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State of California—Health and Human Services Agency
California Department of Public Health

AFL 20-04
January 16, 2020

General Acute Care Hospitals (GACHs)

Notice of New Penalties for Violating Nurse to Patient Staffing Ratios

​​​​This AFL has been superseded - please see AFL 23-27

AU​THORITY:     Health and Safety Code (HSC) 1280.3

​Al​l Facilities Letter (AFL) Summary

This AFL notifies facilities of the chaptering of SB 227 (Chapter 843, Statutes 2019) mandating fines for GACHs not in compliance with nurse-to-patient ratios.

​Effective January 1, 2020, SB 227 requires CDPH to issue administrative penalties to GACHs that fail to comply with nurse-to-patient staffing ratios.

SB 227 creates an administrative penalty for a GACH, if CDPH determines it has violated a nurse-to-patient staffing ratio. CDPH must assess an administrative penalty of $15,000 for the first violation and $30,000 for the second and each subsequent violation. Multiple staffing violations found on the same inspection will only constitute a single violation. A violation occurring more than three years after the date of the last violation must be treated as a first violation. CDPH must verify compliance with mandatory nurse-to-patient staffing ratios during periodic, unannounced inspections of GACHs. CDPH must take into consideration the special circumstances of small and rural hospitals, to protect access to quality care in those hospitals.

A GACH is not subject to an administrative penalty for violating nurse-to-patient staffing ratios if the hospital demonstrates all of the following:
1) that any fluctuation in required staffing levels was unpredictable and uncontrollable;
2) prompt efforts were made to maintain required staffing levels;
3) the hospital immediately used and subsequently exhausted the hospital’s on-call list of nurses and the charge nurse.

Facilities must document their efforts to ensure compliance with nurse-to-patient staffing ratios.​

SB 227 authorizes CDPH to implement, clarify or make specific the bill's requirements through an AFL. As such CDPH defines:

  • Unpredictable as unable to be known in advance.
  • Uncontrollable as outside the facilities control.
  • Unprepdictable and uncontrollable as, the facility had no way to know, or control the staffing shoratage that occurred.​

CDPH’s failure to expressly notify facilities of statutory or regulatory requirements does not relieve facilities of their responsibility for following all laws and regulations. Facilities should refer to the full text of all applicable sections of HSC and the California Code of Regulations to ensure compliance.​


Original signed by Heidi W. Steinecker

Heidi W. Steinecker

Deputy Director

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