Section 70954 - Determining the Initial Penalty for Each Violation(a) An initial penalty shall be determined for each deficiency, considering the nature, scope and severity of the deficiency by using the matrix set forth in subdivision (d).(b) Severity of the deficiency. (1) Severity of actual and potential harm to patients shall be considered when using the matrix. The categories for degree of severity based on actual or potential patient harm are defined as follows: Level 1-No actual patient harm but with potential for no more than minimal harm. Level 2-No actual patient harm but with potential for more than minimal patient harm, but no immediate jeopardy.
Level 3-Actual patient harm that is not immediate jeopardy.
Level 4-Immediate jeopardy to patient health or safety that is likely to cause serious injury or death.
Level 5-Immediate jeopardy to patient health or safety that caused serious injury to a patient.
Level 6-Immediate jeopardy to patient health or safety that caused the death of a patient.
(2) In determining the level of severity using the matrix in subdivision (d), the following factors shall be considered: (A) The patient's physical and mental condition.(B) The probability and severity of the risk that the violation presents to patients.(c) Scope of the noncompliance. (1) The scope of the noncompliance with hospital licensure requirements shall be considered using the matrix set forth in subsection (d).(2) The scope of the noncompliance shall be assessed as follows: (A) Isolated: (i) One or a very limited number of patients affected, or(ii) One or a very limited number of staff involved, or(iii) The situation occurred only occasionally, or(iv) The situation occurred in a very limited number of locations.(B) Pattern: (i) More than a very limited number of patients affected, or(ii) More than a very limited number of staff involved, or(iii) The situation occurred in several locations, or(iv) The same patient(s) had been affected by repeat occurrences.(C) Widespread: (i) Situation was pervasive throughout the hospital or(ii) The situation represented a systemic failure that affected or had the potential to affect a large portion or all of the hospital's patients.(d) The matrix set forth in this subdivision shall be used to determine the initial penalty for a deficiency by selecting a penalty percentage from the range provided in the matrix cell that corresponds to the appropriate scope of noncompliance and the severity of harm categories. The percentages in each cell of the following matrix shall be applied to the maximum administrative penalties as set forth in Health and Safety Code section 1280.3: (1) $25,000 for any deficiency that does not constitute an immediate jeopardy,(2) $75,000 for the first deficiency constituting an immediate jeopardy,(3) $100,000 for the second deficiency constituting an immediate jeopardy, and(4) $125,000 for the third deficiency and every subsequent deficiency constituting an immediate jeopardy. An immediate jeopardy penalty shall be considered a first administrative penalty if the date the violation occurred is over three years from the date of violation of the last issued immediate jeopardy penalty, the hospital has not received additional immediate jeopardy violations, and the department finds that the hospital has been in substantial compliance for over three years prior to the date of the violation that is the subject of the penalty calculation.
Scope and Severity Matrix
Click here to view image
Cal. Code Regs. Tit. 22, § 70954
1. New section filed 12-5-2013; operative 4-1-2014 (Register 2013, No. 49). Note: Authority cited: Sections 1280.3, 100275(a), 131050, 131051, 131052 and 131200, Health and Safety Code. Reference: Section 1280.3, Health and Safety Code.
1. New section filed 12-5-2013; operative 4-1-2014 (Register 2013, No. 49).