[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR1004.80]



[Page 1192]

 

                         TITLE 42--PUBLIC HEALTH

 

      GENERAL--HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PART 1004_IMPOSITION OF SANCTIONS ON HEALTH CARE PRACTITIONERS AND 

 

                     Subpart C_QIO Responsibilities

 

Sec.  1004.80  QIO report to the OIG.



    (a) Manner of reporting. If the violation(s) identified by the QIO 

have not been resolved, it must submit a report and recommendation to 

the OIG at the field office with jurisdiction.

    (b) Content of report. The QIO report must include the following 

information--

    (1) Identification of the practitioner or other person and, when 

applicable, the name of the director, administrator or owner of the 

entity involved;

    (2) The type of health care services involved;

    (3) A description of each failure to comply with an obligation, 

including specific dates, places, circumstances and other relevant 

facts;

    (4) Pertinent documentary evidence;

    (5) Copies of written correspondence, including reports of 

conversations with the practitioner or other person regarding the 

violation and, if applicable, a copy of the verbatim transcript of the 

meeting with the practitioner or other person;

    (6) The QIO's finding that an obligation under section 1156(a) of 

the Act has been violated and that the violation is substantial and has 

occurred in a substantial number of cases or is gross and flagrant;

    (7) A case-by-case analysis and evaluation of any additional 

information provided by the practitioner or other person in response to 

the QIO's initial finding;

    (8) A copy of the CAP that was developed and documentation of the 

results of such plan;

    (9) The number of admissions by the practitioner or other person 

reviewed by the QIO during the period in which the violation(s) were 

identified;

    (10) The professional qualifications of the QIO's reviewers; and

    (11) The QIO's sanction recommendation.

    (c) QIO recommendation. The QIO must specify in its report--

    (1) The sanction recommended;

    (2) The amount of the monetary penalty recommended, if applicable;

    (3) The period of exclusion recommended, if applicable;

    (4) The availability of alternative sources of services in the 

community, with supporting information; and

    (5) The county or counties in which the practitioner or other person 

furnishes services.



[60 FR 63640, Dec. 12, 1995, as amended at 62 FR 23143, Apr. 29, 1997]