarterly audits to assure accuracy.
F8Use SHIFT+ENTER to open the menu (new window).
R1
The new computer system will include automated notices and reminders.
Sam Marshall6/30/2008CompletedYesNoNo
Completed 2/19/2008; infrastructure complete actual notices and reminders completed with centralization of the compliance monitoring function in July 2008.
F8Use SHIFT+ENTER to open the menu (new window).
R2
We adopted a procedure in 2006 that requires a single reminder letter to practitioners who have not met a due date.  We will continue to send follow-up or requests for additional information where needed.
Patti LatschCompletedNoNoNo
Completed prior to audit.  The current process allows only one reminder letter to a provider who has failed to meet an order requirement. 
F8Use SHIFT+ENTER to open the menu (new window).
R4
A central compliance unit will support consistency in the compliance process.
Karen Jensen6/30/2008CompletedYesNoNo

Functions centralized 6/1/2008; Moves completed November 2008.

F8Use SHIFT+ENTER to open the menu (new window).
R5
The compliance procedure, which includes the letter templates, is available on the HPQA Intranet site.   We are replacing desk manuals with online procedures.
Patti Latsch6/30/2008CompletedNoNoNo
Completed prior to audit.  Procedure under revision to reflect centralized compliance unit and ILRS.
F9Use SHIFT+ENTER to open the menu (new window).
R1
We have enhanced our performance management system to meet the criteria suggested in the audit.
Karen JensenCompletedNoNoNo
Completed 6/1/2007
F9Use SHIFT+ENTER to open the menu (new window).
R2
We have enhanced our performance management system to meet the criteria suggested in the audit.
Karen JensenCompletedNoNoNo
Completed 6/1/2007
F9Use SHIFT+ENTER to open the menu (new window).
R3
We will post measures of importance to the public on the agency Web site.
Steve Hodgson, Michael Wilson6/30/2008CompletedYesNoNo
Completed 11/30/2008
F10Use SHIFT+ENTER to open the menu (new window).
R1
We will update job descriptions to incorporate quality assurance as we consolidate functions.
Sam Marshall, Kathryn LePome3/31/2008CompletedYesNoNo
Completed 3/14/2011
F10Use SHIFT+ENTER to open the menu (new window).
R1
We will identify the costs of adding staff to the Department’s internal audit function. 
Sam MarshallCompletedYesYesNo
DOH has established a second internal auditor position and recruitment is under way.  HSQA also completed a self assessment pilot and added quality assurance duties to all appropriate job descriptions.
F10Use SHIFT+ENTER to open the menu (new window).
R2
We have begun a pilot of a Control Self Assessment in HPQA. 
Shannon Beigert, Josh Shipe, Charles Satterlund9/30/2008CompletedYesNoNo
Completed 6/4/2008 with ongoing activities; First pilot completed.  Self assessment completed and changes implemented to address findings.
F10Use SHIFT+ENTER to open the menu (new window).
R3
We will contract out specialized internal audits as needed.
Bill WhiteCompletedNoNoNo
Ongoing
F11Use SHIFT+ENTER to open the menu (new window).
R1
We are implementing the new ILRS computer system that meets agency standards.
Sam Marshall6/30/2008CompletedYesNoNo
Completed 2/19/2008
F11Use SHIFT+ENTER to open the menu (new window).
R2
We are implementing the new ILRS computer system that meets agency standards.
Sam Marshall6/30/2008CompletedYesNoNo
Completed 2/19/2008
F11Use SHIFT+ENTER to open the menu (new window).
R3
We will continue to regularly install security patches, as they are available.
Sam Marshall, DIRMCompletedNoNoNo
DIRM updates as required. 
F11Use SHIFT+ENTER to open the menu (new window).
R4
We will develop a notification system between HSQA managers and the technology staff to maintain current system access for all users and IT development / maintenance staff. 
Sam Marshall, HR, DIRM11/30/2007CompletedYesNoNo
Completed 12/7/2007
F11Use SHIFT+ENTER to open the menu (new window).
R4
We will update the user access records and restructure the way they are maintained. 
Sam Marshall11/30/2007CompletedYesNoNo
Completed 12/12/2007
F11Use SHIFT+ENTER to open the menu (new window).
R5
HPQA is in the midst of analyzing and correcting data in the legacy systems in preparation of the conversion to ILRS.  This will continue until the new system is implemented.
Sam Marshall6/30/2008CompletedYesNoNo
ILRS was implemented 2/19/2008
F11Use SHIFT+ENTER to open the menu (new window).
R6
We will avoid the use of computer "side systems."
Sam MarshallCompletedNoNoNo
Completed 2/19/2008
F12Use SHIFT+ENTER to open the menu (new window).
R1
We will complete a business continuity plan to sustain critical investigation and disciplinary activities.
Patti Latsch, Bill Kellington, Dave Magby, Karl Hoehn, Tracy Auldredge12/31/2007CompletedYesNoNo
Under revision due to reorganization.  Initial plan completed 12/31/2007. 
F12Use SHIFT+ENTER to open the menu (new window).
R2
We will develop an alternative means of contact for key personnel. 
Office Directors12/31/2007CompletedYesNoNo
Under revision due to reorganization.  Initially completed 11/20/2007.  10/2009 Contact lists revised and up-to-date.
F12Use SHIFT+ENTER to open the menu (new window).
R3
We will review disaster recovery plans to make sure there is sufficient information for staff to follow them.
Shannon Beigert, Patti Latsch, Tracy Auldredge12/31/2007CompletedYesNoNo
Completed 11/15/2007
F12Use SHIFT+ENTER to open the menu (new window).
R4
We are working with the Department of Information Services for a primary "hot" site for disaster recovery.
DIRM9/30/2012In ProgressNoYesNo
Doing what we can within current resources.  Site secured 4/9/2008; Lack of funding from 2008 Legislature has slowed progress.  Funding secured FY12; implementation set for the fourth quarter of FY12.
F12Use SHIFT+ENTER to open the menu (new window).
R4
We will have an interim disaster recovery site in operation.
DIRM12/31/2007CompletedYesNoNo
Completed 12/12/2007
F12Use SHIFT+ENTER to open the menu (new window).
R5
We will have an interim disaster recovery site in operation.
DIRMCompletedYesNoNo
Completed 12/12/2007
F13Use SHIFT+ENTER to open the menu (new window).
R1
We have upgraded our policies on destruction of confidential records to require that they be deposited in locked containers and shredded.
DOHCompletedNoNoNo
Completed 7/16/2007
F13Use SHIFT+ENTER to open the menu (new window).
R2
We have procedures in place regarding confidential materials in keeping with DOH policy.
DOHCompletedNoNoNo
Completed 7/16/2007