How to Fill Out the NHPPD Form (CDPH 612): Census, Hours, and DHPPD

California skilled nursing facilities use the CDPH 612 form to document, one patient day at a time, how many direct care hours their nursing staff actually delivered against the day’s census. Its full title is Census and Direct Care Service Hours Per Patient Day. Facilities complete it daily, keep it on-site, and produce it on demand when a California Department of Public Health auditor arrives unannounced and asks for records covering any date within the previous 90 days.

Which Facilities Have to Complete It

The form is built for freestanding skilled nursing facilities licensed under subdivision (c) of Health and Safety Code Section 1250. Those SNFs are subject to the 3.5 direct care service hours per patient day standard in Health and Safety Code Section 1276.65, and the CDPH 612 is how they prove it.¹

Two SNF types fall outside the 3.5-hour rule and instead follow the older 3.2-hour minimum in Section 1276.5: skilled nursing units that are a distinct part of a general acute care hospital, and those inside state-owned hospitals or developmental centers.² Intermediate care facilities for people with developmental disabilities have their own staffing ratios; because the CDPH 612 is designed around the SNF audit framework, an ICF/DD should confirm with its regional CDPH office whether to use this form or a facility-specific alternative.

What the Numbers on the Form Have to Show

Every calculation on CDPH 612 exists to test two floors set by Section 1276.65, effective July 1, 2018:

At least 3.5 total direct care service hours per patient day, across all direct caregiver categories combined.¹
At least 2.4 of those hours provided by certified nurse assistants.¹

These are minimums. The statute requires facilities to schedule additional staff whenever individual resident needs demand it.¹

Who Counts as a Direct Caregiver

Section 1276.65 defines a direct caregiver as a registered nurse, licensed vocational nurse, psychiatric technician, certified nurse assistant, or a nursing assistant in an approved training program — and only while that person is actually performing nursing services.¹ Food service, housekeeping, laundry, and maintenance staff never count, even when they help with a resident.

A Director of Nursing who provides bedside care can count, but only for the hours spent in direct clinical work. Same for corporate nursing staff on-site. Those split-role and off-payroll hours belong on the companion form, CDPH 530 (the Nursing Staffing Assignment and Sign-In Sheet), which captures direct care time for salaried employees, registry workers, contract staff, and anyone whose hours don’t show up in normal payroll.³

Filling Out CDPH 612 Section by Section

The current form is a fillable PDF in the CDPH controlled forms library, and it references All Facilities Letter 19-16 for the definitions of DHPPD, census, direct caregiver, and direct care service hours.⁴ Use the current version so that the auto-calculation fields align with the auditing software.⁵ The form has nine sections.

Sections 1–5: Facility Identification

Section 1, Date: the patient day in MM/DD/YY format. One form covers one 24-hour patient day.
Section 2, Licensed beds: total licensed skilled nursing beds.
Section 3, Patient day start time: entered as HH:MM AM/PM. The patient day begins at midnight (12:00 AM) and runs 24 hours.⁴
Section 4, License number: the facility’s CDPH license number.
Section 5, Facility name: the full legal name as it appears on the license.

Section 6: Scheduled Hours and Beginning Census

This section captures what you planned before the day started. Enter the total direct care service hours scheduled for the full patient day and the beginning patient census at midnight. The form divides scheduled hours by beginning census to produce scheduled DHPPD. Enter scheduled CNA direct care hours separately; the form calculates scheduled CNA DHPPD the same way.⁴

Section 7: Census Tracking Through the Day

Record the beginning census at three points: midnight (12:00 AM), 8:00 AM, and 4:00 PM. Within each eight-hour period, log every admission, discharge, transfer, death, and other census change. The form calculates each period’s ending census automatically and carries it forward as the next period’s beginning census.⁴ Count all patients receiving nursing services who are physically present in the facility during the patient day.

Section 8: Actual Hours and Final DHPPD

After the 24-hour day closes, enter the actual total direct care service hours worked by all direct caregivers, and the actual total CNA hours separately. The form averages the three period beginning censuses (midnight, 8 AM, 4 PM) by adding them and dividing by three, then computes:⁴

Actual DHPPD: actual total direct care hours ÷ average patient census.
Actual CNA DHPPD: actual CNA direct care hours ÷ average patient census.

The actual figures are what compliance turns on, not the scheduled ones. If a CNA called out or a nurse left mid-shift, the actual hours have to reflect the reduced time.

Section 9: Director of Nursing Signature

At the end of each patient day, the Director of Nursing or a designee reviews the completed form and signs it, attesting that the information is complete, true, and correct.⁴ Auditors check that signature early.

Records You Have to Keep With the Form

The CDPH 612 does not stand alone. AFL 19-16 requires the facility to produce every requested document at the time of the audit; if the backup for an audited day is missing, CDPH issues a finding of non-compliance regardless of what your staffing actually was.⁵

Expect to hand over:

The completed CDPH 612 for each audited day.
CDPH 530, the nursing staffing assignment and sign-in sheet for salaried, dual-role, registry, contract, and corporate staff outside standard payroll.
Individual timecards, payroll reports, and nursing payroll codes for all direct caregivers.
Signed registry and contract invoices with staff-level detail.
Admission, discharge, transfer, death, bed-hold, and absent-patient records supporting the census figures.
A complete roster of direct caregivers, with a separate list of anyone not appearing in facility payroll or timecards.
The facility license and any program flex or waiver documentation approving admissions beyond licensed bed capacity.⁶

What the Auditor Does With the Form

CDPH conducts unannounced on-site staffing audits at all open, active, freestanding SNFs. The auditor arrives without notice, asks for a lockable room with power and table space, holds an entrance conference with the administrator or designee, then picks specific dates from the prior 90 days and requests the documentation for those days.⁶

Auditors enter the data into a DHPPD database and independently calculate the daily DHPPD for each selected date, comparing their figures against your CDPH 612s and cross-checking timecards, payroll, and sign-in sheets. Their calculation mirrors the form: total actual nursing hours by direct caregivers divided by the average census for the patient day.⁶

The mismatches auditors flag most often involve hours that shouldn’t count as direct care: administrative meetings, orientation of new hires, in-service training. If a registry nurse’s invoice shows eight hours but the sign-in sheet shows six, that discrepancy pulls the whole audit period into closer scrutiny.

Penalties If the Numbers Don’t Meet the Standard

Administrative penalties under Health and Safety Code Section 1276.66 scale with how many audited days fell below the DHPPD minimum:

$25,000 if the facility misses the DHPPD requirements on 5 percent or more of audited days, up to 49 percent.⁷
$50,000 if the facility misses on 49 percent or more of audited days.⁷

A separate Medi-Cal framework under Welfare and Institutions Code Section 14126.022 imposes $15,000 for 5–49 percent non-compliant days and $30,000 for 49 percent or more.⁶ Medi-Cal facilities can face penalties under both. Beyond fines, CDPH issues formal citations that appear on the facility’s public record through Cal Health Find, and repeat or severe findings can shorten the interval to the next audit and weigh on license renewal.

Related Requirements the CDPH 612 Does Not Replace

California regulations also require SNFs to post patient census and staffing information daily where residents and visitors can see it. The posting must show the actual number of licensed and certified nursing staff responsible for patient care each shift, and must specify each room and bed assignment for every CNA along with each licensed nurse’s assignment.⁸ The CDPH 612 is internal audit documentation; the daily posting is public. If the two tell different stories, auditors will see it.

Facilities that participate in Medicare or Medicaid also file federal Payroll-Based Journal data quarterly to CMS, due 45 calendar days after the end of each fiscal quarter (for example, January–March data by May 15).⁹ PBJ and CDPH 612 track overlapping but different data: PBJ covers all staff categories from payroll records, while CDPH 612 focuses on direct caregiver hours against census for the state DHPPD standard. Clean, consistent payroll, timecards, and assignment sheets feed both.

1
California Legislative Information. California Health and Safety Code 1276.65
2
Legal Information Institute. California Code of Regulations Title 22 Section 72329.2 – Nursing Service – Staff
3
California Department of Public Health. Nursing Staffing Assignment and Sign-In Sheet
4
California Department of Public Health. Census and Direct Care Service Hours Per Patient Day
5
California Department of Public Health. Guidelines for 3.5 Direct Care Service Hours Per Patient Day Staffing Audits
6
California Department of Public Health. AFL 18-27
7
California Legislative Information. California Code Health and Safety Code HSC 1276.66
8
Cornell Law School. California Code of Regulations Title 22 Section 72329.1 – Nursing Service – Staff
9
Centers for Medicare & Medicaid Services. Staffing Data Submission Payroll Based Journal (PBJ)