FAQs: Staffing

How can a hospital get a waiver of nurse-staffing ratios?

The California Department of Public Health (CDPH) is now offering an expedited option for hospitals to flex the nurse staffing ratios. This process, which took effect immediately with the release of All-Facilities Letter 20-26.4, means hospitals can use certain alternative measures as soon as they submit the waiver request form.   

These alternative measures are that, for hospitals with patient surges or staffing shortages, the state will allow nurses to care for one additional patient in the ICU and in step-down units, and two additional patients in telemetry, ED, and med/surg units. As a result, this will flex nurse-to-patient ratios as follows: 

  • ICU — from 1:2 to 1:3 
  • Step-down units — from 1:3 to 1:4 
  • ED and telemetry — from 1:4 to 1:6 
  • Med/surg — from 1:5 to 1:7 

Hospitals that meet these criteria will be presumptively approved. CDPH will have 10 working days to ask the hospital any questions, largely for line of sight into surge activity, and these waivers will be in place for 60 days from the date of the request. 

This expedited process is an important addition to the current waiver process, in which hospitals individually submit ratio waivers for review and approval by CDPH surveyors. In many cases, this current waiver process has resulted in significant delays as hospitals wait for approval and does not provide the certainty hospitals need. 

Hospitals that need additional relief beyond the ratios or units of the hospital outlined in the expedited process can continue to submit waiver requests through the current process. CDPH will consider these on a case-by-case basis.  

For both the expedited process and the current process, a hospital seeking a waiver must submit CDPH form 5000A and supporting documentation to the CDPH Center for Health Care Quality (CHCQ) Duty Officer at [email protected] and copy the local CDPH District Office. (12/22)

Are there any resources available to help with hospitals’ nurse staffing shortages during the current surge?

Yes. CHA has compiled a quick-reference set of FAQs that address the expedited option for nurse staffing ratio flexes recently issued by CDPH; how to request a program flex for nursing documentation; samples of team nursing models currently in use by other hospitals; how to use nursing students to supplement care and for administering vaccines; and available critical care training specific to COVID-19 ICU patients. (1/11)

Some of my nurses’ certificates evidencing training in basic life support, advanced life support, cardiopulmonary resuscitation, pediatric advanced life support, electronic fetal monitoring, neonatal resuscitation, and similar skills are expiring. What do we do?

Neither the California Department of Public Health (CDPH) nor the Centers for Medicare & Medicaid Services (CMS_ requires certificates from specific organizations. Instead, they require “documented competency.” Many hospitals choose to require some of the certificates listed above to fulfill this requirement, but other ways to document competency are acceptable. Of course, a practitioner doesn’t lose competency simply because their certificate expired. The American Heart Association (AHA) and the American Academy of Pediatrics have recommended that regulatory bodies consider extending recognition of these certifications beyond their renewal dates for at least 60 days and perhaps longer depending on the pandemic. The Joint Commission (TJC) has agreed to do this.

On April 2, the AHA announced that its certificates remain valid for 120 days beyond their recommended expiration date. In addition, CMS, TJC and other survey agencies have reduced survey activity and are focusing on serious complaints and infection control issues. CHA believes that a hospital can utilize staff whose certificates may have expired recently without fear of penalties or sanctions. Hospitals should revise their written policies and procedures as needed. Also, please note that many training classes are available online. (1/4)

I’m a nursing student and have applied for a preceptorship at an area hospital, but the Board of Registered Nursing has not approved the hospital site. Can I still perform the preceptorship? 

Yes, as long as the hospital clinical setting gets approval from your school’s nursing education consultant. Additional details are available here. (7/2)

Do we know how hospitals can get staffing from Health Corps?

The California Department of Public Health (CDPH) has issued All Facilities Letter 20-46.2, which outlines the process for health care facilities experiencing an urgent staffing shortage to request staffing resources from the state. Health care facilities must report these as unusual occurrences to the CDPH Licensing and Certification District Office. CDPH, in collaboration with the local public health department, will assess the situation and determine whether the facility can continue to operate safely.

At the same time, the local public health department will contact the Medical Health Operational Area Coordinator to begin the process of locating resources within the local area, region, or state. State resources include the California Emergency Medical Services Authority’s California Medical Assistance Teams, the California Health Corps, or other staffing contracts. (4/22)

Our hospital employs nursing assistants who have not yet completed their certification training. Can we utilize them as certified nursing assistants during this state of emergency​?

Per guidance from CDPH, a nursing assistant enrolled in an approved certification training program may continue to be employed as long as they provide services only at the competency level confirmed by the training program on a competency checklist to be shared with the facility. (7/21)

I’ve been a nursing student in a hospital and I have not been able to complete the required clinical hours for my degree because the hospital has deemed us non-essential personnel. How can I finish the requirements for my degree?

The Department of Consumer Affairs has reduced the direct clinical patient care requirement for obstetrics, pediatrics, and mental health/psychiatric nursing from 75% to 50%. Special accommodations may be made for geriatric and medical/surgical hours, too. See the department’s waiver and talk to your nursing school. (7/2)

Our staff needs help with childcare. What resources are available?

The California Childcare Resource and Referral Center California Child Care Resource & Referral Network has created a document including available resources document of resources.

In addition, all levels of government are working on childcare solutions for health care workers. Currently, several resources are available. Read more (6/8)

Have physician credentialing and privileging requirements at hospitals been waived?

Yes. These were waived in Governor Newsom’s Executive Order N-39-20, dated March 30, 2020.  (9/22)

What are the rules around when a possibly exposed but asymptomatic health care worker can continue to work and when a symptomatic health care worker can return to work?

Health care workers who are asymptomatic but have been exposed to a known or suspected COVID-19-positive patient can continue to work during this period of emergency, subject to infection control precautions, according to the Governor’s Executive Order of March 15, 2020. The CDC has issued guidance based on the exposure risk. With respect to health care workers who have COVID-19 symptoms, whether they have been tested or not, CDC guidance provides two methods for determining when they can return to work. (4/9)

How can I get approval for out-of-state doctors, nurses, and other health care practitioners to work in California?

The state Emergency Medical Services Authority (EMSA) has a simple application form and instructions for facilities to complete to allow out-of-state licensed health care professionals to work in California. It is located at https://emsa.ca.gov/covid19/  under “Authorization of Out-of-State Medical Personnel.”  (4/9)

Are hospitals able to provide compensation or loans for physicians who are suffering from loss of income?

Under normal circumstances, a complex legal analysis must be undertaken to determine if, and how much, compensation can be provided by a hospital to a physician. During the pandemic, the Secretary of the U.S. Department of Health and Human Services has issued 18 blanket waivers of the federal physician self-referral law, making this issue somewhat less complicated. In addition, the Office of the Inspector General (OIG) announced it will exercise enforcement discretion not to impose penalties under the federal anti-kickback statute for payments related to eleven of the self-referral waivers. To use one of the other seven waivers, OIG suggests providers consult them beforehand.

However, hospitals should be aware that certain comparable provisions in state law have not been waived at this time. Under California’s similar statute, there is a broad exception for referrals to hospitals and other health facilities if the recipient of the referral does not compensate the physician for the referral. An equipment lease arrangement between the licensee and the referral recipient must meet certain requirements.  (see Business and Professions Code section 650 et seq.) CHA is advocating for a full waiver of state law, but in the meantime, hospitals should seek competent legal counsel before entering into an arrangement that involves compensating a physician.

To help financially struggling health care providers, the president signed the Coronavirus Aid, Relief, and Economic Security Act on March 27. This legislation includes $100 billion of federal funding to reimburse eligible health care providers for health care-related expenses or lost revenues not otherwise reimbursed that are directly attributable to COVID-19. Eligible providers include Medicare- or Medicaid-enrolled providers. In addition, physicians can sign up to work during the pandemic – with pay – at the California Health Corps website. (4/27)

Can a hospital provide telehealth services using out-of-state physicians who are not licensed in California?

Yes, during the COVID-19 emergency the state EMSA has set up a quick process for hospitals to be able to use health care practitioners and telehealth licensed providers from other states. For details, go to https://emsa.ca.gov/covid19/. (4/9)

Some doctors and nurses at my hospital have licenses that are about to lapse. However, they can’t renew them because they can’t take their needed continuing education class as a result of the pandemic. Can they continue to work?

Yes. The Department of Consumer Affairs (DCA), which oversees most health care professional licensing boards, has waived continuing education and exam requirements for certain professionals whose license expires between March 31 and October 31, 2020. This waiver applies to  physicians, nurses, pharmacists, mental health professionals, physician assistants, respiratory therapists, clinical lab scientists/bioanalysts, optometrists, dietitians, physical therapists, occupational therapists, speech-language pathologists, perfusionists, and other professionals licensed under Division 2 of the Business and Professions Code. However, this waiver does not apply to certified nursing assistants, paramedics, or emergency medical technicians; they are licensed/certified by other state agencies that have issued different waivers. See CDPH All Facilities Letter 20-35.1 for information about certified nursing assistants, and the Emergency Medical Services Administration’s website for information about paramedics and emergency medical technicians.

DCA licensees must still submit their required renewal form on time, and satisfy waived exam or continuing education requirements by April 1, 2021, unless an additional extension is issued. The health care professional licensing boards continue to process license renewals, although there are processing delays. (9/22)

Are there any accommodations for pharmacy staffing during the COVID-19 emergency?

The Board of Pharmacy previously authorized numerous waivers to accommodate pharmacy staffing issues due to COVID-19. Those waivers have expired, and the Board of Pharmacy encourages you to request an invidual waiver as described below.

How to Request a Pharmacy Law Waiver Related to COVID-19 Emergency

Gov. Gavin Newsom declared a statewide emergency March 4, 2020, to help the state prepare for the broader spread of COVID-19. Under the provisions of Business and Professions Code section 4062, the Board has authority to waive provisions of Pharmacy Law or regulations adopted pursuant to it if, in the Board’s opinion, the waiver will aid in the protection of public health or provision of patient care. Under the Board’s policy, such a determination may be made at the discretion of the Board President for a period of up to 30 days.

Licensees may submit a request for a waiver to [email protected]. (Note: This email address is for any type of waiver, not just compounding.) The request should include the following information:

  • License number(s)
  • A brief statement regarding the extent of the waiver requested
  • A brief statement detailing how the declared emergency caused the need for the waiver
  • Relevant laws that the licensee is requesting be waived
  • Authorized contact person – any owner, officer, member, pharmacist-in-charge, or other individual otherwise authorized to act on behalf of the licensee
  • Board staff will respond to the authorized contact via email  (7/21)

I’ve heard that licensed health care professionals, medical retirees, and medical and nursing students are being encouraged to join a new Health Corps in California. How can I sign up for this and contribute through my professional experience?

Interested medical and health care professionals are encouraged to visit healthcorps.ca.gov for more information and to register for the California Health Corps. Medical doctors, nurses, respiratory therapists, behavioral health scientists, pharmacists, emergency medical technicians, medical and administrative assistants, and certified nursing assistants are encouraged to help California respond to the outbreak. (4/9)