​The purpose of this All Facilities Letter (AFL) is to serve as a reminder of Health and Safety Code requirements regarding the transmittal of Joint Commission survey reports to the California Department of Public Health (CDPH).

Health and Safety Code Section 1282(b) states:

"If, pursuant to this section, the state department contracts with the Joint Commission on Accreditation of Hospitals to perform all or any part of a quality of care inspection for a health facility specified in subdivision (a) of Section 1250, and if that health facility contracts with the Joint Commission on Accreditation of Hospitals to perform an accreditation inspection and survey at the same time as the quality of care inspection, the health facility shall transmit to the state department, within 30 days of receipt, a copy of the final accreditation report of the Joint Commission on the Accreditation of Hospitals. However, if the Joint Commission on Accreditation of Hospitals conducts an accreditation inspection and survey at a health facility at a time other than the time at which, pursuant to this section, it participates in a quality of care inspection at that facility, then the health facility shall not be required to transmit a copy of the final accreditation report to the state department."

General Acute Care Hospitals (GACHs) undergoing a Joint Commission (formerly known as the Joint Commission on Accreditation of Hospitals) accreditation inspection and survey at the same time as CDPH is conducting its quality of care survey must transmit a copy of the final Joint Commission accreditation report to their local CDPH Licensing and Certification District Office within 30 days of receiving the report.

If the accreditation inspection and survey is conducted at a different time than a CDPH quality of care inspection, the GACH is not required to submit a copy of the final Joint Commission accreditation report to the local CDPH Licensing and Certification District Office.

If you have questions regarding this issue, please contact your local Licensing and Certification District Office.

Sincerely,

Original Signed by Pamela Dickfoss

Pamela Dickfoss
Acting Deputy Director