§ 122.613. Standards for quality assurance program.
A CCO shall establish, operate and maintain a quality assurance program which includes a record on file of and provides for the following:
(1) A formal quality assurance committee consisting of participating coordinated care providers, under the direction of a medical director, which shall be responsible for approving quality assurance standards and criteria, assessing the performance of the CCO’s health service delivery system, identifying quality problems and taking appropriate corrective action.
(2) A written description of the structure and organization of its quality assurance committee and plans for documenting quality assurance activities.
(3) Formal minutes and reports documenting the activities of the quality assurance committee, which shall be available for review by the Department and external quality review agencies.
(4) An adequate staff of quality assurance professionals, particularly quality assurance registered nurses, to implement the quality assurance plan and objectives developed by the quality assurance committee and medical director.
(5) The resume and job description of its medical director and other professionals responsible for conducting quality assurance activities.
(6) A 2-year quality assurance work plan listing specific quality assurance activities the CCO will undertake in terms of focused medical care chart audits, adverse outcome reviews, credentialing activities and other activities; the estimated time frames for completion of each activity; and responsible personnel. As part of its 2-year quality assurance work plan, the CCO shall review a statistically significant sample of medical records pertaining to the treatment of injured workers. Injured workers treated by the CCO shall be selected for review and the medical records of the participating coordinated care providers that treated the injured worker shall be independently reviewed by the quality assurance system to ascertain the following:
(i) The quality of care provided by each provider.
(ii) The timeliness and appropriateness of treatment provided.
(iii) Verification that each physician who is a participating coordinated care provider has staff admitting privileges in at least one hospital that is a participating coordinated care provider.
(iv) A requirement that there be disclosure to the CCO by the provider of a financial interest in another provider to which the credentialed provider may be making referrals.
(v) Verification of the provider’s training and experience.
(vi) Verification of compliance with another standard the CCO adopts as part of its credentialing process, and with treatment protocols established by the CCO through its quality assurance system.
(vii) Establishment of standards for medical records and periodic review of medical records/charts to verify provider compliance with the standards.
(viii) For providers for which Health Care Cost Containment Council data is available, consideration of the data in the credentialing and recredentialing of participating coordinated care providers.
(7) An injured worker satisfaction program which meets the requirements of § 122.614 (relating to injured worker satisfaction program).
Cross References This section cited in 34 Pa. Code § 122.603 (relating to uncertified CCOs); and 34 Pa. Code § 122.608 (relating to contents of an application for certification as a CCO).
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