D.C. Mun. Regs. tit. 17, r. 17-4017

Current through Register 71, No. 45, November 7, 2024

Rule 17-4017 - REPORTING REQUIREMENTS

4017.1

Any health care provider that employs a physician who is licensed in the District of Columbia shall report the following to the Board of Medicine within ten (10) days:

(a) Any disciplinary action that is taken against the physician by the health care provider; and

(b) The resignation of any physician that occurs while the physician is being investigated by the health care provider.

4017.2

The Board of Medicine shall impose a penalty not to exceed two thousand five hundred dollars ($2,500.00) on a physician who employs a physician and who fails to comply with the provisions of § 4017.1.

4017.3

The Board of Medicine shall refer to the appropriate board or to the System Administrator for appropriate action non-physician health care providers who fail to report the discipline of physicians or the resignation of physicians while under investigation pursuant to § 4017.1, or who do so more than ten (10) days after the discipline is imposed or the resignation occurs.

4017.4

Health care providers and medical facilities providing services in the District of Columbia shall submit biannual adverse event reports, on January 1 and July 1 of each calendar year, to the System Administrator.

4017.5

Each adverse event report shall:

(a) Be reported using the form approved by the Board of Medicine and available on the Department's Health Regulation and Licensing Administration (HRLA) website;

(b) Ensure that the patient's identity shall be de-identified and anonymous. For each adverse event reported, the reporting health care provider or medical facility shall use a numeric internal event identifier that will allow the System Administrator to subpoena health records and conduct investigations when needed; and

(c) Include a corrective action plan designed to prevent future similar adverse events.

4017.6

Individual health care providers shall not be required to report adverse events occurring in medical facilities in which they have privileges or in which they are employed or provide contracted services unless they own the medical facility.

4017.7

Medical facilities shall report adverse events to the System Administrator that occur in the facility or as a result of the service.

4017.8

The appropriate board or the Office of Administrative Hearings (OAH) shall adjudicate contested cases for failing to timely file adverse event reports.

4017.9

The appropriate board, the System Administrator, or OAH shall impose a penalty of not less than five hundred dollars ($500.00) or more than two thousand five hundred dollars ($2,500.00) for failure to submit a timely adverse event report.

4017.10

The System Administrator shall be responsible for:

(a) Investigating adverse events as needed, including the subpoenaing of de-identified and anonymous primary health records;

(b) Collecting, organizing, and storing data on adverse events occurring in the District of Columbia;

(c) Tracking, assessing, and analyzing the incoming reports, findings, and corrective action plans;

(d) Identifying common adverse event patterns or trends;

(e) Recommending methods to reduce systematic adverse events;

(f) Providing technical assistance to health care providers and medical facilities on the development and implementation of patient safety plans to prevent adverse events;

(g) Disseminating information and advising health care providers and medical facilities in the District of Columbia on medical best practices;

(h) Monitoring national trends in best practices and disseminating relevant information and advice to health care providers and medical facilities in the District of Columbia; and

(i) Publishing an annual report that includes summary data of the number and types of adverse events for the prior calendar year by type of healthcare provider and medical facility, rates of change per type of event, other analyses, and recommendations to improve health care delivery in the District of Columbia.

4017.11

Information provided to or obtained by the System Administrator pursuant to §§ 4017.4 and 4017.5, including the identity of persons providing such information and the reports or documents provided pursuant to § 4016.5, as well as files, records, findings, opinions, recommendations, evaluations, and reports of the System Administrator, shall be confidential and shall not be subject to disclosure pursuant to any other provision of law, and shall not be discoverable or admissible into evidence in any civil, criminal, or legislative proceeding. The information shall not be disclosed by any person under any circumstances, except as such data in the aggregate may be published in the annual report by the System Administrator.

4017.12

No person providing information to the System Administrator shall be compelled to testify in any civil, criminal, or legislative proceeding with respect to any confidential matter contained in the information provided to the System Administrator, except the System Administrator may provide information in a criminal proceeding in which an individual is accused of a felony, if ordered to do so by a court pursuant to D.C. Official Code § 7 -161(e)(3).

4017.13

Information gathered by the System Administrator on adverse events pursuant to this section shall not be used for purposes other than as set forth in § 4017.10.

4017.14

Information submitted by health care providers and medical facilities pursuant to this section shall not be shared with the Healthcare Facilities Division (HFD) of the HRLA.

4017.15

Medical facilities and individual health care providers are subject to investigation by the System Administrator, in addition to investigations pursuant to §§ 4017.5(b) and 4017.10(a), for a failure to file an adverse event report in a timely manner.

4017.16

When information on an adverse event comes to the System Administrator by other means, such as by complaint or by regular processes performed by the HFD, such information may be used by HFD to initiate an investigation for purposes of regulatory compliance unrelated to the reporting of adverse events pursuant to D.C. Official Code § 7-161.

D.C. Mun. Regs. tit. 17, r. 17-4017

Final Rulemaking published at 55 DCR 6452 (June 13, 2008)