Purpose

To determine the extent of implementation of the four recommendations included in our initial audit report, Facility Structure, Safety, and Health Code Waivers (Report 2014-S-27).

Background

There are almost 4,000 health care facilities operating across New York State, including hospitals, nursing homes, intermediate care facilities, and other treatment centers such as ambulatory care centers and health clinics. These facilities are required to operate in compliance with architectural codes and safety regulations issued by the Department of Health (Department). 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. Our initial audit which was issued on June 18, 2015, found the Department’s waiver practices did not effectively ensure that safety and structural risks related to physical plant standards at health care facilities were appropriately addressed. The Department lacked both a formal written process for waiver management and monitoring, and adequate internal controls, which together led to poor communication among various units with critical responsibilities such as monitoring. Among other findings, there was inadequate documentation of waiver applications and decisions, and of monitoring for approved waivers. As a result, the Department could not efficiently and effectively ascertain what waivers were in place at a given facility, nor could it identify the code violations that had been waived at those facilities. Further, there was limited assurance that violations were corrected or mitigated during the time frame allowed by the waivers.

Key Finding

Department officials have made significant progress in addressing the problems we identified in the initial audit. We found the initial report’s four recommendations were all implemented.

Other Related Audit/Report of Interest

Department of Health: Facility Structure, Safety, and Health Code Waivers (2014-S-27)