CHA News

CDPH Issues Clarification on Nurse Ratios

This post has been archived and contains information that may be out of date.

The California Department of Public Health (CDPH) recently released an All-Facilities Letter (AFL) on the nurse ratio regulations. In addition to restating the administrative penalties for non-compliance, AFL 23-27 clarifies what constitutes an “unpredictable” and “uncontrollable” situation affecting staffing levels which would excuse non-compliance.  

For example, CDPH will not consider staff callouts during flu season to be unpredictable and uncontrollable, unless those callouts are truly at an unprecedented level.

As a reminder, the ratio penalty statute states the following:  

A general acute care hospital shall not be subject to an administrative penalty if the hospital demonstrates to the satisfaction of [CDPH] all the following:   

  • Any fluctuation in required staffing levels was unpredictable and uncontrollable.  
  • Prompt efforts were made to maintain required staffing levels.  
  • In making those efforts, the hospital immediately used and subsequently exhausted the hospital’s on-call list of nurses and the charge nurse. 

CHA believes that, by releasing this letter, CDPH intends to signal stronger enforcement of the ratio requirements soon. CHA recommends the following: 

  • Hospitals should review the regulations and their written policies related to nurse staffing and confirm that actual practice aligns with both. 
  • Hospitals should document callout levels and all efforts made to maintain staffing levels. 

If you have any questions, please contact Trina Gonzalez, Vice President, Policy, at or Lois Richardson, Vice President & Legal Counsel, at