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 Code of Federal Regulations (Last Updated: November 8, 2024)
 Title 42 - Public Health
 Chapter V - Office of Inspector General-Health Care, Department of Health and Human Services
 SubChapter B - OIG Authorities
 Part 1004 - Imposition of Sanctions on Health Care Practitioners and Providers of Health Care Services by a Quality Improvement Organization
 Subpart C - QIO Responsibilities

  § 1004.80 - QIO report to the OIG.  

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  • § 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]