Mission: The California Hospital Association (CHA) Certification and Licensing (CAL) Committee’s mission is to assure that licensing, regulatory and accreditation issues pertinent to California hospitals are addressed in a manner that is positive for patients, hospitals and the overall efficient delivery of health care.
Purpose: The purpose of the Committee is to address hospital accreditation, regulatory and licensing issues in an open and collegial forum. The Committee will recommend policy and actions related to certification, accreditation, licensing and regulatory policy to CHA staff and the CHA board.
Mission: The California Hospital Association
(CHA) Certification and Licensing (CAL) Committee’s mission is to
assure that licensing, regulatory and accreditation issues
pertinent to California hospitals are addressed in a manner that
is positive for patients, hospitals and the overall efficient
delivery of health care.
Purpose: The purpose of the Committee is to
address hospital accreditation, regulatory and licensing issues
in an open and collegial forum. The Committee will
recommend policy and actions related to certification,
accreditation, licensing and regulatory policy to CHA staff and
the CHA board.
COLLABORATIVE WORK WITH REGULATORY AGENCIES
Facilitate open lines of communication with regulatory agencies
including: California Department of Public Health (CDPH), Centers
for Medicare and Medicaid (CMS), Accreditation Organizations and
other regulatory agencies to:
Come to consensus on interpretation and application of
Identify and identify statewide issues and work with
regulatory agencies to find resolution.
Advocate on behalf of CHA members using the expertise of the
Evaluate Legislation and Regulatory initiatives.
Objective: Identify pertinent issues, influence
policy decisions by working with the appropriate regulatory
agency to find resolution.
Disseminate information from the CAL Committee to CHA member
hospitals, allowing CHA members access to the information and
work from the CAL Committee, including pertinent information from
each committee meeting.
Objective: The CAL Committee information shall
be disseminated using the following methods:
Post committee information on the CHA members’ only website.
Collaborate with regulatory agencies on educational
opportunities (e.g. webinars, etc.).
Disseminate information from CAL Committee members to their
The Centers for Medicare & Medicaid Services (CMS) has released
revisions to the State Operations Manual, Appendix V,
effective June 4, on complaint investigation timelines for
Emergency Medical Treatment and Labor Act (EMTALA) and deaths
associated with seclusion or restraint for hospitals and critical
The United States Pharmacopeia (USP) has released newly revised
standards to assist health care practitioners in
consistently producing high-quality compounded medicines that are
the right strength and free of contaminants. The final
825, and USP
General Chapter 800 standards will take effect Dec.
Beginning July 1, the California Department of Public Health will
not accept payment for health facility license application fees
until its Licensing & Certification Centralized Applications
Branch validates that all required forms and supporting
documentation have been received. For more information, see
Facilities Letter 19-20.
The California Department of Public Health (CDPH) earlier this
week released All
Facilities Letter 19-19, which updates its application
process for new or remodeled pharmacy clean rooms and mobile
sterile compounding units (MSCUs). Notably, CDPH will no longer
accept incomplete applications for pharmacy clean rooms or MSCUs.
CDPH states the update is in response to Assembly Bill 2978
(Chapter 992, Statutes of 2018), which requires CDPH to review or
deny applications within 100 days of receipt.
submitted comments to the California Department of Public
Health (CDPH), responding to its requests for input on changes to
Title 22 regulations. In the letter, CHA thanks CDPH for
undertaking the process of revising the regulations, noting
that the majority are outdated and no longer relevant to current
hospital care delivery.
The California Department of Public Health has released All
Facilities Letter (AFL) 19-02.1, which rescinds AFL 19-02 and
further clarifies licensing requirements related to treatment for
All Facilities Letter 19-07, the California Department of
Public Health reminds facilities that post-survey satisfaction
evaluations may now be completed online.
These surveys are intended to help improve the survey process.
The Drug Enforcement Administration has moved Epidiolex
from Schedule I to Schedule V. According to
All Facilities Letter 19-06, issued last week by the
California Department of Public Health, cannabis-derived drugs
that are approved by the Food and Drug Administration and that
have no more than 0.1 percent residual tetrahydrocannabinols will
be moved to Schedule V. Currently, only Epidiolex meets
those requirements. Drugs that do not meet these criteria may not
be prescribed or dispensed.
health advisory from the Centers for Disease Control and
Prevention shares information about an investigation of a
penicillin-resistant strain of Brucella spreading across
the U.S. Suspected to be linked to consumption of unpasteurized
milk from a farm in Pennsylvania, cases have now been identified
in 19 states — including California. More information on the
infection and recommended treatment is available in the advisory.
In preparation for an
upcoming meeting to solicit stakeholder feedback on
possible changes to Title 22 infection control and physical
plant regulations for general acute care hospitals, the
California Department of Public Health has released a series of
questions. More details are available in All
Facilities Letter 18-56.1.
The California Department of Public Health reminds
general acute care hospitals and acute psychiatric hospitals
that, effective Jan. 1, they may not require, as a condition of
admission, a person who voluntarily seeks care to be placed on an
involuntary hold under Section 5150 of the Welfare and
Facilities Letter 18-57, the California Department of Public
Health announces a new web-based data collection tool intended to
assist providers that participate in the Palliative Care Pilot
Program with annual reporting. Program participants must submit
certain information using this tool by Jan. 1 of each program
year. 2018 reports were due Jan. 1, 2019, but the
online reporting portal will remain open through March 1.
The California Department of Public Health has issued All Facilities
Letter 19-01 reminding hospitals of the new law requiring
that they try to coordinate homeless patients’ discharge to
appropriate area shelters or other community-based
services. To help hospitals comply with the law, CHA
has developed a guidebook titled Discharge
Planning for Homeless Patients.
The California Department of Public Health reminds
health care providers that, effective Jan. 1, they must make
plant-based meal options — without meat, poultry, fish, dairy or
eggs — available to patients, in accordance with their
physician’s orders. For more information about the law, see page
15 of CHA’s 2018
Report on Legislation.
The Centers for Disease Control and Prevention has updated its
health alertaddressing a multistate outbreak of coagulopathy — a
bleeding disorder that impacts the way blood clots — that has
been linked to synthetic cannabinoid use.
According to an
annual report from the California Department of Public
Health, the overall vaccination rate among health care
personnel in California hospitals increased from 72 percent in
2012-13 to 84 percent in 2017-18, meaning that California is well
on its way to reaching the goal of 90 percent vaccination
coverage among hospital personnel by 2020.
Hospitals in need of relief from licensing regulations due to the
recent wildfires across California should refer to All Facilities
Letter 18-51, issued last week by the California Department
of Public Health (CDPH).
Effective Jan. 1, 2020, general acute care hospitals and acute
psychiatric hospitals must adopt and implement a linen laundry
processing policy that aligns with the most recent standards from
the Centers for Disease Control and Prevention and the Centers
for Medicare & Medicaid Services.