N.J. Admin. Code § 13:45E-3.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:45E-3.1 - Notification to the Clearing House Coordinator by a health care entity

(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.

N.J. Admin. Code § 13:45E-3.1