(b) The patient safety plan required pursuant to subdivision (a) shall, at a minimum, provide for the establishment of all of the following:

1. (1) A patient safety committee or equivalent committee in composition and function. The committee shall be composed of the facility’s various health care professionals, including, but not limited to, physicians, nurses, pharmacists, and administrators. The committee shall do all of the following:

   1. (A) Review and approve the patient safety plan.
   2. (B) Receive and review reports of patient safety events as defined in subdivision (c).
   3. (C) Monitor implementation of corrective actions for patient safety events.
   4. (D) Make recommendations to eliminate future patient safety events.
   5. (E) Review and revise the patient safety plan, at least once a year, but more often if necessary, to evaluate and update the plan and to incorporate advancements in patient safety practices.
2. (2) A reporting system for patient safety events that allows anyone involved, including, but not limited to, health care practitioners, facility employees, patients, and visitors, to make a report of a patient safety event to the health facility, including anonymous reporting options.

3. (3) A process for a team of facility staff to conduct analyses, including, but not limited to, root cause analyses of patient safety events. The team shall be composed of the facility’s various categories of health care professionals with the appropriate competencies to conduct the required analyses. The process shall also include analyses of patient safety events, including the following sociodemographic factors, to identify disparities in these events:

   1. (A) Age.
   2. (B) Race.
   3. (C) Ethnicity.
   4. (D) Gender identity.
   5. (E) Sexual orientation.
   6. (F) Preferred language spoken.
   7. (G) Disability status.
   8. (H) Payor.
   9. (I) Sex.
4. (4) For the purposes of paragraph (3), it is the intent of the Legislature that a health facility use the same stratification categories as developed and defined by the Department of Health Care Access and Information for purposes of Section 127372, which is part of the Medical Equity Disclosure Act (Article 3 (commencing with Section 127370) of Chapter 2 of Part 2 of Division 107). With respect to the information set forth in subparagraphs (D) and (E) of paragraph (3), a health facility shall only be required to disclose information that is voluntarily provided by the patient or client.
5. (5) A reporting process that supports and encourages a culture of safety and reporting patient safety events.
6. (6) A process for providing ongoing patient safety training for facility personnel and health care practitioners.

7. (7) A process for addressing racism and discrimination, and their impact on patient health and safety, that includes, but is not limited to:

   1. (A) Monitoring sociodemographic disparities in patient safety events and developing interventions to remedy known disparities.
   2. (B) Encouraging facility staff to report suspected instances of racism and discrimination.

(c) Commencing January 1, 2026, and biennially thereafter, a health facility shall submit a patient safety plan to the department’s licensing and certification division.

1. (1) The department may impose a fine not to exceed five thousand dollars ($5,000) on a health facility for failure to adopt, update, or submit a patient safety plan.
2. (2) The department may grant a health facility an automatic 60-day extension for submitting a biennial patient safety plan.