2014 California Hospital Survey Manual — A Guide to the Licensing & Certification Survey Process
Includes free basics webinar CD


The surveyors have arrived, unannounced, at your hospital. What do you do first? What will the surveyors do?

The California Hospital Survey Manual is intended to help hospital staff understand and prepare for the survey process, from start to finish. It was written specifically for California’s hospital licensing and accreditation professionals, compliance officers, legal counsel, risk managers, and other members of the hospital’s licensing and compliance teams.

The California Hospital Survey Manual explains important differences between state and federal surveys, provides tips on how to achieve a successful survey, and outlines tasks that must be completed after the survey. Although state and federal surveyors may be the same people, there are differences in processes and potential outcomes. This manual will help hospitals understand the differences and describes the laws with which surveyors assess compliance.

The new edition of the survey manual:

  • Explains CDPH’s new penalty system for violations of hospital licensing requirements
  • Includes answers to FAQs on writing hospital policies
  • Discusses the new CMS waiver process for specified portions of the 2000 edition of the LSC and the 1999 edition of NFPA 99
  • Explains the impact of receiving a federal immediate jeopardy citation when participating in the CMS Value-Based Purchasing program
  • Provides suggested questions for internal feedback from staff following a mock survey

Topics include:

  • Preparing for state and federal surveys                                              
  • Survey processes and procedures                                    
  • How to interact with surveyors                                   
  • Entrance and exit conferences                                   
  • How surveyors determine deficiency levels                              
  • Possible outcomes of a survey                          
  • Appealing adverse actions                         
  • Writing plans of correction                           
  • And much more!                             

Appendixes include self-report requirements for privacy breaches, adverse events and unusual occurrences; a sample cover letter; and timeline documents.

Free Webinar CD
With every manual purchase, a complimentary copy of the Licensing and Certification Survey Basics Webinar CD is included. Presenters from legal, surveyor and hospital backgrounds offer practical information and procedures to help survey veterans, or those new to the process, respond with confidence.

(Second Edition, January 2014)


Chapter 1: Introduction and Background

  • State licensing — CDPH
  • Federal certification — CMS
  • Accreditation — TJC, AOA/HFAP, DNV Healthcare

Chapter 2: State Surveys

  • CDPH Licensing & Certification organizational structure and staffing
  • Types of state surveys, including CALS, complaint surveys, Patient Safety Licensing Surveys (PSLS), and Medication Error Reduction Plan (MERP) surveys
  • Which laws are state surveyors assessing compliance with?
    • Health and Safety Code, Title 22
  • Overview of surveyors’ procedures, the State-2567 (Statement of Deficiencies and Plan of Correction)
  • Possible survey outcomes, including immediate jeopardy, penalties

Chapter 3: Federal Surveys

  • CMS organizational structure and staffing
  • Types of federal surveys, including certification, validation, complaint surveys
  • Which laws are federal surveyors assessing compliance with?
    • Medicare Conditions of Participation, State Operations Manual, Interpretive Guidelines
  • Overview of surveyors’ procedures
    • Entrance conference, what to provide the survey team
    • Sample size and selection
    • Observation, interviews, record review by surveyors
    • Exit Conference
  • Possible survey outcomes, including condition-level vs. standard-level deficiency, immediate jeopardy, penalties, notice of termination
  • CMS-2567 (Statement of Deficiencies and Plan of Correction)

Chapter 4: Tips for Achieving a Successful Survey

  • Establish a Survey Readiness/Response Team
  • Train the licensing, certification and accreditation (LCA) team and hospital staff
  • Perform mock surveys
  • How to interact with surveyors, what to do during the survey
  • Checklist for exit conference

Chapter 5: After the Survey

  • Communicating survey results to governing body, employees, medical staff, media
  • Developing immediate corrective action steps and the plan of correction
  • Appealing penalties

Free Webinar CD

Webinar Recorded Live August 21, 2012


This webinar provides clear and concise direction on licensing and certification surveys. Presenters from legal, surveyor and hospital backgrounds offer practical information and procedures to help survey veterans, or those new to the process, respond with confidence.


Jana Du Bois is vice president and legal counsel for the California Hospital Association.

Cheryl Gann, RN, MBA, CPHQ, is senior director of Patient Safety and Regulatory Readiness, in Corporate Quality for Scripps Health in San Diego.

David Perrott, MD, DDS is senior vice president and chief medical officer for CHA.