Under existing law prior to January 1, 2025, GACHs, APHs and SNFs must develop, implement, and comply with patient safety plans for the purpose of improving the health and safety of patients and reducing preventable patient safety events.
The patient safety plan must, at a minimum, include:
- The establishment of a patient safety committee,
- A reporting system for patient safety events,
- A process for a team of facility staff to conduct analyses of patient safety events,
- A reporting process that supports and encourages a culture of safety and reporting patient safety events, and
- A process for providing ongoing patient safety training for facility personnel and health care practitioners.
Patient safety events are defined by the patient safety plan and include, but are not limited to, all adverse events or potential adverse events as described in HSC section 1279.1, and preventable health-care-associated infections.
Requirements starting January 1, 2025:
AB 3161 requires affected facilities to review and, as necessary, revise the patient safety plans to ensure the plans include anonymous reporting options and the ability to analyze, address, and monitor patient safety events for possible discrimination based on: age, race, ethnicity, gender identity, sexual orientation, preferred language spoken, disability status, payor, and sex.
Furthermore, AB 3161 requires affected facilities, as part of their patient safety plans, to develop a process for addressing racism and discrimination, and its impacts on patient health and safety, including but not limited to: monitoring sociodemographic disparities in patient safety events and developing interventions to remedy known disparities, and encouraging facility staff to report suspected instances of racism and discrimination.
Starting January 1, 2026:
Upon license renewal beginning January 1, 2026, and every two years thereafter, affected facilities are required to submit patient safety plans to CDPH for review. The Patient Safety Plan Checklist (PDF) will help facilities ensure that their updated patient safety plans include all required components. Facilities must submit the Patient Safety Plan to CDPH by emailing it to AB3161hospitals@cdph.ca.gov or AB3161skillednursingfacilities@cdph.ca.gov. Please submit a PDF and use the naming convention for files as follows: Facility Name, Facility ID, Facility Type, District Office, Patient Safety Plan. Please include the file name in the subject line of your email.
Facilities are responsible for following all applicable laws. 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 AB 3161 and all applicable sections of the HSC and Title 22 of the California Code of Regulations.
If you have any questions about this AFL, please contact the CDPH Field Operations Support Unit at CDPHCHCQFieldOperationsSupportUnit@cdph.ca.gov.
Sincerely,
Original signed by Mandi Posner
Mandi Posner
Deputy Director
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