| | R1 | We will follow any legislative direction regarding changes to operating agreements between HPQA and the boards and commissions. | Legislature | 7/1/2008 | Completed | No | No | Yes | Operating agreements negotiated in 2011 are in place for 16 boards and commissions. One board is still considering the agreement. |
| | L1 | We are conducting a second study of the registered counselors' profession. | Bob Nicoloff, Legislature | | Completed | Yes | No | Yes | Completed 11/20/2007 |
| | L2 | We will follow legislative direction regarding registered professions. | Patti Latsch | | Completed | No | No | Yes | Legislation re counseling professions implemented 7/1/2009; legislature has not acted on the other registered professions. |
| | R1 | We are replacing desk manuals with online procedures. | Sam Marshall | 6/30/2008 | Completed | Yes | No | No | Desk manuals and business practices are now available online for staff access |
| | R2 | The new computer system will have checks against errors. | Sam Marshall | 2/19/2008 | Completed | Yes | No | No | Completed 2/19/2008 |
| | R2 | We will centralize our credentialing work units to promote standard business practices. | Karen Jensen | 6/18/2008 | Completed | Yes | No | No | Functions were centralized in June 2008. Physical moves completed 10/6/08. |
| | R2 | We will include audit suggestions and quality assurance pilot project results in revised procedures. | Patti Latsch | 9/30/2008 | Completed | Yes | No | No | CSO procedures 4-3-11 (8/2009)and 4-3-13 (4/2009) adopted; ILRS workflow documents requirements – in place 2/19/2008 |
| | 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 Saxe | 12/31/2007 | Completed | Yes | No | No | Completed 12/31/2007 |
| | 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 Managers | 3/31/2008 | Completed | Yes | No | No | Completed 3/14/2008 |
| | R4 | We will follow legislative direction regarding establishing a minimum age for health care professions. | Steve Saxe | | Completed | No | No | Yes | DOH completed study indicating that it was not appropriate to set a minimum age limit for individual professions. |
| | R1 | We will identify necessary resources for a formal training program | Sam Marshall | | Deferred | No | Yes | No | DOH completed work 12/12/2007; need budget authority from legislature. Further work deferred pending budget authority. Working on issue within current resources. |
| | R6 | We will identify necessary resources for a formal training program | Sam Marshall | | Deferred | No | Yes | No | DOH completed work 12/12/2007; need budget authority from legislature. Further work deferred pending budget authority. Working on issue within current resources. |
| | R4 | We will identify necessary resources for a formal training program | Sam Marshall | | Deferred | No | Yes | No | DOH completed work 12/12/2007; need budget authority from legislature. Further work deferred pending budget authority. Working on issue within current resources. |
| | L1 | We will follow legislative direction regarding additional authority to conduct background checks. | Julie Miracle, Steve Hodgson, Dave Magby, Patti Latsch, Shannon Beigert, Joel Emery | | Completed | No | No | Yes | Legislation implemented 7/1/2008. |
| | R2 | We are developing mandatory reporting rules that will include the timeline for reporting unprofessional conduct. | Margaret Gilbert, Tami Thompson | 5/31/2008 | Completed | Yes | No | No | Completed 3/31/2008 |
| | R3 | We will develop a quality assurance sampling process to audit completed background checks. | Patti Latsch | 7/31/2007 | Completed | Yes | No | No | Completed 9/30/07 |
| | 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 Latsch | 7/31/2008 | Completed | Yes | Yes | No | Completed 8/1/08 |
| | 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 Latsch | 7/31/2008 | Completed | Yes | No | No | Completed 5/29/2008 |
| | R10 | We will continue to send notification letters when we assess the complaint. We will look into the cost of additional notifications. | Kristi Weeks | 6/30/2008 | Completed | Yes | Yes | No | Implementation of RCW 18.130.057 addressed this recommendation.
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| | R2 | We will develop specific criteria for imminent danger. (Procedure 212 to be expanded with examples). | Patti Latsch, Executive Directors | 2/29/2008 | Completed | Yes | No | No | Completed 11/1/2007 |
| | 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 Turner | 5/31/2008 | Completed | Yes | No | No | Completed 5/31/2008 |
| | 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 Turner | 5/31/2008 | Completed | Yes | No | No | Completed 5/30/2008 |
| | R5 | We will update training related to disciplinary case tracking after the first internal quality review. | Patti Latsch, Kirby Putscher | 11/30/2007 | Completed | Yes | No | No | Completed 12/07/2007 |
| | 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 Latsch | 11/30/2007 | Completed | Yes | No | No | Completed 11/30/2007 |
| | 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 Marshall | 6/30/2008 | Completed | Yes | No | No | Completed 2/19/2008 |
| | R6 | We will seek funds to study the feasibility of electronic document management. It will include imaging of complaint files. | Sam Marshall, DIRM | 10/31/2007 | Deferred | No | Yes | No | 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. |
| | R3 | We will seek funds to study the feasibility of electronic document management. It will include imaging of complaint files. | Sam Marshall, DIRM | 10/31/2007 | Deferred | No | Yes | No | DOH completed funds request 12/12/2007. Funding was not available. Deferred pending budget authority. |
| | R7 | We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records. | Patti Latsch | 9/30/2008 | Completed | Yes | No | No | Completed 08/2011
Procedure adopted May 2009. Training is complete as of 12/15/2009. Policy effective 01/01/2010 and implementation under way. |
| | R10 | We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records. | Patti Latsch | 9/30/2008 | Completed | Yes | No | No | Completed: 08/2011
Procedure adopted May 2009. Training is complete as of 12/15/2009. Policy effective 01/01/2010 and implementation under way. |
| | R3 | We will re-evaluate what should be included in case records and revise our procedures on how to organize and manage records. | Patti Latsch | 9/30/2008 | Completed | Yes | No | No | Completed 08/2011
Procedure adopted May 2009. Training is complete as of 12/15/2009. Policy effective 01/01/2010 and implementation under way. |
| | R1 | We are developing a public awareness strategy and will identify its costs for the Legislature. | Michael Wilson | | Deferred | No | Yes | No | 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. |
| | R2 | We are developing a public awareness strategy and will identify its costs for the Legislature. | Michael Wilson | 6/30/2008 | Deferred | No | Yes | No | 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. |
| | R3 | We will calculate the cost to redevelop our Web site to focus on customer needs. | Michael Wilson | 10/31/2007 | Deferred | No | Yes | No | DOH work requesting funding completed 12/12/2007; Full website redesign deferred pending Funds needed for further development Substantial progress made within current resources. |
| | R4 | We are testing outreach to vulnerable populations, particularly the elderly, based on the results of the Elway Poll. | Michael Wilson, Meghan Young | 12/31/2007 | Completed | Yes | No | No | Completed 8/30/2007 |
| | L1 | We will follow legislative direction regarding additional investigative tools. | Patti Latsch, Karen Jensen | | Completed | No | No | Yes | Implemented legislation; Oct 2009 |
| | R8 | We already have these practices in place requiring supervisors to officially sign off on all investigations. | Patti Latsch | | Completed | Yes | No | No | Completed prior to audit; 3/1/05 |
| | R1 | We will propose improvements to the process to authorize an investigation | Patti Latsch, Executive Directors, Program Managers | 5/31/2008 | Completed | Yes | No | No | Completed 6/1/2008 |
| | R2 | We have state-approved guidelines in place. | Patti Latsch | | Completed | No | No | No | Completed prior to audit |
| | R4 | We will complete the contract process for expert review of standard of care cases. | Blake Maresh | 12/31/2007 | Completed | Yes | No | No | Completed 3/10/2008 |
| | R6 | We already have these practices in place to ensure all investigators receive appropriate training. | Patti Latsch | | Completed | Yes | No | No | Completed prior to audit |
| | R7 | We already have these practices in place to ensure all investigators receive appropriate training. | Patti Latsch | | Completed | No | No | No | Completed prior to audit |
| | R9 | We will have a single caseload report available for each investigator in the new licensing system. | Sam Marshall | 6/30/2008 | Completed | Yes | No | No | |
| | 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 Latsch | 12/31/2007 | Deferred | No | Yes | No | 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. |
| | 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 Latsch | 12/31/2007 | Deferred | No | Yes | No | 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. |
| | L1 | We will follow legislative direction regarding requiring a deadline for adoption of sanction guidelines. | Margaret Gilbert, Kristi Weeks | | Completed | No | No | Yes | Legislation has been implemented. Emergency rules effective 01/01/09. |
| | 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. | Legislature | | Completed | No | No | Yes | Legislation implemented July 2008. Procedure adopted 5/5/2009. |
| | L3 | We will follow legislative direction regarding sanction guidelines. (Loss of disciplinary authority if sanction guidelines not adopted). | Legislature | | Completed | No | No | Yes | Disciplinary authorities all adopted sanction guidelines by 10/18/2007. |
| | 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 Jensen | 12/31/2007 | Completed | Yes | No | No | All boards and commissions adopted the sanction guidelines as of 10/18/2007. |
| | R2 | We will continue to enter default orders according to the law. | Patti Latsch | | Completed | No | No | No | Completed and ongoing |
| | R4 | We will review our options to assure accuracy in reporting disciplinary actions. (basis of action) | Patti Latsch | 6/30/2008 | Completed | Yes | No | No | Ongoing quarterly audits to assure accuracy. |
| | R1 | The new computer system will include automated notices and reminders. | Sam Marshall | 6/30/2008 | Completed | Yes | No | No | Completed 2/19/2008; infrastructure complete actual notices and reminders completed with centralization of the compliance monitoring function in July 2008. |
| | 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 Latsch | | Completed | No | No | No | Completed prior to audit. The current process allows only one reminder letter to a provider who has failed to meet an order requirement. |
| | R4 | A central compliance unit will support consistency in the compliance process. | Karen Jensen | 6/30/2008 | Completed | Yes | No | No | Functions centralized 6/1/2008; Moves completed November 2008. |
| | 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 Latsch | 6/30/2008 | Completed | No | No | No | Completed prior to audit. Procedure under revision to reflect centralized compliance unit and ILRS. |
| | R1 | We have enhanced our performance management system to meet the criteria suggested in the audit. | Karen Jensen | | Completed | No | No | No | Completed 6/1/2007 |
| | R2 | We have enhanced our performance management system to meet the criteria suggested in the audit. | Karen Jensen | | Completed | No | No | No | Completed 6/1/2007 |
| | R3 | We will post measures of importance to the public on the agency Web site. | Steve Hodgson, Michael Wilson | 6/30/2008 | Completed | Yes | No | No | Completed 11/30/2008 |
| | R1 | We will update job descriptions to incorporate quality assurance as we consolidate functions. | Sam Marshall, Kathryn LePome | 3/31/2008 | Completed | Yes | No | No | |
| | R1 | We will identify the costs of adding staff to the Department’s internal audit function. | Sam Marshall | | Completed | Yes | Yes | No | 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. |
| | R2 | We have begun a pilot of a Control Self Assessment in HPQA. | Shannon Beigert, Josh Shipe, Charles Satterlund | 9/30/2008 | Completed | Yes | No | No | Completed 6/4/2008 with ongoing activities; First pilot completed. Self assessment completed and changes implemented to address findings. |
| | R3 | We will contract out specialized internal audits as needed. | Bill White | | Completed | No | No | No | Ongoing |
| | R1 | We are implementing the new ILRS computer system that meets agency standards. | Sam Marshall | 6/30/2008 | Completed | Yes | No | No | Completed 2/19/2008 |
| | R2 | We are implementing the new ILRS computer system that meets agency standards. | Sam Marshall | 6/30/2008 | Completed | Yes | No | No | Completed 2/19/2008 |
| | R3 | We will continue to regularly install security patches, as they are available. | Sam Marshall, DIRM | | Completed | No | No | No | DIRM updates as required. |
| | 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, DIRM | 11/30/2007 | Completed | Yes | No | No | Completed 12/7/2007 |
| | R4 | We will update the user access records and restructure the way they are maintained. | Sam Marshall | 11/30/2007 | Completed | Yes | No | No | Completed 12/12/2007 |
| | 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 Marshall | 6/30/2008 | Completed | Yes | No | No | ILRS was implemented 2/19/2008 |
| | R6 | We will avoid the use of computer "side systems." | Sam Marshall | | Completed | No | No | No | |
| | R1 | We will complete a business continuity plan to sustain critical investigation and disciplinary activities. | Patti Latsch, Bill Kellington, Dave Magby, Karl Hoehn, Tracy Auldredge | 12/31/2007 | Completed | Yes | No | No | Under revision due to reorganization. Initial plan completed 12/31/2007. |
| | R2 | We will develop an alternative means of contact for key personnel. | Office Directors | 12/31/2007 | Completed | Yes | No | No | Under revision due to reorganization. Initially completed 11/20/2007. 10/2009 Contact lists revised and up-to-date. |
| | R3 | We will review disaster recovery plans to make sure there is sufficient information for staff to follow them. | Shannon Beigert, Patti Latsch, Tracy Auldredge | 12/31/2007 | Completed | Yes | No | No | Completed 11/15/2007 |
| | R4 | We are working with the Department of Information Services for a primary "hot" site for disaster recovery. | DIRM | 9/30/2012 | In Progress | No | Yes | No | 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. |
| | R4 | We will have an interim disaster recovery site in operation. | DIRM | 12/31/2007 | Completed | Yes | No | No | Completed 12/12/2007 |
| | R5 | We will have an interim disaster recovery site in operation. | DIRM | | Completed | Yes | No | No | Completed 12/12/2007 |
| | R1 | We have upgraded our policies on destruction of confidential records to require that they be deposited in locked containers and shredded. | DOH | | Completed | No | No | No | Completed 7/16/2007 |
| | R2 | We have procedures in place regarding confidential materials in keeping with DOH policy. | DOH | | Completed | No | No | No | Completed 7/16/2007 |