28 CA ADC § 1300.80
28 CCR s 1300.80
Cal. Admin. Code tit. 28, s 1300.80
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 10. MEDICAL SURVEYS
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.80. Medical Survey Procedure.
(a) Unless the Director in his discretion determines that advance notice
will render the survey less useful, a plan will be notified approximately
four weeks in advance of the date for commencement of an onsite medical
survey. The Director may, without prior notice, conduct inspections of
plan 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 a plan shall include, but not be limited
to, the following procedures to the extent considered necessary based upon
prior experience with the plan and in accordance with the procedures and
standards developed by the Department.
(1) Review of the procedures for obtaining health services including, but
not limited to, the scope of basic health care services.
(A) The availability and adequacy of facilities for telephone
communication with health personnel, emergency care facilities,
out-of-the-area coverage, referral procedures, and medical encounters.
(B) The means of advising enrollees of the procedures to obtain care,
including the hours of operation, location and nature of facilities, types
of care, telephone and other arrangements for appointment setting.
(C) The availability of qualified personnel at each facility referred to
in Section 1368(b) to receive and handle inquiries concerning care, plan
contracts, and grievances.
(2) Review of the design and implementation of procedures for reviewing
and regulating utilization of services 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 enrollee, including
out-patient, in-patient and referral services and significant telephone
consultations.
(5) Review of the overall performance of the plan in providing health care
benefits, 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
enrollees, plan 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 physician;
(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
enrollees, of all provided services;
(L) The organization of the plan and its mechanisms for furnishing health
care services, 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 plan in meeting the health
needs of enrollees.
(A) Accessibility of facilities and services, based upon location of
facilities, hours of operation, waiting periods for services and
appointments, including elective services, the availability of parking and
transportation;
(B) Continuity of care, including the ability of enrollees to select a
primary care 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 education to enrollees;
(C) The grievance procedure required by Section 1368 of the Act, including
the availability to enrollees and subscribers of grievance procedure
information, the time required for and the adequacy of the response to
grievances and the utilization of grievance information by plan
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 enrollees, physicians
and other health professionals, and members of its administrative staff
including, but not limited to, its principal management persons.
(B) Examination of any records, books, reports and papers of the plan and
of any management company, provider or subcontractor providing health care
or other services to the plan 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 plan,
and contracts and correspondence with enrollees and with providers of
health care services and of other services to the plan, and such
additional documentation the Director may specifically direct the
surveyors to examine.
(C) Physical examination of facilities, including equipment.
(D) Investigation of grievances or complaints from enrollees or from the
general public.
Note: Authority cited: Section 1344, Health and Safety Code. Reference:
Section 1380, Health and Safety Code.
HISTORY
1. Amendment of subsection (b)(7)(D) filed 12-8-82; effective thirtieth
day
thereafter (Register 82, No. 50).
2. Change without regulatory effect amending subsections (a) and (b)(7)(B)
filed 7-18-2000 pursuant to
section 100, title 1, California Code ofRegulations (Register 2000, No.
29).
28 CA ADC s 1300.80
END OF DOCUMENT
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