Current through Register Vol. 56, No. 18, September 16, 2024
(a) Except as
provided in (c) below, a health care entity shall file a report with the
Clearing House Coordinator concerning a health care professional who is
employed by, under contract to render professional services to, or has clinical
privileges granted by that health care entity, or who provides such services
pursuant to an agreement with a health care services firm or staffing registry
if:
1. For reasons relating to the health
care professional's impairment, incompetency or professional misconduct, which
incompetency or professional misconduct relates adversely to patient care or
safety, the health care entity:
i. Summarily
or temporarily revokes or suspends or permanently reduces, suspends or revokes
the health care professional's full or partial clinical privileges or
practice;
ii. Removes the health
care professional from the list of eligible employees of a health services firm
or staffing registry;
iii.
Discharges the health care professional from the staff of the health care
entity; or
iv. Terminates or
rescinds a contract with the health care professional to render professional
services;
2. The health
care entity places conditions or limitations on the health care professional's
exercise of clinical privileges or practice within the health care entity for
reasons relating to the health care professional's impairment, incompetency or
professional misconduct, which incompetency or professional misconduct relates
adversely to patient care or safety, including, but not limited to, second
opinion requirements, non-routine concurrent or retrospective review of
admissions or care specifically tailored after a preliminary review of care,
non-routine supervision by one or more members of the staff, or the completion
of remedial education or training;
3. The health care professional voluntarily
resigns from the staff if:
i. Whether or not
known to the health care professional, the health care entity is undertaking an
investigation or a review of:
(1) The quality
of patient care rendered by the health care professional to determine if the
care could have had adverse consequences to the patient;
(2) Conduct by the health care professional
that demonstrates an impairment;
(3) Conduct by the health care professional
that demonstrates incompetence that relates adversely to patient care or
safety; or
(4) Unprofessional
conduct by the health care professional that relates adversely to patient care
or safety; or
ii. A body
within the health care entity that has the authority to initiate an
investigation that may lead to disciplinary action, has expressed an intention
through any member of the medical or administrative staff, reflected in the
records of the health care entity or expressed directly to the health care
professional, to conduct such a review of the health care professional's
patient care or conduct and the healthcare entity notifies the health care
professional that the health care entity is conducting or intends to conduct
the review or investigation.
4. The health care professional voluntarily
relinquishes any partial clinical privilege or authorization to perform a
specific procedure if:
i. Whether or not known
to the health care professional, the health care entity is undertaking an
investigation or a review of:
(1) The quality
of patient care rendered by the health care professional to determine if the
care could have had adverse consequences to the patient;
(2) Conduct by the health care professional
that demonstrates an impairment;
(3) Conduct by the health care professional
that demonstrates incompetence that relates adversely to patient care or
safety; or
(4) Unprofessional
conduct by the health care professional that relates adversely to patient care
or safety; or
ii. A body
within the health care entity that has the authority to initiate an
investigation that may lead to disciplinary action has expressed an intention,
through any member of the medical or administrative staff, reflected in the
records of the health care entity or expressed directly to the health care
professional, to conduct such a review of the health care professional's
patient care or conduct and the healthcare entity notifies the health care
professional that the health care entity is conducting or intends to conduct
the review or investigation.
5. The health care entity grants a leave of
absence to the health care professional for reasons relating to a physical,
mental or emotional condition or drug or alcohol use which impairs the health
care professional's ability to practice with reasonable skill and safety while
the health care professional is under, or subsequent to, a review by the health
care entity of the health care professional's patient care or professional
conduct, except that no report is required for pregnancy-related leaves of
absence; or
6. The health care
professional is a party to a medical malpractice liability suit, to which the
health care entity is also a party, and in which there is a settlement,
judgment or arbitration award.
(b) The initiation of an investigation under
(a)3i or 4i above shall have been reflected contemporaneously in the records of
the health care entity.
(c) A
health care entity is not obligated to file a report under (a)5 above if the
health care professional is participating, or agrees to participate, in an
intervention program approved by the Division or the relevant licensing board
and agrees to follow, and then does follow the treatment regimen or monitoring
required by the program.
1. The health care
entity shall confirm with the intervention program that the health care
professional has agreed to participate and is participating in the program and
has agreed to follow and continues to follow the treatment regimen or
monitoring required by the program.
2. The health care entity shall notify the
health care professional that the health care entity would have filed a report
under (a)5 above but for the health care professional's participation in, and
compliance with the treatment regimen or monitoring required by, an approved
intervention program.
3. The health
care entity shall file the report under (a)5 above within seven days after
obtaining knowledge that the health care professional is not in compliance with
the requirements of the program.
(d) When a health care entity is required to
notify the Clearing House Coordinator under (a)1, 2 or 5 above about a health
care professional who has exhibited conduct relating adversely to patient care
or safety, the action to be reported to the Clearing House Coordinator is
action taken by the health care entity that limits, curtails or prevents a
health care professional from performing the full scope of his or her duties or
places conditions on that performance.
(e) A health care entity shall file an
additional report if the entity's due process review or the passage of time
results in the health care entity taking other action that results in the full
or partial restoration of the duties that had been limited, curtailed or
prevented, or further limits, curtails or prevents a health care professional
from performing the full scope of his or her duties.
(f) A health care entity shall file a report
with the Clearing House Coordinator pursuant to this section if the action
taken by the health care entity is to require the health care professional to
undergo remedial education or training.
(g) A report required by this section shall
be filed with the Clearing House Coordinator within seven calendar days of:
1. The date action under (a)1, 2 or 5 or (e)
above was taken by the health care entity;
2. The entry of a final order or judgment on
an arbitration award; settlement by the parties in a litigated matter either by
stipulation of the parties or the entry of a final order to dismiss; or entry
of a final judgment or order on a motion under (a)6 above; or
3. The date the health care professional
voluntarily resigns under the conditions provided in (a)3 above or voluntarily
relinquishes any partial privilege or authorization to perform a specific
procedure under the conditions provided in (a)4 above.
