Responding to Licensing and Certification Deficiencies Webinar
New CDPH penalties, working with surveyors, plans of correction, appeal process

Webinar Recorded Live on May 21, 2014


You’ve received a licensing violation. You may have been expecting it from a recent survey, or it may have come as a complete surprise. One thing is for certain, survey activity — and subsequent violations — will be more common now that California Department of Public Health (CDPH) has issued new regulations for hospital penalties, including non-immediate jeopardy violations.

This webinar instructs viewers on how to manage violations from receipt to appeal. Viewers gain a better understanding of how to work with surveyors on site and know how to respond when an IJ has been called against your facility. Guidance on how to draft the Plan of Correction and documentation needed for an administrative appeal was also be covered.


Revisions to CDPH penalty authority

  • New regulations for administrative penalties
  • What to expect from surveyors

The surveyors are here — are you ready?

  • What hat today? — federal vs. state surveyors
  • Activating your survey plan, process
  • Federal surveyor calls an IJ — assembling the response team
  • Guidance for working with surveyors

Receiving a deficiency

  • Driven by complaint, routine survey, self-report
  • Violation types: federal vs. state, IJs vs. non-IJs, condition vs. standard levels
  • Ramifications of multiple deficiencies — VBP, termination, fines

After the survey

  • The two 2567s — state vs. federal
  • Plan of Correction — who should write, elements to include
  • What is a thorough response?

Appealing a penalty

  • Notice of appeal — the critical 10-day window                   
  • Factors to consider — should you appeal?                                     
  • What to submit and by when                       
  • The appeal — who crafts, what facts to include         
  • After you file the appeal — what happens next      
  • Negotiating a settlement — your options       


Ann Sparkman, JD, has served for eight years as the deputy campus counsel for Health Affairs for the University of California, San Francisco (UCSF). Ms. Sparkman has extensive health care experience and was appointed to serve on the Marin Healthcare District Board in November, 2011. Prior to joining UCSF, she held the position of in-house counsel for Kaiser Permanente and was a partner in healthcare law at Hassard Bonnington.

Claire Castles, JD, is an associate for Jones Day advising clients across the health care industry on compliance strategies and regulatory issues, and in proceedings before federal and state government agencies. Her areas of practice include licensing and certification, payment and reimbursement, health privacy, Emergency Medical Treatment and Active Labor Act (EMTALA), Medicare Conditions of Participation, contracting and transactional matters, internal investigations, and government investigations and audits. Prior to joining Jones Day, Ms. Castles advised hospitals in operational and administrative responses to California Department of Public Health immediate jeopardy and privacy breach findings and Centers for Medicare and Medicaid Services’ surveys and deficiency findings, including threatened termination actions.


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.


To learn more about the manual or to order, click here.