Purpose

To determine if the Department of Health’s (Department) waiver practices are effectively addressing safety and risks related to physical plant standards at health care facilities. This audit covered the period April 1, 2012 to November 12, 2014.

Background

Health care facilities in New York State are required to operate in compliance with architectural codes and safety regulations issued by the Department. The Department is the State agency responsible for enforcing compliance with these codes and regulations and for granting exceptions. Regulations permit the Department to grant waivers, temporary or permanent, to a facility to allow it to continue to operate while corrections are made or alternative means of compliance are achieved.

Key Findings

• We found the Department’s waiver practices do not effectively ensure that safety and structural risks related to physical plant standards at health care facilities are appropriately addressed.
• The Department’s internal controls, including monitoring and internal communications efforts, were lacking and led to a backlog of at least 179 unprocessed waiver requests at the time of our audit. Some of the requests dated back to 2003.
• The Department lacked formal written policies and procedures governing the waiver process, and did not maintain sufficient collective documentation supporting waiver applications, approvals, and monitoring efforts.
• Although the Department’s Nursing Homes Division appeared to properly monitor waivers granted to such facilities, the Hospitals Division had no detailed awareness of the waivers that were granted to the hospitals and clinics it oversees.

Key Recommendations

• Establish and maintain formal Department-wide waiver policies, procedures, and controls, including the assignment of responsibility for monitoring compliance and maintaining adequate documentation.
• After implementation, periodically evaluate all policies, procedures, and controls to ensure they are functioning as intended, and revise as needed.
• Maintain a complete, accurate, and timely shared waiver database to record all waiver requests, approvals, and denials and to document completion of time-limited waivers.

Other Related Audit/Report of Interest

Department of Health: Selected Operating and Administrative Practices of the Bureau of Narcotic Enforcement (2011-S-19)