click here to download MS Word format

UNIVERSITY POLICY 

To facilitate compliance with the State of New Jersey Health Care Professional Responsibility and Reporting Enhancement Act, also known as Chapter 83.

II.       ACCOUNTABILITY

Under the direction of the President, the Executive Vice President for Academic and Clinical Affairs, Senior Vice President for Administration and the Vice President for Legal Management shall ensure compliance withthis policy. The Vice President for Human Resources, Deans, and the Presidents/CEOs of the Healthcare Units utilizing healthcare professionals shall implement this policy.

III.      APPLICABILITY

This policy shall apply to those units that employ healthcare professionals or retain healthcare professionals through a healthcare services firm or staffing registry; and all healthcare professionals, paid or volunteer.

IV.      DEFINITIONS

A.       Healthcare Entity: A healthcare facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.); a health maintenance organization authorized to operate pursuant to P.L. 1073, c.337 (C.26:2J-1 et seq.); a carrier which offers a managed care plan regulated pursuant to P.L.1997, c.192 (C.26:2S-1 et seq.); a state or county psychiatric hospital; a state developmental center; a staffing registry; and, a home care services agency as defined in section 1 of P.L.1947, c.262 (C.45:11-23). The following University healthcare units meet the definition of “healthcare entity:”

• University Hospital
• University Behavioral HealthCare
• Eric B. Chandler Health Center

B.      Healthcare Professionals: Individuals, whether paid or unpaid, licensed or authorized to practice a healthcare profession regulated by the Division of Consumer Affairs and other professional and occupational licensing boards including physicians, podiatrists, nurses, pharmacists, physical, occupational and respiratory therapists, nurses aides and personal assistants, psychologists, psychoanalysts, social workers, speech and language pathologists, optometrists, opticians, dentists, orthotics and prosthetic providers, marriage and family therapists, veterinarians and chiropractors, ophthalmic dispensers and ophthalmic technicians, audiologists, and acupuncturists.

C.      Job performance: Suitability of the employee for re-employment at a healthcare entity as well as the employee’s skills and abilities related to future employment at a healthcare entity.

D.     Incompetence, professional misconduct and unprofessional conduct: In determining whether a University healthcare entity must notify the Division of Consumer Affairs, these terms shall not include personal conduct, such as tardiness, insubordination or other similar behavior, which does not relate to patient care or safety.

V.       REFERENCES

A.       Excluded Individuals and Entities         00-01-10-08:00

B.       State of New Jersey, P.L. 2005, c.083, S-1804 1R

C.       NJSA 26: 2H-12.2

D.       NJSA 45: 1-28 through NJSA 45: 1-41

E.       NJSA 45: 9-19.9 through NJSA 45: 9-19.11

VI.     POLICY

Those University Units that employ healthcare professionals or retain healthcare professionals through a healthcare services firm or staffing registry, shall implement procedures, including designating those individuals responsible for receiving the notifications and providing information to others as required by this policy, to ensure compliance with the provisions of the State of New Jersey Health Care Professional Responsibility and Reporting Enhancement Act.

A.       Notification Requirements

1.       Healthcare Entities

a.       The healthcare entities of the University shall notify the Division of Consumer Affairs (DCA) in writing if a healthcare professional who is either employed by, under contract to render professional services to, or has privileges granted by the healthcare entity, or who provides such services pursuant to an agreement with a healthcare services firm or staffing registry, and for reasons relating to impairment, incompetency, or professional misconduct, which relates adversely to patient care or safety, has one of the following events occur:

• Has full or partial privileges summarily or temporarily revoked or suspended, or permanently reduced, suspended or revoked;
• Has been removed from the list of eligible employees of a health services firm or staffing agency;
• Has been discharged from the staff;
• Has had a contract to render professional services terminated or rescinded;
• Has conditions or limitations placed on the exercise of clinical privileges or practice within the healthcare entity to include, but not limited to, second opinion requirements, non-routine concurrent or retrospective review of admissions or care, non-routine supervision by one or more members of the staff, or the completion of remedial education or training;
• Voluntarily resigns from staff if the healthcare entity is reviewing the healthcare professional’s conduct or the healthcare entity, through any member of the medical; or administrative staff, has expressed an intention to do such a review;
• Voluntarily relinquishes any partial privilege or authorization to perform a specific procedure; or the healthcare entity, through any member of the medical or administrative staff, has expressed an intention to do such a review;
• While under, or subsequent to, a review by the healthcare entity of the healthcare professional’s patient care or professional conduct, is granted a leave of absence relating to a physical, mental or emotional condition or drug or alcohol use which impairs the healthcare professional’s ability to practice with reasonable skill and safety, except that no report is required for pregnancy-related leaves of absence or if the healthcare professional has sought assistance from a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the healthcare professional, and is following the treatment regimen or monitoring as that program requires.

b.       Healthcare entities of the University shall notify the DCA in writing about all malpractice lawsuits resolved by settlement, judgment or arbitration award in which both the healthcare professional and the University are parties. Such notification shall be coordinated with the University’s Department of Risk & Claims.

c.       Healthcare entities of the University shall notify the DCA in writing if it is in possession of information that indicates that a healthcare professional has failed to comply with a request to seek assistance from a professional assistance or intervention program approved or designated by the DCA or a licensing board to provide confidential oversight of the healthcare professional, or has failed to follow the treatment regimen or monitoring program required by that program.

d.       Healthcare entities of the University shall notify the DCA in writing if any healthcare professional who has been the subject of a report to the DCA has had conditions or limitations on the exercise of clinical privileges or practice within the healthcare entity altered, or privileges restored, or has resumed exercising clinical privileges that had been voluntarily relinquished.

e.       Healthcare entities of the University, pursuant to an agreement with a healthcare services firm or staffing agency regarding a healthcare professional, shall provide a copy of the notice to the healthcare services firm or staffing agency, when the notice is submitted to the DCA.

f.       Healthcare entities of the University shall provide the healthcare professional who is the subject of a notice to the DCA a copy of the notice provided to the DCA, when the notice is submitted to the DCA.

g.      Healthcare entities of the University shall make notifications to the DCA within seven days of the date of the reportable action, settlement, judgment or arbitration award, including such information as may be required by the DCA.

2.       Healthcare Professionals

a.      University healthcare professionals from any unit of the University shall promptly notify DCA if they have information that another professional has demonstrated impairment, gross incompetence or unprofessional conduct, which would present an imminent danger to an individual patient, the public health, safety or welfare. No notification is required if knowledge of the other healthcare professional’s impairment or incompetence was obtained from treating the professional.

b.      University healthcare professionals from any unit of the University shall inform the University, through the designated official of the unit in which the subject of the notification practices, if they have information that another professional has demonstrated impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient, the public health, safety or welfare. The obligation to report this information to the University is in addition to the requirement to report this information to the DCA.

B.       Exchange of Information between Healthcare Entities

1.       Upon inquiry, healthcare entities of the University shall inform other healthcare entities if they have submitted any notices to DCA, medical practitioner review panel, or professional or occupational licensing board within the prior seven years preceding the inquiry about a healthcare professional. The healthcare entities of the University will provide the other entity with a copy of the notification and any supporting documentation that was submitted to DCA, Medical Practitioner Review Panel, or professional or occupational licensing board.

2.       Upon inquiry, the healthcare entities of the University shall provide information about a current or former employee’s job performance as it relates to patient care and the reasons for the former employee’s separation. The job performance information shared shall relate to the suitability of the employee for re-employment at a healthcare entity, and the employee’s skills and abilities as they relate to suitability for future employment at a healthcare entity. The job performance information will be based on the employee’s performance evaluation and provided to another healthcare entity only under the following conditions:

a.       The evaluation has been signed by the evaluator and shared with the employee;

b.       The employee has had the opportunity to respond; and

c.       The employee’s response has been taken into consideration when providing information to another healthcare entity.

C.       Maintenance of Records

1.        The University shall maintain for a period of seven (7) years all records of all disciplinary proceedings or actions involving affiliated or employed healthcare professionals and also retain all documented complaints of patient care-related incidents.

2.        The healthcare entities of the University shall maintain for a period of four (4) years all records and source data relating to mortality, morbidity, complication, infection and readmission.

3.        Upon request, the healthcare entities of the University shall make such information available to DCA, the professional’s licensing board, the Medical Practitioner Review Panel and the Department of Health and Senior Services (DHSS).

4.        If either of the record retention periods noted in 1 and 2 above are less than the record retention period defined in the University’s policy, Record Management, 00-01-10-50:00, the retention period in the University’s policy shall apply.

D.      Responsibilities:

1.        The Deans of the schools and the President/CEOs of the healthcare entities shall each designate a single individual responsible for notifying the Division of Consumer Affairs or licensing boards as required by this policy and the Health Care Professional Responsibility and Reporting Enhancement Act and to receive reports from University healthcare professionals pursuant to section I. B.1 and 2 of this policy.

2.       Exchange of information between healthcare entities (reference checks) shall be as follows:

a.       Staff: The Department of Human Resources shall be responsible for responding to reference checks in accordance with POLICY section VI., A and B of this policy. Human Resources shall collaborate with the healthcare entities in providing such reference checks.

b.       Faculty and House Staff: The Deans of the schools shall either

i.         designate a single individual to be responsible for responding to reference checks in accordance with POLICY section VI., A and B of this policy, or

ii.        permit Department Chairs, Program Directors, GME/GDE Deans or Directors and other supervisors of faculty and House Staff to respond to reference checks in accordance with POLICY section VI., A and B of this policy.

VII.     PROCEDURES

A.       The Event Reporting Form, found online at: http://www.umdnj.edu/hrweb/forms_main_for_review.htm shall be used by:

1.       All schools/units/healthcare entity designees and healthcare professionals responsible for notifying DCA and/or licensing boards in compliance with this policy and the Health Care Professional Responsibility and Reporting Enhancement Act.

2.      The Department of Human Resources in responding to reference checks in accordance with this policy and the Health Care Professional Responsibility and Reporting Enhancement Act.

B.       Distribution of the report shall be in accordance with the instructions noted on the Event Reporting Instruction page.

VIII.   SANCTIONS

A.       Failure to comply with the provisions of the Health Care Professional Responsibility and Reporting Enhancement Act may subject the University and its healthcare professionals to possible disciplinary action and civil penalties and cause the University to be subject to penalties as determined by the DHSS or DCA.

B.       Any individual who violates any provision of this policy may be subject to discipline up to and including termination.

IX.     EXHIBITS

A.      Event Reporting Instructions

B.      Event Reporting Form

By Direction of the President:

_____________________________________
Vice President for Human Resources

 University of Medicine & Dentistry of New Jersey

Health Care Professional Responsibility & Reporting

Enhancement Act (HCPRREA)

EVENT REPORTING - INSTRUCTIONS

Use the attached form to: (1) to report HCPRREA events to the Division of Consumer Affairs (DCA) and (2) to respond to HCPRREA requests from outside entities.

APPLICABILITY

Healthcare facilities licensed pursuant to N.J.S.A. § 26:2H-l. UMDNJ facilities: University Hospital (UH), University Behavioral HealthCare (UBHC), Eric B. Chandler Health Center and UMDNJ Health Care Professionals, either paid or volunteer.

APPLICABLE PROFESSIONS

Individuals licensed or authorized to practice a healthcare profession regulated by the Division of Consumer Affairs (DCA) and other professional and occupational licensing boards: physicians, podiatrists, nurses, pharmacists, physical, occupational and respiratory therapists, nurses aides and personal assistants, psychologists, psychoanalysts, social workers, speech and language pathologists, optometrists, opticians, dentists, orthotics and prosthetics providers, marriage and family therapists, veterinarians and chiropractors, and acupuncturists.

REPORTABLE EVENTS UNDER HCPRREA

For reasons relating to a heath care professional’s impairment, incompetency or professional misconduct which relates adversely to patient care or safety:  1.       Has full or partial privileges summarily or temporarily revoked or suspended, or permanently reduced, suspended or revoked; 2.       Has been discharged from staff; 3.       Has been terminated or had a contract rescinded; 4.       Has been removed from a list of eligible employees of a health service firm or staffing registry; 5.       Has conditions or limitations imposed on clinical privileges; 6.       Voluntarily relinquishes any partial privilege/authorization to perform a specific procedure if under review by the healthcare entity or if the entity has expressed an intention to do so; 7.       Voluntarily resigns because the healthcare entity is reviewing his/her patient care because it believes that the conduct is unprofessional or demonstrates impairment or incompetence or if the entity has indicated an intention to conduct such a review. 8.       Has been granted a leave of absence due to a physical, mental or emotional condition or drug or alcohol use that impaired his/her ability to practice, unless the professional sought assistance from a professional assistance or intervention program and is following the required treatment program. 9.       Has malpractice lawsuits resolved by settlement, judgment or arbitration in which both the professional and healthcare entity are parties.

 

DISTRIBUTION

Original to DCA or requesting entity

Copy to Licensed Professional

Copy to Human Resources (for staff employees only; do not send reports on Volunteers to HR)

Copy to  Faculty Affairs (for faculty, paid or unpaid)

Copy retained by School/Unit and/or Reporting Professional

---

EXHIBIT B

Health Care Professional Responsibility & Reporting

Enhancement Act (HCPRREA)

EVENT REPORTING FORM

(CONFIDENTIAL DOCUMENT) 

For use by Schools/Healthcare Entities/Healthcare Professionals

Employee Name:                                                                  University ID#:

Licensed Profession:                                         License # (if available)

School/Healthcare Entity Assigned:

Action to Report (see Instruction Sheet):

Date of Occurrence:

Other Related Information:

 

Reference for Employees (Labor Relations/HR use)

Suspended Pending Investigation:         Yes              No

Was suspension:   With pay          Without pay

Separation was:                          Voluntary                      Involuntary

 

Information provided by:   (Print Name and Title/Date)

Signature:

If more information is required, contact:

Location:                                                              Telephone:

 

---

Policy Manual Table of Contents

OPPM Home Page

UMDNJ Home Page