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Licensing and Certification Program

General Acute Care Relicensing Survey

The purpose of a GACH Relicensing Survey (GACHRLS) is to promote quality of care in hospitals, verify compliance with State regulations and statutes, and ensure a program wide consistency in the hospital survey methodology. The GACH Relicensing Survey was implemented on March 1, 2016 and merged California’s licensing regulations and statue requirements with elements of the former stand-alone Medication Error Reduction Plan (MERP) survey and Patient Safety Licensing Survey (PSLS) into one survey process.

These documents are final copies.  Any modifications, such as, additions, deletions, or revisions made to these documents will be uploaded after they are approved. The date of modification will be indicated on the document’s title and the document.

Relicensing Survey Overview (PDF)
The PowerPoint presentation describes the purpose and core elements of the GACH Relicensing Survey, its relationship to other current surveys, survey team compositions, and CDPH pilot testing and implementation. It also includes links to survey documents.

(Revised 5-5-2016)

Process Guidance (PDF)
The Process Guidance document provides the regulatory authority for the GACH Relicensing Survey, the design of the survey protocols, methods of information gathering for the surveyors, and the mechanics of surveyors’ non-compliance decisions.  The core elements of the survey will be the provision of nursing and medical care, the provision of medications, and previous non-compliance issues identified during a three year lookback of the file history of the facility.  Included in this lookback would be State and Federal survey deficiencies, substantiated complaints and/or entity reported events, and administrative penalties

(Revised 3-2016)

Regulations with Survey Procedures (PDF)
The Regulations with Survey Procedures document contains a comprehensive listing of California’s laws and regulations for surveyors’ reference with recommended surveyor procedures

(Revised 9-2016)

General Entrance List (PDF)
The Entrance List is a checklist of documents and policies that may be requested from the facility at the start of a survey.  A surveyor will go over the list with hospital staff during the entrance activities.

(Revised 7-2016)

Pharmacy Entrance List (PDF)
The MERP Entrance List is a checklist of documents and policies that may be requested from the facility by the pharmaceutical surveyor at the start of a survey

(Revised 7-2016)

Survey Activity Schedule (PDF)
The Tentative Timeline provides a preliminary overview of the anticipated survey activities

(Revised 7-2016)

Medication Pass Worksheet (PDF)
The Medication Pass Worksheet is used by all surveyors to record the observation of hospital staff administering medications to patients.

(Revised 7-2016)

Relicensing Evaluation Form (PDF)
The Evaluation Form rates the survey process in order to capture data related to quality improvement efforts by the Department.

(Revised 7-2016)

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