Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

§9771.76 Medical Survey Procedure.

(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.

NOTE

Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.

HISTORY

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).