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

AFL 18-05
January 5, 2018

All Deemed General Acute Care Hospitals,
Home Health Agencies,
Ambulatory Surgical Centers,
and Hospices

Referrals to Accreditation Organizations (AO)
Supersedes AFL 17-11

All Facilities Letter (AFL) Summary

This AFL supersedes AFL 17-11, to clarify the district office (DO) will not refer an entity reported incident (ERI) directly to the AO; the DO will instead direct the entity to contact the AO directly.

AFL 17-11 notified entities that effective August 1, 2017, the California Department of Public Health’s (CDPH) Licensing and Certification Program began referring low and medium non-immediate jeopardy ERIs from deemed non-long term care facilities to AOs for investigation.

CDPH is revising its process to align with the current guidance located in the Centers for Medicare and Medicaid Services’ State Operations Manual (SOM), Chapter 5, sections 5073.3 and 5073.4 available at:

CMS: SOM Chapter 5 - Complaint Process

Entities should continue to report ERIs to their DO for triage and prioritization. If the DO determines that the ERI is eligible for AO referral, the DO will instruct the entity to contact the applicable AO.

If you have any questions regarding the content of this AFL, please contact your respective L&C district office.



Original signed by Jean Iacino

Jean Iacino
Deputy Director

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