Education event

Licensing and Certification Survey Basics Web Seminar
Survey types, applicable laws, preparation and response

August 21, 2012
10:00 a.m. – Noon, Pacific Time


The survey process is complicated. Hospital survey staff must be prepared to switch gears at a moment’s notice when the surveyors walk through the door. Often, many questions arise when confronted with an unannounced survey. Whether or not the survey goes smoothly will depend heavily upon knowing:

  • What kind of survey will take place — state or federal
  • Which of the many different laws, regulations or guidelines will be considered
  • Which staff should be alerted and involved with the surveyors
  • Who the surveyors could interact with and why
  • What the surveyors can and will ask for

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

Register now to improve or renew your knowledge of licensing and certification surveys.

Recommended for

Chief nursing officers, compliance officers, risk managers, survey and accreditation managers, quality managers and in-house legal counsel.


Licensing v. certification v. accreditation — what’s the difference?

State surveys

  • Survey types — consolidated accreditation and licensure (CALS), complaint-driven, self-report, patient safety licensing (PSLS), medication error reduction plan (MERP)
  • Which laws apply — Health and Safety Code, Title 22
  • Administrative penalties and appeals

Federal surveys

  • Survey types — certification, complaint-driven, validation
  • Which laws and guidelines apply — CoPs, State Operations Manual, Interpretive Guidelines
  • Immediate jeopardy — federal and state differences

The surveyor’s perspective on the process

  • Starting off right — the entrance conference
  • Documents review — what surveyors may ask for
  • Interviewing patients and staff
  • Exit conference — clarifying expectations, next steps

How hospitals can prepare and respond to survey

  • Develop your process — employee training, documentation, mock surveys
  • Interacting with surveyors — appropriate responses
  • Survey in progress — alerting key staff, escorts, daily debriefs

After the survey

  • Communicating survey results, steps to address issues
  • Addressing 2567s, plans of correction
  • Documentation and continuous improvement


Jana Du Bois is vice president and legal counsel for the California Hospital Association. Ms. Du Bois has a broad foundation of health law experience, including serving as in-house counsel for a large integrated hospital health system and regulatory counsel for state public health and managed care departments. Prior to becoming an attorney, Ms. Du Bois was a registered nurse for over 10 years.

Cheryl Gann, RN, MBA, CPHQ, is senior director of Patient Safety and Regulatory Readiness, in Corporate Quality for Scripps Health in San Diego. Ms. Gann is responsible for patient safety, risk management, accreditation, and licensure activities across the Scripps Health system. In addition to improving patient safety, reducing medical errors, and coordinating compliance, she also teams with other organization leaders to address and resolve patient safety issues and elevate the standard of care. 

David Perrott, MD, DDS is senior vice president and chief medical officer for CHA. His responsibilities include all clinical issue areas, including the Center for Hospital Medical Executives, Healthcare Quality Committee, the Medication Safety Committee, and the Joint Committee on Accreditation and Licensing. He is actively involved in the California Hospital Patient Safety Organization, and was recently appointed to The Joint Commission (TJC) Board of Commissioners.


Members $185 (per connection)
Nonmembers $275 (per connection)

Multiple staff can gather and participate from one location for one tuition fee. Register online using the button on the right or complete the registration form and fax it to (916) 552-7506. Checks should be made payable to CAHHS/CHA and mailed to:

California Hospital Association
Education Department
1215 K Street, Suite 800
Sacramento, CA 95814

Cancellation Policy
A $50 non-refundable processing fee will be retained for each cancellation. Cancellations must be made in writing seven days prior and e-mailed to, or faxed to (916) 552-7506. No refunds will be made after this date. If the seminar is cancelled paid participants will be fully refunded within 30 days.

Continuing Education

Full attendance, completion of online survey, and attestation of attendance is required to receive continuing education credit for this seminar.

Note: only registrant may receive complimentary CEs. If additional participants under the same registration would like to be awarded CEs, a fee of $20 per person, will apply. Post-event survey will provide information on how to apply online for additional CEs.

Health Care Executives:
CHA is authorized to award 2 hours of pre-approved ACHE Qualified Education Credit (non-ACHE) for this program toward the advancement, or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credit should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification.

Provider approved by the California Board of Registered Nursing, CEP #11924, for 2.4 Contact Hours

Access Info

This web seminar allows you to attend and participate without ever leaving the office. The seminar is produced live, via the Internet and a telephone line. You only need a telephone and a computer with a web browser to participate.

Once you register, a confirmation e-mail will be sent with pertinent program information.

Audio for the seminar is accessed through a toll-free number (U.S. calls only). During the program, you will have the opportunity to ask questions of the speakers. If multiple people will be listening to the program at your office, only one person needs to register for the group. The slide presentation is accessed on your computer via the web.

IMPORTANT: Test your computer today

  • Click here to go to the Adobe Connect Enterprise Server Connection test page.
  • Follow instructions to ensure that your computer and network connections are properly configured.

If your internal security settings block access to Adobe Connect, contact your IT department to grant you access. The web seminar runs on Adobe Connect and you won’t be able to view the program without access.


Click here to view attendees.