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

AFL 23-27
September 11, 2023

General Acute Care Hospitals (GACHs)

Nurse-to-Patient Ratios Penalties and Clarification on Unpredictable Situations Affecting Staffing Levels
(This AFL supersedes AFL 20-04)


​Al​l Facilities Letter (AFL) Summary

  • ​This AFL reminds GACHs of the administrative penalties when facilities are not in compliance with nurse-to-patient ratios.
  • This AFL also provides clarification on unpredictable situations affecting staffing levels. ​

​Pursuant to HSC section 1280.3(f), the California Department of Public Health (CDPH) must assess an administrative penalty if it determines that a GACH 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.

Unpredictable Situations Affecting Staffing Levels

CDPH defines:

  • “Unpredictable” as unable to be known in advance.
  • “Uncontrollable” as outside the facility’​s control.
  • “Unpredictable and uncontrollable” as the facility had no way to know or control the staffing shortage that occurred.

CDPH will assess unpredictable and uncontrollable situations on a case-by-case basis. Emergency circumstances will not automatically be considered an unpredictable or uncontrollable situation. Staff call-outs during predictable times, such as seasonal flu, should be expected, and unless the numbers are unprecedented, would not be considered unpredictable. Other situations that are not considered unpredictable, unknown, or uncontrollable include consistent, ongoing patterns of understaffing. Facilities are expected to maintain required nurse-to-patient staffing ratios at all times, including, but not limited to, weekends, holidays, leaves of absences, among others. GACHs are expected to plan for and respond to surges to ensure prompt efforts are made to maintain staffing levels.

To not be subject to an administrative penalty, GACHs must demonstrate that fluctuations in required staffing levels are due to the facility not knowing in advance and not having control of the staffing shortage that occurred. In determining whether a GACH is subject to an administrative penalty, CDPH shall consider the documented facts and evidence when the violation occurred and the specific circumstances at a hospital at the time of the violation. In addition to issuing an administrative penalty for noncompliance with nurse-to-patient staffing ratios, CDPH may also issue an administrative penalty if the inadequate staffing resulted in patient harm.

If you have any questions about this AFL, please contact your local district office.



Original signed by Cassie Dunham​

Cassie Dunham

Deputy Director​

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