DOH lays out plan to reach inspection targets after JLARC flagged late hospital surveys

The Department of Health told the Joint Legislative Audit and Review Committee it has launched a strategic management plan to address JLARC findings that the department missed hospital inspection timeframes, did not consistently verify third-party inspections, and had limited adverse-event review capacity.

DOH officials Ramiro Cantu and Shawna Fox outlined six objectives tied to staffing, systems and reporting. The department has launched a new licensing enforcement system (HELMS), increased staffing and raised fees to stabilize licensing functions, and said it expects to reach 70% on-time compliance for acute-care hospital inspections by the end of 2026, 86% by the end of 2027 and 100% by October 2028.

DOH said it will work with accrediting organizations to determine "substantial equivalency" for third-party inspections and will expand translated complaint forms from the top five to the top 10 languages. DOH also plans a facility workload staffing model due by June 2027 and a phased plan to implement improved adverse-event reporting and a public-facing financial data dashboard by 2028.

Committee members asked whether DOH measures compliance by last inspection date or by facility size and pressed the agency on the pace of improving language access; DOH said compliance is measured by when a hospital's last inspection occurred and that it will engage communities and hospitals to identify better outreach channels.

The DOH presentation included specific near-term milestones and budget-development steps; the department said some improvements depend on funding decisions and potential legislative action in 2027.