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§ 3999.141. Peer Review Formal Investigations.

15 CA ADC § 3999.141Barclays Official California Code of Regulations

Barclays California Code of Regulations
Title 15. Crime Prevention and Corrections
Division 3. Adult Institutions, Programs and Parole
Chapter 2. Rules and Regulations of Health Care Services
Subchapter 1. Health Care Governance and Administration
Article 4. Professional Workforce
15 CCR § 3999.141
§ 3999.141. Peer Review Formal Investigations.
Currentness
(a) Peer Review Formal Investigations are impartial fact-finding reviews into:
(1) Clinical practice concerns involving quality of care issues, including, but not limited to, patient care and decision-making and shall be conducted by a provider of the same discipline and to the extent possible the same licensure as the subject medical provider.
(2) Professional misconduct concerns including, but not limited to, disruptive conduct, behavior, or ethical issues and may be conducted by a clinical provider of the same discipline and licensure as the subject provider or by a non-clinical investigator. A non-clinical investigator shall not reach any conclusions or make any findings regarding issues involving clinical decision-making, patient care decision-making, or direct patient care issues which involve clinical decision-making.
(b) A Peer Review Formal Investigation shall be initiated when suspected substandard clinical practices or professional misconduct occurs which is likely to be detrimental to patient safety or the delivery of health care including, but not limited to, the following:
(1) Failure to perform required standards of care.
(2) Evidence of disruptive behavior or conduct.
(3) Unethical conduct.
(4) Failure to practice within known competencies.
(5) Failure to notify management or the Medical Peer Review Committee (MPRC) that substandard care is being provided by another individual or that circumstances exist in particular instances that may result in preventing access to care.
(c) Within five business days of the MPRC initiating a Peer Review Formal Investigation, written notification to the licensed medical provider shall be personally served or served by overnight mail to the last known address of the licensed medical provider with a Proof of Service and return receipt requested. The notification shall include copies of all documents relied upon by the MPRC in making the determination to initiate the Peer Review Formal Investigation.
(d) The Peer Review Formal Investigation may include, but is not limited to, the following:
(1) An examination of documents relating to the event in question.
(2) A review of the licensed medical provider's patient charts to assess either overall quality of clinical care, a more focused aspect of the quality of clinical care, or a combination of both as based on the clinical practice issue(s).
(3) Interview with the subject medical provider.
(A) The licensed medical provider may be interviewed.
(B) The licensed medical provider may be accompanied by a representative of their own choosing who shall not disrupt or interfere with the interview. The licensed medical provider or the investigator may end the interview at any time.
(C) The investigator and the licensed medical provider may record the interview.
(4) Interviews with staff possessing knowledge about the licensed medical provider's clinical performance or conduct issues.
(e) A copy of the investigation report shall be sent to the licensed medical provider at their last known home address by overnight mail with a return receipt requested. The investigation report shall contain the investigator's factual findings including all documents and evidence and explanations as to why the clinical performance deviates from or adheres to the applicable standard of care.
(f) The licensed medical provider shall have ten calendar days from service of the investigation report to submit a written rebuttal to the MPRC via the Professional Practice Evaluation Support Unit (PPESU) via email to [email protected]. In the absence of email availability, the written rebuttal shall be sent to CDCR/CCHCS, P.O. Box 588500, Elk Grove, CA, 95758, to the attention of PPESU, Bldg. E.
(g) The licensed medical provider shall be offered an opportunity to provide a response to the allegations outlined in the investigative report through a scheduled interview with the reviewer(s).
(1) The licensed medical provider may be accompanied by a representative of their own choosing who shall not disrupt or interfere with the interview. The licensed medical provider or the investigator may end the interview at any time.
(2) Both the investigator and the licensed medical provider may record the interview.
(h) The MPRC may take any of the following actions in response to the investigative report and the licensed medical provider's rebuttal, if any:
(1) Request additional information by a specified date.
(2) Take remedial action including, but not limited to, education, proctoring, performance monitoring, referral for physical or mental evaluation or treatment.
(3) Modify or restrict clinical privileges including, but not limited to, restricting privileges to prescribe particular medications or to perform particular procedures.
(4) Issue letters of admonition, censure, reprimand, or warning, although, nothing herein shall be deemed to preclude the licensed medical provider's direct supervisor from issuing informal written or oral warnings outside of the mechanism for corrective action, nor shall it preclude the hiring/contracting authority from taking adverse action.
(5) Take no action against the medical provider.
(6) Suspend privileges.
(7) Revoke privileges.
(i) If the MPRC recommends a privilege modification of any kind, the recommendation shall be in the form of a Final Proposed Action.

Credits

Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
History
1. New section filed 7-1-2019 as an emergency; operative 7-1-2019 (Register 2019, No. 27). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 12-9-2019 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-5-2019 as an emergency; operative 12-10-2019 (Register 2019, No. 49). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 3-9-2020 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 3-9-2020 as an emergency; operative 3-10-2020 (Register 2020, No. 11). A Certificate of Compliance must be transmitted to OAL by 6-8-2020 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-9-2020 order transmitted to OAL 6-8-2020 and filed 7-20-2020 (Register 2020, No. 30).
This database is current through 5/3/24 Register 2024, No. 18.
Cal. Admin. Code tit. 15, § 3999.141, 15 CA ADC § 3999.141
End of Document