Additional Temporary Waivers Tied to the Hospital Surge Public Health Order

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AFL 21-09 From the California Department of Public Health

February 1, 2021

TO: General Acute Care Hospitals
SUBJECT: Additional Temporary Waivers Tied to the Hospital Surge Public Health Order

AUTHORITY:      Proclamation of Emergency (PDF), Executive Order N-27-20 (PDF), Executive Order N-39-20 (PDF), Hospital Surge Public Health Order

All Facilities Letter (AFL) Summary

This AFL notifies hospitals of a temporary waiver of specified regulatory requirements that will remain in place only for the duration of the Hospital Surge Public Health Order.

​Pursuant to the Governor’s declaration of a state of emergency related to COVID-19, the Director of CDPH may waive any of the licensing requirements of Chapter 2 of Division 2 of the Health and Safety Code (HSC) and accompanying regulations with respect to any hospital or health facility identified in HSC section 1250. CDPH is temporarily waiving the following specified hospital licensing requirements and suspending regulatory enforcement in the following counties (Fresno, Kern, Kings, Madera, Merced, San Benito, San Joaquin, Stanislaus, and Tulare, Imperial, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara, and Ventura) that are impacted by the Hospital Surge Public Health Order:

Services and Administration

1. HSC section 1254.4: Hospitals are not required to allow family or next of kin to gather at a deceased patient’s bedside to accommodate religious and cultural practices. Hospitals should continue to try to accommodate religious and cultural practices and concerns if they do not directly or indirectly jeopardize the health and safety of other patients or hospital staff or impede hospital operations. 

2. HSC section 1257.7Hospitals may suspend annual detailed security and safety assessments, revisions to the hospital’s security plan, and tracking of incidents of aggressive or violent behavior as part of the quality assessment and improvement program. 

3. HSC section 1280.15(b): Hospitals may delay reporting any unlawful or unauthorized access to, or use or disclosure of, a patient’s medical information to CDPH and to the affected patient or the patient’s representative beyond the current 15-business day requirement. 

4. Title 22, Section §70215, “Planning and Implementing Patient Care”: 

a. Ongoing patient assessments shall continue to be performed as required by each unit’s guidelines of care; however, documentation of these assessments may be made by exception. “By exception” means that a notation is made only when there is a deviation from baseline, deviation from normal limits, or an unexpected outcome.

b. Ongoing patient education shall continue to be performed as required by each unit’s guidelines of care. Documentation in the medical record may be made by exception; however, discharge patient education shall continue to be performed and documented for each patient as usual.

c. Documentation of formal nursing diagnosis and care plans in the medical record may be eliminated. This aligns with CMS’s COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, which waives the requirements of 42 CFR §482.23(b)(4) and requires the nursing staff to develop and keep current a nursing care plan for each patient.

5.   Title 22, Division 5, Chapter 1, §70749 (a) (6) (A), “Patient Health Record Content”:

a. Documentation of nursing care administered pursuant to each unit’s guidelines of care may be restricted to the following:

a. Patient assessments by exception

b. Abnormal findings and pertinent clinical status changes (e.g., lungs that are clear to auscultation are documented if the patient had crackles previously)

c. Critical lab values/critical results not already documented

d. Vital signs, including pain assessment

e. Administered medications and treatments (including blood transfusions)

f. Invasive lines and tubes – lines, drains, and airway (LDA) documented upon insertion or presentation. Ongoing assessment of LDAs will take place; documentation of care by exception (abnormal findings)

g. Clinically relevant attending and consulting provider communication

h. Clinically relevant intake and output

i. Key patient information (e.g., height, weight, allergies, advance directives, home medications, and admission intake form)

j. Restraint assessments and monitoring

k. Patient education at discharge

l. Isolation precautions

m. Anything that, in the judgment of the nurse, would compromise patient safety if it were not documented

i. In addition, nurses shall document a note at the end of each shift for clinically significant events if not documented elsewhere.

b. Other nursing care that is provided (including but not limited to activities of daily living, hygiene, routine catheter and ostomy care, repositioning, infection control practices, etc.), shall continue to be performed as required by each unit’s guidelines of care, but documentation may be done by exception. For example, if a patient must be turned and repositioned Q2H, a note will be entered only if this is not done. 

a. Alternatively, a GACH may adopt a policy requiring the care described in this paragraph to be documented in an end-of-shift note. For example, the note would state that “the patient was turned and positioned Q2H as per policy,” rather than having the nurse document every two hours throughout the shift.

b. A hospital may adopt a hybrid policy. For example, activities of daily living and hygiene will be documented by exception, but routine ostomy care and repositioning will be documented in an end-of-shift note rather than documenting throughout the shift. GACHs adopting a hybrid policy shall list which activities are documented by exception and which are documented in the end-of-shift note.

6.   Title 22 California Code of Regulations (CCR) section 70213(a)(3) & (4)Hospitals are not required to review and revise nursing service patient care policies and procedures, nor does the administration and governing body need to review and approve all nursing service-related policies and procedures.

7.   Title 22 CCR section 70435(b)(2): Hospital surgical teams do not need a minimum of three surgeons for the performance of all cardiovascular operative procedures requiring extracorporeal bypass. Hospitals implementing this waiver must provide a minimum of two surgeons to constitute this surgical team, one of whom must be certified or eligible for certification by the American Board of Thoracic Surgery or the American Board of Surgery with training and experience in cardiovascular surgery.

8.   Title 22 CCR section 70741(d): A hospital’s disaster plan does not need to be rehearsed at least twice a year, with a written report and evaluation of all drills.
9.   Title 22 CCR section 70751(g): The timeline for completion and authentication of medical records for discharged patients is extended from 2 weeks to within 30 days following the patient’s discharge for any patients discharged while this waiver is effective.

10. Title 22 CCR section 70213 and 70719: Hospitals are not required to complete annual written performance evaluations for all nursing staff and all other staff.

This waiver is valid until the lifting of the Hospital Surge Public Health Order.

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


Original signed by Heidi W. Steinecker

Heidi W. Steinecker
Deputy Director