Dear Chief Executive Officer Letter: 2012 submission of the Community Service Plan (CSP), February 22, 2012

February 22, 2012


Dear Chief Executive Officer:

This letter is written to inform you of the Department of Health (Department)'s expectations with respect to the 2012 submission of the Community Service Plan (CSP). This guidance is being issued in conjunction with development of the new state health improvement plan. The direction will incorporate components from the new plan that updates the Prevention Agenda toward the Healthiest State and will include the new federal requirements for collaborative community health needs assessments (CHNA) and planning contained in the Affordable Care Act (ACA) and Section 501(r)(3) of the Internal Revenue Code ("Code").

By September 15, 2012, hospitals must submit a one-year update to their CSP. In September of 2013, a hospital's comprehensive plan should be submitted. Submission of the comprehensive plan in 2013, will facilitate the collaborative planning process and align the Department's established process with the new community benefit reporting requirement established by the ACA and the Code. These new requirements, like our current CSP process, require nonprofit hospitals to work with community partners to determine community health needs and adopt strategies to address those needs on a three-year cycle.

CSP Reports: 2012 Update and 2013 Comprehensive Plan

It is our understanding that the new federal reporting requirement will affect the majority of hospitals in 2013. For those hospitals that must comply with the Code and report to the Treasury/IRS in 2012, the Department will accept your comprehensive plan in 2013. Your 2012 CSP Update must indicate that you will submit a comprehensive plan in 2013.

For those hospitals that must comply with the Code and report to the Treasury/IRS in 2013, you must submit a 2012 CSP Update and a 2013 comprehensive plan to the Department.

As with last year's submission, hospitals will submit the CSP online.

Prevention Agenda

To assist hospitals in their planning efforts, the Department directs your attention to the Prevention agenda webpage at the following link: From this page, you will find links to data and best practice strategies specific to each Prevention Agenda priority. The data is routinely updated and supplemental information, such as examples of high quality CSPs, will be added to the page soon. The Department encourages hospitals to articulate four components: (1) a quantifiable and time-limited purpose statement aligned with defined priorities; (2) specific, measurable goals and/or objectives using process and impact measures that are monitored; (3) use of best practice and/or evidence-based strategies that will bring about improvement; and (4) brief explanation of the process for conducting the assessment and the specific role of community partners in the process.

Details regarding the content and logistics of the CSP submission will be distributed in a separate letter in the near future.

Please contact Charles Bonsu of the Division of Certification and Surveillance at 518-402-1003, or via e-mail at with questions.


Mary Ellen Hennessy Director
Division of Certification & Surveillance