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Title 911 | Chapter 001 | Regulation 060

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911 KAR 1:060.Medical staff.

RELATES TO:

KRS 200.460, 313.035

STATUTORY AUTHORITY:

KRS 194A.030(5)

NECESSITY, FUNCTION, AND CONFORMITY:

KRS 194A.030(5) authorizes the Office for Children with Special Health Care Needs to promulgate administrative regulations to implement and administer its responsibilities. This administrative regulation establishes requirements relating to the Office for Children with Special Health Care Needs Medical Staff.

Section 1.

Definitions.

(1)

"Advanced practice registered nurse" is defined by KRS 314.011(7).

(2)

"Dentist" is defined by KRS 313.010(10).

(3)

"MAC" means the Medical Advisory Committee, which is an internal OCSHCN committee that consists of thirteen (13) members and advises OCSHCN on issues pertaining to medical staff qualification, credentialing, quality, and other related issues.

(4)

"OCSHCN" means Office for Children with Special Health Care Needs.

(5)

"Physician" is defined by KRS 311.550(12).

(6)

"Physician assistant" is defined by KRS 311.840(3).

(7)

"Psychologist" is defined by KRS 319.010(9).

Section 2.

Qualifications for Acceptance to OCSHCN Active Medical Staff.

(1)

In order to be eligible for acceptance to the OCSHCN active medical staff, an individual shall be:

(a)

Licensed to practice in Kentucky as a:

1.

Physician;

2.

Dentist;

3.

Advanced practice registered nurse;

4.

Physician assistant; or

5.

Psychologist; and

(b)

Able to document:

1.

Background, experience, training, and competence;

2.

Adherence to the ethics of the individual's profession;

3.

Professionalism; and

4.

Interpersonal skills.

(2)

A physician or dentist shall be:

(a)

1.

Eligible for membership in the national medical or dental society; or

2.

Enrolled as a member of the national medical or dental society; and

(b)

Enrolled as a participating provider in the Kentucky Medicaid program, in accordance with 907 KAR 1:672.

(3)

For specific medical specialties, for which there is a generally recognized certification by a board giving examinations in the field, the individual shall be:

(a)

Eligible to sit for the examination of the board; or

(b)

Board certified.

(4)

The OCSHCN executive director, upon advice of the MAC, may exempt an individual from the requirements established in subsection (3) of this section if the individual:

(a)

Agrees to provisional status for twelve (12) months; and

(b)

Agrees to provide the MAC at the completion of twelve (12) months, with three (3) references, including:

1.

Two (2) peer reference letters that:

a.

Are written by Kentucky physicians, dentists, or psychologists as appropriate; and

b.

Are completed on the:

(i)

OCSHCN-60g, Peer Reference Letter Medical or Dental; or

(ii)

OCSHCN-60h, Peer Reference Letter Psychologist; and

2.

One (1) reference letter that:

a.

(i)

Is written by the medical director of a Kentucky children's hospital where the individual is on medical staff; or

(ii)

If not on medical staff at a children's hospital, is written by the medical director at the Kentucky hospital where the individual is on medical staff and admits the majority of the individual's patients; and

b.

Is completed on the OCSHCN-60j, Facility Recommendation Letter.

(5)

For initial appointment to the medical staff in a dental specialty area, the individual shall be licensed in the specialty area, in accordance with KRS 313.035 and 201 KAR 8:532.

Section 3.

Categories of Medical Staff. The medical staff shall consist of the following categories:

(1)

Temporary active status, pursuant to Section 6 of this administrative regulation;

(2)

Active status, pursuant to Sections 2, 4, and 5 of this administrative regulation;

(3)

Provisional status, pursuant to Sections 2, 4, 5, and 7 of this administrative regulation; and

(4)

Contracted status, pursuant to Section 8 of this administrative regulation.

Section 4.

Initial Application Process for Active Medical Staff.

(1)

An individual seeking initial appointment to the medical staff shall submit to OCSHCN a completed application packet containing:

(a)

A completed and signed:

1.

a.

OCSHCN-60a, Application for Active Medical or Dental Staff, if the individual is a dentist or physician;

b.

OCSHCN-60b, Application for Active Medical APRN Staff, if the individual is an advanced practice registered nurse;

c.

OCSHCN-60c, Application for Active Psychology Staff, if the individual is a psychologist; or

d.

OCSHCN-60d, Application for Active Medical Physician Assistant Staff, if the individual is a physician assistant;

2.

OCSHCN-60e, Authorization, Attestation, and Release; and

3.

OCSHCN-60f, Anti-Harassment and Discrimination Acknowledgment;

(b)

A copy of the individual's current Council for Affordable Quality Healthcare (CAQH) application;

(c)

A current curriculum vitae;

(d)

A copy of the individual's malpractice insurance endorsement; and

(e)

The applicable information required by subsections (2) though (5) of this section.

(2)

If the individual is a dentist or physician, the following attachments shall be included:

(a)

A copy of the individual's license to practice, issued by the Kentucky:

1.

Board of Dentistry; or

2.

Board of Medical Licensure; and

(b)

If applicable, a copy of the individual's current Form DEA-223, Controlled Substance Registration Certificate issued by the United States Department of Justice, Drug Enforcement Administration.

(3)

If the individual is an advanced practice registered nurse, the following attachments shall be included:

(a)

A copy of a signed Collaborative Practice Agreement between the physician and the individual, as submitted to the Kentucky Board of Nursing; and

(b)

A copy of the individual's current credentialing from the:

1.

American Nurses Credentialing Center (ANCC); or

2.

American Academy of Nurse Practitioners (AANP).

(4)

If the individual is a psychologist, the application packet shall include a copy of the individual's license to practice, issued by the Kentucky Board of Examiners of Psychology.

(5)

If the individual is a physician assistant, the following attachments shall be included:

(a)

A copy of the individual's license to practice, issued by the Kentucky Board of Medical Licensure;

(b)

A copy of the initial and any applicable Supplemental Application for Physician to Supervise Physician Assistant, as submitted to the Kentucky Board of Medical Licensure; and

(c)

A copy of the National Commission on Certification of Physician Assistants (NCCPA) certification.

Section 5.

Procedures for Application Review and Appointment.

(1)

Within seven (7) working days of receipt of the application pursuant to Section 4 of this administrative regulation, designated OCSHCN staff shall request that:

(a)

Individuals listed as references complete the:

1.

OCSHCN 60g, Peer Reference Letter Medical or Dental; or

2.

OCSHCN 60h, Peer Reference Letter Psychologist, if the individual is a psychologist; and

(b)

An individual submit missing information or other required documents necessary to an evaluation of the individual's qualifications.

(2)

If the documentation requested pursuant to subsection (1) of this section is not received by OCSHCN within forty-five (45) working days from the date of the request, designated OCSHCN staff shall notify the individual in writing that:

(a)

The individual shall be responsible for following up to obtain missing information and ensuring receipt by OCSHCN within twenty (20) working days of written notice;

(b)

Failure to submit the missing information within twenty (20) working days of written notice under paragraph (a) of this subsection shall result in the application being placed in closed status without further review;

(c)

Reapplication for staff appointment shall not be considered for a period of six (6) months from the date of the notice that the application has been closed pursuant to paragraph (b) of this subsection; and

(d)

Reapplication for staff appointment shall be processed as an initial application.

(3)

Upon receipt of documentation requested pursuant to subsection (1) of this section, designated OCSHCN staff shall make the application and other documentation available to the MAC chair, who shall present the application at the next meeting of the MAC.

(4)

The MAC shall:

(a)

Ensure that all necessary documents and investigations have been validated with objectivity, fairness, and impartiality, and that recommendations are soundly based and compatible with the objectives of OCSHCN;

(b)

Determine if the individual meets all necessary qualifications for the category of staff membership and clinical privileges requested;

(c)

If the MAC determines that the individual meets all necessary qualifications for the category of staff membership and clinical privileges requested, recommend to designated OCSHCN staff:

1.

Appointment to the appropriate staff category; and

2.

Granting of privileges according to the specialty to which the individual shall be assigned; and

(d)

If the MAC determines that the individual does not meet all necessary qualifications for the category of staff membership and clinical privileges requested:

1.

Defer consideration of the application, if clarifying information is needed; or

2.

Reject the application.

(5)

Upon the MAC approving the individual, designated OCSHCN staff shall add the individual approved in accordance with this section to OCSHCN's active medical staff for a period of three (3) years.

(6)

An individual aggrieved by an adverse decision pursuant to subsection (4)(d) of this section may request to address the MAC to seek reconsideration pursuant to Section 13 of this administrative regulation.

Section 6.

Temporary Active Medical Staff.

(1)

The executive director or designee may make a temporary active medical staff appointment if necessary to provide clinical coverage. This type of staff appointment shall be:

(a)

Emergency in nature;

(b)

Made based on information currently available that may reasonably be obtained as to the competence and ethical standing of the individual; and

(c)

Reviewed by the MAC within six (6) months following the appointment.

(2)

A temporary active medical staff appointment shall last no longer than six (6) months, at which time the appointment shall be eligible for conversion to the active medical staff pursuant to the processes established in Sections 4 and 5 of this administrative regulation.

(3)

Each appointee to the temporary active medical staff shall have an assigned member of the active medical staff review performance during clinic and make recommendations to the MAC as necessary regarding conversion to the active medical staff.

(4)

An appointee to temporary active medical staff status shall be compensated in accordance with Section 11 of this administrative regulation.

Section 7.

Provisional Staff.

(1)

In accordance with Section 2(4) of this administrative regulation, the executive director may make a provisional staff appointment if an individual meets the requirements of Sections 2, 4, and 5 of this administrative regulation.

(2)

An appointment to provisional status shall be effective for twelve (12) months.

(3)

Prior to the end of the twelve (12) months, the MAC shall:

(a)

Review reference letters submitted in accordance with Section 2(4) of this administrative regulation; and

(b)

Make a recommendation to designated OCSHCN staff at its next meeting as to whether to:

1.

Move the appointee to active status; or

2.

Terminate provisional status.

(4)

An appointee aggrieved by a recommendation to terminate provisional status may be heard by the MAC pursuant to Section 13 of this administrative regulation.

Section 8.

Contracted Staff.

(1)

In accordance with KRS Chapter 45A, OCSHCN may contract with medical or dental specialists to provide services to children outside of OCSHCN offices and clinics.

(2)

OCSHCN-enrolled children may be referred to contracted staff by a member of the active OCSHCN medical staff or the OCSHCN medical director.

Section 9.

Annual Review and Reappointment Process.

(1)

OCSHCN shall, on an annual basis, verify for each member of the active medical staff:

(a)

Current state license; and

(b)

Current malpractice insurance.

(2)

Each member of the active medical staff shall undergo a re-credentialing process every three (3) years. Required documents to be submitted to OCSHCN shall include:

(a)

OCSHCN-60i, Renewal Application for Active Medical or Dental Staff; and

(b)

All documents requested by OCSHCN-60i, Renewal Application for Active Medical or Dental Staff.

(3)

The reappointment evaluation shall include:

(a)

Review of required forms and documents;

(b)

Timely completion and preparation of medical and other required patient records;

(c)

Satisfactory evidence of compliance with ethics;

(d)

Compliance with OCSHCN procedures;

(e)

General cooperation and ability to work with others;

(f)

Results of quality assurance audits, if conducted; and

(g)

Reports of disciplinary action requested, or proceedings initiated against a provider at any institution.

(4)

At each regularly scheduled meeting, the MAC shall complete a review of the active medical staff that are due for a three (3) year re-credentialing appraisal. The review shall include:

(a)

OCSHCN-60i, Renewal Application for Active Medical or Dental Staff; and

(b)

Any other information pertinent to continuation on the medical staff.

(5)

After the review, the MAC shall make a determination to re-credential or not re-credential based on the information requested in this section.

Section 10.

Duties and Responsibilities of Medical Staff.

(1)

Each member of the medical staff shall assume the same responsibility for care and treatment of the staff member's assigned patients as in private practice.

(2)

A resident physician or dentist in training may assist in the care of patients, if a member of the active medical staff:

(a)

Remains entirely responsible for the care of each patient;

(b)

Examines and, if indicated, recommends treatment for each new patient under the staff member's care;

(c)

Remains present in the surgical suite at all operations and other procedures in which general anesthesia is used;

(d)

Directs the examination of all patients assigned to the active staff member for discharge from the hospital and designates follow-up care; and

(e)

Maintains oversight of the resident physician or dentist.

(3)

Active medical staff members assigned to OCSHCN clinics shall be present to conduct an assigned clinic. If an active medical staff member cannot be present to conduct an assigned clinic, the staff member shall:

(a)

Make arrangements with another member of the OCSHCN medical staff to serve in the staff member's place, if the staff member advises the assigned OCSHCN staff of this change; or

(b)

Request that assigned OCSHCN staff reschedule the clinic, if the request is timely enough to allow OCSHCN staff to notify patients of the rescheduling.

(4)

For a clinic with more than one (1) provider representing different specialties, if an active medical staff member cannot be present to conduct an assigned clinic, the staff member shall:

(a)

Make arrangements with another member of the OCSHCN medical staff to serve in the staff member's place, if the staff member advises the assigned OCSHCN staff of this change; or

(b)

Make arrangements with the other active medical staff members assigned to the clinic to reschedule the entire clinic, if the request is timely enough to allow OCSHCN staff to notify patients of the rescheduling.

(5)

If an active medical staff member who has responsibility for a clinic fails to attend two (2) clinics during a twelve (12) month period and does not comply with subsection (3) or (4) of this section, the active medical staff member shall be:

(a)

Removed from the active medical staff; and

(b)

Advised in writing of:

1.

The removal; and

2.

Right to be heard by the MAC pursuant to Section 13 of this administrative regulation.

(6)

Medical staff members participating in OCSHCN onsite clinics shall document a summary of each patient visit. Documentation shall be completed:

(a)

On the day of the visit; or

(b)

Within seventy-two (72) hours of the visit if it cannot be finished on the day of the visit.

(7)

Medical staff members participating in OCSHCN onsite clinics shall:

(a)

Not remove patient medical records from OCSHCN premises; and

(b)

Authenticate their medical record entries regarding diagnosis, findings, and recommendations for treatment, by:

1.

Signature; or

2.

Initials.

(8)

If a medical staff member elects to initial the medical record pursuant to subsection (7) of this section, OCSHCN shall maintain a legend for purpose of identity, which shall include the typed or printed name of the medical staff member, followed by hand signed initials.

(9)

A medical staff member may see OCSHCN patients in the staff member's private office, as deemed necessary by the medical staff member. Office visit records shall be:

(a)

Completed; and

(b)

Forwarded to the assigned OCSHCN office within three (3) working days of the visit.

(10)

To the extent possible, total care for the child shall be considered while the specific condition for which treatment is sought is being cared for. Coexistent diseases, disabilities, or anomalies shall be investigated and treated if:

(a)

The referring physician or dentist, if any, approves and consents; and

(b)

The services fall within the categories eligible for treatment by OCSHCN in accordance with 911 KAR 1:010.

(11)

A program of total care for the child shall be developed by a team approach. There shall be discussion of all phases of the problem of each child by all medical personnel concerned with the child's care, including therapists and other professional personnel. Team care shall be provided within the context of a multidisciplinary clinic.

(12)

Contracted staff shall be available for consultation and treatment if indicated. Arrangements for contracts shall be made through the assigned OCSHCN office on an individual basis.

Section 11.

Compensation.

(1)

A member of the medical staff shall be compensated for services provided during onsite OCSHCN clinics in accordance with a contract agreed to pursuant to the provisions of KRS Chapter 45A.

(2)

If OCSHCN staff refer patients to a member of the active medical staff for services outside of an OCSHCN clinic, information needed to bill the appropriate insurance carrier shall be included.

Section 12.

Corrective Action.

(1)

The following parties may request corrective action be directed toward a member of the medical staff:

(a)

Any member of the medical staff;

(b)

The chair of the MAC;

(c)

OCSHCN staff; or

(d)

A member of the family of an OCSHCN-enrolled child.

(2)

The basis for a request for corrective action shall include activities or professional conduct that are considered to be:

(a)

Contrary to the standards or aims of the medical staff; or

(b)

Disruptive to OCSHCN operations, programs, or clinics.

(3)

A request for corrective action shall be:

(a)

In writing;

(b)

Addressed to the executive director; and

(c)

Supported by references to the specific activities or conduct that constitutes grounds for the request.

(4)

Within ten (10) working days of receipt of a request for corrective action, the executive director or designee shall:

(a)

Initiate an investigation of the facts and circumstances surrounding the grounds for the requested corrective action;

(b)

Interview the member of the medical staff against whom the corrective action is requested;

(c)

Document the interview in writing; and

(d)

Submit a report and recommendation to the MAC for consideration.

(5)

Within ninety (90) working days following the receipt of the recommendation by the executive director, the MAC shall make recommendations on the request.

(6)

In accordance with subsection (5) of this section, the MAC may:

(a)

Reject the request for corrective action;

(b)

Issue a warning, letter of admonition, or letter of reprimand;

(c)

Impose terms of probation or a suspension from the medical staff; or

(d)

Recommend that the affected member's medical staff membership be suspended or revoked.

(7)

The executive director shall have the authority to summarily suspend or dismiss a member of the medical staff if action is needed immediately in the interest of patient care. Grounds for summary suspension or dismissal from the medical staff shall include:

(a)

Action by the governing Board of Medical Licensure, Board of Dentistry, Board of Nursing, or Board of Examiners of Psychology, in which a member's license is revoked or suspended;

(b)

Loss of hospital privileges; or

(c)

Behavior that creates a risk of harm to children or OCSHCN staff.

Section 13.

Request for Reconsideration.

(1)

A provider may request to appear before the MAC to advocate for reconsideration if the provider:

(a)

Was denied appointment to the medical staff pursuant to Section 5 of this administrative regulation;

(b)

Had provisional status terminated pursuant to Section 7 of this administrative regulation;

(c)

Was removed from the active medical staff pursuant to Section 10(5) of this administrative regulation; or

(d)

Has been the subject of corrective action pursuant to Section 12 of this administrative regulation.

(2)

A provider who is aggrieved pursuant to subsection (1) of this section shall complete form OCSHCN-60k, Request for Reconsideration by Medical Advisory Committee, to include:

(a)

Name of provider;

(b)

Specialty;

(c)

Address;

(d)

Telephone;

(e)

E-mail address, if available;

(f)

Justification for reconsideration;

(g)

Supporting documentation, if available, including:

1.

Verification of training or work history; and

2.

Provider statements or recommendations; and

(h)

Dated signature of the provider.

(3)

The MAC shall review the completed form and supporting documentation.

(4)

The MAC may request additional information as needed within five (5) working days of the review date.

(5)

The provider shall return the information requested pursuant to subsection (4) of this section within ten (10) working days.

(6)

The MAC shall communicate to the provider:

(a)

The date to appear before the MAC; and

(b)

Within five (5) working days of the receipt of all information requested.

(7)

Following the provider's appearance at the MAC, the MAC shall communicate within five (5) working days to the provider:

(a)

The decision made; and

(b)

A brief explanation.

Section 14.

Incorporation by Reference.

(1)

The following material is incorporated by reference:

(a)

OCSHCN-60a, "Application for Active Medical or Dental Staff," 01/2019;

(b)

OCSHCN-60b, "Application for Active Medical APRN Staff," 01/2019;

(c)

OCSHCN-60c, "Application for Active Psychology Staff," 01/2019;

(d)

OCSHCN-60d, "Application for Active Medical Physician Assistant Staff," 01/2019;

(e)

OCSHCN-60e, "Authorization, Attestation, and Release," 01/2019;

(f)

OCSHCN-60f, "Anti-Harassment and Discrimination Acknowledgment," 01/2019;

(g)

OCSHCN-60g, "Peer Reference Letter Medical or Dental," 01/2019;

(h)

OCSHCN-60h, "Peer Reference Letter Psychologist," 01/2019;

(i)

OCSHCN-60i, "Renewal Application for Active Medical or Dental Staff," 01/2019;

(j)

OCSHCN-60j, "Facility Recommendation Letter," 01/2019; and

(k)

OCSHCN-60k, "Request for Reconsideration by Medical Advisory Committee," 01/2019.

(2)

This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Office for Children with Special Health Care Needs, 310 Whittington Parkway, Suite 200, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the agency's Web site at https://chfs.ky.gov/agencies/ccshcn.
HISTORY: (45 Ky.R. 2823, 3434; eff. 7-19-2019.)

7-Year Expiration: 3/16/2030

Last Updated: 3/22/2023

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