California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 4 - Certification Standards for Health Care Organizations
Section 9771.76 - Medical Survey Procedure
Universal Citation: 8 CA Code of Regs 9771.76
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Unless the Administrative Director in his discretion determines that advance notice will render the survey less useful, an organization will be notified approximately four weeks in advance of the date for commencement of an onsite medical survey. The Administrative Director may, without prior notice, conduct inspections of organization facilities or other elements of a medical survey, either in conjunction with the medical survey or as part of an unannounced inspection program.
(b) The onsite medical survey of an organization shall include, but not be limited to, the following procedures to the extent considered necessary based upon prior experience with the organization and in accordance with the procedures and standards developed by the Administrative Director.
(1) Review of
the procedures for obtaining workers' compensation health care including, but
not limited to, the scope of health care.
(A)
The availability and adequacy of facilities for telephone communication with
health personnel, emergency health care facilities, out-of-the-area coverage,
referral procedures, and medical encounters.
(B) The means of advising employees of the
procedures to obtain health care, including the hours of operation, location
and nature of facilities, types of health care, telephone and other
arrangements for appointment setting.
(C) The availability of qualified personnel
at each facility referred to in Section 4600.6(j) of the Code to receive and
handle inquiries concerning health care and grievances.
(2) Review of the design and implementation
of procedures for reviewing and regulating utilization of health care and
facilities.
(3) Review of the
design and implementation of procedures to review and control costs.
(4) Review of the design, implementation and
effectiveness of the internal quality of care review systems, including review
of medical records and medical records systems. A review of medical records and
medical records systems may include, but is not limited to, determining
whether:
(A) The entries establish the
diagnosis stated, including an appropriate history and physical
findings;
(B) The therapies noted
reflect an awareness of current therapies;
(C) The important diagnoses are summarized or
highlighted; (Important are those conditions that have a bearing on future
clinical management.)
(D) Drug
allergies and idiosyncratic medical problems are conspicuously noted;
(E) Pathology, laboratory and other reports
are recorded;
(F) The health
professional responsible for each entry is identifiable;
(G) Any necessary consultation and progress
notes are evidenced as indicated;
(H) The maintenance of an appropriate system
for coordination and availability of the medical records of the employee,
including out-patient, in-patient and referral services and significant
telephone consultations.
(5) Review of the overall performance of the
organization in providing workers' compensation health care, by consideration
of the following:
(A) The numbers and
qualifications of health professional and other personnel;
(B) The provision of, incentives for, and
participation in, continuing education for health personnel and the provision
for access to current medical literature;
(C) The adequacy of all physical facilities,
including lighting, cleanliness, maintenance, equipment, furnishings, and
convenience to employees, organization personnel and visitors;
(D) The practice of health professionals and
allied personnel in a functionally integrated manner, including the extent of
shared responsibility for patient care and coordinated use of equipment,
medical records and other facilities and services;
(E) The appropriate functioning of health
professionals and other health personnel, including specialists, consultants
and referrals;
(F) Nursing
practices, including reasonable supervision;
(G) Written nondiscriminatory personnel
practices which attract and retain qualified health professionals and other
personnel;
(H) The adequacy and
utilization of pathology and other laboratory facilities, including the
quality, efficiency and appropriateness of laboratory procedures and records
and quality control procedures;
(I)
X-ray and radiological services, including staffing, utilization, equipment,
and the promptness of interpretation of X-ray films by a qualified
provider;
(J) The handling and
adequacy of medical record systems, including filing procedures, provisions for
maintenance of confidentiality, the efficiency of procedures for retrieval and
transmittal, and the utilization of sampling techniques for medical records
audits and quality of care review;
(K) The adequacy, including convenience and
readiness of availability to employees, of all provided health care;
(L) How the organization is organized and its
mechanisms for furnishing workers' compensation health care, including the
supervision of health professionals and other personnel;
(M) The extent to which individual medical
decisions by qualified medical personnel are unduly constrained by fiscal or
administrative personnel, policies or considerations;
(N) The adequacy of staffing, including
medical specialties.
(6)
Review of the overall performance of the organization in meeting the health
needs of employees.
(A) Accessibility of
facilities and workers' compensation health care, based upon location of
facilities, hours of operation, waiting periods for health care and
appointments, the availability of parking and transportation;
(B) Continuity of health care, including the
ability of employees to select a primary treating physician, staffing in
medical specialties or arrangements therefor; the referral system (including
instructions, monitoring and follow-up); the maintenance and ready availability
of medical records; and the availability of health care education to
employees;
(C) The grievance
procedure required by Section 4600.6(j) of the Code, including the availability
to employees of grievance procedure information, the time required for and the
adequacy of the response to grievances and the utilization of grievance
information by the organization's management.
(7) In considering the above and in pursuit
of the survey objectives, the survey team may perform any or all of the
following procedures:
(A) Private interviews
and group conferences with employees, physicians and other health care
professionals and providers, and members of its administrative staff including,
but not limited to, persons in principal management positions.
(B) Examination of any records, books,
reports and papers of the organization and of any management company, provider
or subcontractor providing workers' compensation health care or other services
to the organization including, but not limited to, the minutes of medical staff
meetings, peer review, and quality of care review records, duty rosters of
medical personnel, surgical logs, appointment records, the written procedures
for the internal operation of the organization, and contracts and
correspondence with employees and with providers of workers' compensation
health care and of other services to the organization, and such additional
documentation the Administrative Director may specifically direct the surveyors
to examine.
(C) Physical
examination of facilities, including equipment.
(D) Investigation of grievances or complaints
from employees, or from the general public.
1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346 Section 5 (Register 98, No. 16).
Note: Authority cited: Stats. 1997, Ch. 346 Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
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