California Hospital Survey Manual — A Guide to the Licensing & Certification Survey Process
Details new state survey process and outlines complaint investigation process


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 surveyors use to assess compliance.

Significant changes to the survey process enacted  recently and described in the new edition include:

  • Details on procedural changes in the survey process. In brief, the California Department of Public Health (CDPH) is no longer participating in Consolidated Accreditation and Licensure (CALS) surveys.  Hospitals that are accredited by The Joint Commission (TJC) will have two separate surveys: one by TJC (with or without the Institute for Medical Quality, depending on the hospital’s preference) and a separate “Relicensing Survey” conducted by CDPH. Beginning March 2016, the relicensing surveys will replace the Patient Safety Licensing Surveys and Medication Error Reduction Plan surveys.
  • An expanded discussion of surveyor rights and restrictions regarding access to peer review materials, attorney-client privileged materials, and Patient Safety Work Product that has been expanded. Explanation of changes to the Centers for Medicare & Medicaid Services (CMS) policies and procedures regarding investigating complaints against hospitals. Notably, some complaints are now referred by CMS to the accreditation agency for investigation.
  • New charts and instruction sheets to calculate the amount of administrative penalties that CDPH may assess, and that summarize the differences between a state immediate jeopardy deficiency and a federal immediate jeopardy deficiency.

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.

(Third Edition, August 2015)


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