Skip Navigation LinksAFL-18-17

State of Cal Logo

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

AFL 18-17
March 30, 2018

Skilled Nursing Facilities

Posting Schedule for the 3.5 Direct Care Hours – Patient Acuity Waiver

AUTHORITY:     Health and Safety Code section 1276.65 (c)(2)

All Facilities Letter (AFL) Summary

This AFL notifies skilled nursing facilities (SNFs) of the California Department of Public Health’s (CDPH) patient acuity waiver posting schedule.

I. Overview

Effective July 1, 2018, all freestanding SNFs, excluding distinct parts of general acute care hospitals (GACHs), state-owned hospitals, or developmental centers, are required to increase staffing from the current 3.2 nursing hours per patient day requirement to 3.5 direct care service hours per patient day, with CNAs performing a minimum of 2.4 hours per patient day.


Health and Safety Code section 1276.65 (c)(2) requires CDPH to develop a waiver process for SNFs seeking a waiver of the 2.4 CNA requirement to address individual patient needs (patient acuity waiver). SNFs will submit waiver requests using the program flexibility procedures specified in Title 22 of the California Code of Regulations section 72213. CDPH will post a list of facilities that have applied for a patient acuity waiver on CDPH’s SB 97 Stakeholder website as specified:

  • For waivers received on or before September 1, 2018 no later than September 30, 2018.
  • For waivers received on or before April 1 each subsequent year no later than April 30.


CDPH will consider resident quality of care and the needs and acuity level of residents at the facility during the program flexibility request review. Following approval of the waiver application, CDPH will post a list of facilities with approved patient acuity waivers on CDPH’s SB 97 Stakeholder website as specified:

  • For waivers approved in 2018 no later than January 30, 2019.
  • For waivers approved in 2019 and thereafter no later than July 30 each year. 



Original signed by Jean Iacino

Jean Iacino
Deputy Director

Page Last Updated :