Chapter 4731-15 | Reporting Requirements

Rule 4731-15-01 | Licensee reporting requirement; exceptions.

• Effective: November 30, 2023
• Promulgated Under: 119.03

(A) As used in this chapter of the Administrative Code:

(1) "The board" means the state medical board of Ohio;

(2) "Confidential monitoring program" means a confidential non-disciplinary program for the evaluation and treatment of practitioners and applicants who are, or may be impaired under sections 4731.25 to 4731.255 of the Revised Code.

(3) "Impaired" or "Impairment" has the same meaning as used in divisions (A)(2)(a) to (A)(2)(b) of section 4731.25 of the Revised Code. Impairment includes inability to practice in accordance with such standards without appropriate treatment, monitoring, or supervision.

(4) "Monitoring organization" means an entity that meets the requirements of division (B) of section 4731.25 of the Revised Code and enters into a contract with the board for the operation of the confidential monitoring program for impaired practitioners and applicants, review and approval of evaluators and treatment providers in section 4731.251 of the Revised Code, and assists the board with monitoring impaired practitioners who are subject to formal disciplinary action by the board under division (C) of section 4731.251 of the Revised Code.

(5) "Licensee" means any of the following:

(a) An individual authorized under Chapter 4730. of the Revised Code to practice as a physician assistant;

(b) An individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, podiatric medicine and surgery, or a limited branch of medicine;

(c) An individual authorized under Chapter 4759. of the Revised Code to practice as a dietitian;

(d) An individual authorized under Chapter 4760. of the Revised Code to practice as an anesthesiologist assistant;

(e) An individual authorized under Chapter 4761. of the Revised Code to practice respiratory care;

(f) An individual licensed under Chapter 4762. of the Revised Code to practice as an acupuncturist;

(g) An individual licensed under Chapter 4774. of the Revised Code to practice as a radiologist assistant; or

(h) An individual licensed under Chapter 4778. of the Revised Code to practice as a genetic counselor.

(6) "Duty to report" includes the obligation to report violations of laws and rules under section 4730.32 of the Revised Code, section 4731.224 of the Revised Code, section 4759.13 of the Revised Code, section 4760.16 of the Revised Code, section 4761.19 of the Revised Code, section 4762.16 of the Revised Code, section 4774.16 of the Revised Code, section 4778.17 of the Revised Code and this chapter of the Administrative Code.

(7) "Malpractice reporting statutes" includes the obligation to report malpractice payments under division (D) of section 4730.32 of the Revised Code, division (D) of section 4731.224 of the Revised Code, division (D) of section 4760.16 of the Revised Code, division (D) of section 4762.16 of the Revised Code, and division (D) of section 4774.16 of the Revised Code.

(B) Licensees of the board shall be required to report as listed below, subject to paragraph (C) of this rule:

(1) Any individual licensed under Chapter 4731. of the Revised Code or any association or society of individuals licensed under Chapter 4731. of the Revised Code shall report to the board a belief that a violation of Chapter 4730., Chapter 4731., Chapter 4759., Chapter 4760., Chapter 4761., Chapter 4762., Chapter 4774., or Chapter 4778. of the Revised Code, or any rule of the board has occurred.

(2) Any physician assistant or any association or society of physician assistants shall report to the board a belief that a violation of Chapter 4730. or 4731. of the Revised Code, or any rule of the board has occurred.

(3) Any dietitian or any association or society of dietitians shall report to the board a belief that a violation of Chapter 4731. or Chapter 4759. of the Revised Code, or any rule of the board has occurred.

(4) Any anesthesiologist assistant or any association or society of anesthesiologist assistants shall report to the board a belief that a violation of Chapter 4731. or 4760. of the Revised Code, or any rule of the board has occurred.

(5) Any respiratory care professional or any association or society of respiratory care professionals shall report to the board a belief that a violation of Chapter 4731. or 4761. of the Revised Code, or any rule of the board has occurred.

(6) Any acupuncturist or any association or society of acupuncturists shall report to the board a belief that a violation of Chapter 4731. or 4762. of the Revised Code, or any rule of the board has occurred.

(7) Any radiologist assistant or any association of radiologist assistants shall report to the board a belief that a violation of Chapter 4731. or 4774. of the Revised Code, or any rule of the board has occurred.

(8) Any genetic counselor or any association of genetic counselors shall report to the board a belief that a violation of Chapter 4731. or 4778. of the Revised Code or any rule of the board has occurred.

(C) An individual, association or society shall be relieved of the obligation to report under paragraph (B) of this rule if one of the following requirements is met:

(1) The individual or organization is an approved treatment provider under section 4731.251 of the Revised Code, or the individual is an employee, agent, or representative of an approved treatment provider, and

(a) The licensee or applicant has been referred to the monitoring organization that conducts the confidential monitoring program;

(b) The licensee or applicant cooperates with the requirements of the confidential monitoring program and the treatment plan; and

(c) There is no reason to believe that the licensee has violated any provision of Chapter 4730., Chapter 4731., Chapter 4759., Chapter 4760., Chapter 4761., Chapter 4762, Chapter 4774., or Chapter 4778. of the Revised Code or any rule of the board other than impairment of ability to practice.

(2) The individual is a member of an impaired practitioner committee, or the equivalent, established by a hospital or its medical staff, or is a representative or agent of a committee or program sponsored by a professional association of individuals licensed under Chapter 4731. of the Revised Code to provide peer assistance to impaired practitioners, and

(a) The practitioner has been referred to the monitoring organization that conducts the confidential monitoring program under section 4731.25 of the Revised Code;

(b) The practitioner co-operates with requirements of the confidential monitoring program; and

(c) There is no reason to believe that the practitioner has violated any provision of Chapter 4730., Chapter 4731., Chapter 4759., Chapter 4760., Chapter 4761., Chapter 4762., Chapter 4774., or Chapter 4778. of the Revised Code, or any rule of the board, other than impairment of ability to practice .

(3) The individual reasonably believes all of the following:

(a) The practitioner has been referred to the monitoring organization that conducts the monitoring program under section 4731.25 of the Revised Code;

(b) The practitioner co-operates with the requirements of the confidential monitoring program; and

(c) There is no reason to believe that the practitioner has violated any provision of Chapter 4730., Chapter 4731., Chapter 4759., Chapter 4760., Chapter 4761., Chapter 4762., Chapter 4774., or Chapter 4778. of the Revised Code, or any rule of the board, other than impairment of ability to practice pursuant to division (A)(2) of section 4731.25 of the Revised Code.

(4) The individual is a member of a review committee described in section 2305.25 of the Revised Code and the sole source for the belief that a violation has occurred is derived from evidence or other matters produced or presented during the proceedings of such committee.

(5) The individual is otherwise prohibited from reporting to the board by a superseding state or federal law.

(D) For purposes of section 4730.32, section 4731.224, section 4759.13, section 4760.16, section 4761.19, section 4762.16, section 4774.16, or section 4778.17 of the Revised Code, and this rule, "reason to believe" or "belief" does not require absolute certainty or complete unquestioning acceptance, but only an opinion that a violation may have occurred based upon firsthand knowledge or reliable information.

(E) Any report required under paragraph (B) of this rule shall be made to the board within forty-eight hours. Reporting of any belief that a violation has occurred to a review committee as described in section 2305.251 of the Revised Code or any entity other than the board does not discharge the duty or obligation to report to the board. In cases where the secretary and supervising member determined that peer review is being conducted by a review committee as described in section 2305.251 of the Revised Code for purposes of denying, determining, changing, or modifying the scope of the licensee's clinical privileges, they may defer further investigation by the board while awaiting the outcome of that peer review. An individual, association, or society making a report of a violation of law or rule may remain anonymous by complying with all of the following actions:

(1) The individual, association, or society shall request and shall be assigned a confidential identifying number by the board.

(2) The individual, association, or society shall be responsible for notifying the board that he or she is a licensee or is an association or society of licensees and shall be responsible for maintaining the confidential identifying number in order to verify compliance with the reporting obligations of section 4730.32 of the Revised Code, section 4731.224 of the Revised Code, section 4759.13 of the Revised Code, section 4760.16 of the Revised Code, section 4761.19 of the Revised Code, section 4762.16 of the Revised Code, or section 4774.16 or section 4778.17 of the Revised Code and this chapter.

(F) Each report pursuant to this rule shall include:

(1) The name of the practitioner or other individual in violation;

(2) The violation which is believed to have occurred; and

(3) The date(s) of and place(s) of occurrence(s), if known.

Last updated November 30, 2023 at 8:22 AM

Supplemental Information

Authorized By: 4730.07, 4731.05, 4759.05, 4760.19, 4761.03, 4762.19, 4774.11, 4778.12
Amplifies: 4730.25, 4730.32, 4731.22, 4731.224, 4731.25, 4731.251, 4759.07, 4759.13, 4760.13, 4760.16, 4761.09, 4761.19, 4762.13, 4762.16, 4774.13, 4774.16, 4778.14, 4778.17
Five Year Review Date: 11/30/2028
Prior Effective Dates: 6/30/2005

Rule 4731-15-02 | Healthcare facility reporting requirement.

• Effective: November 30, 2023
• Promulgated Under: 119.03

(A) The chief administrator or executive officer of any healthcare facility as defined in section 3702.51 of the Revised Code, including a hospital, healthcare facility operated by a health insuring corporation, ambulatory surgical facility, or similar facility, shall report to the board any formal disciplinary action against any individual licensed by the board within sixty days after its completion.

(B) "Formal disciplinary action" means any procedure resulting in the revocation, restriction, reduction, or termination of clinical privileges for violations of professional ethics, or for reasons of medical incompetence, medical malpractice, misconduct, or impairment. Clinical privileges mean the authorization by the healthcare facility to a person licensed by the board for the provision of health care services.

(C) Formal disciplinary actions shall include:

(1) Summary actions, actions that take effect notwithstanding any appeal rights that may exist and actions that result in an individual surrendering clinical privileges while under investigation during proceedings regarding the action being taken or in return for not being investigated or having proceedings held, resulting in revocation, restriction, reduction, or termination of privileges for the violations or reasons set forth in paragraph (B) of this rule; and

(2) Actions resulting in refusal or denial of clinical privileges for the violations or reasons set forth in paragraph (B) of this rule;

(D) Formal disciplinary actions shall not include any action taken for the sole reason of failure to maintain records on a timely basis, failure to pay dues, or failure to attend staff, department, or section meetings.

(E) Formal disciplinary actions need not be reported if:

(1) The practitioner has been referred to the monitoring organization that conducts the confidential monitoring program for examination by an approved treatment program;

(2) The practitioner cooperates with the requirements of the confidential monitoring program; and

(3) There is no reason to believe that the practitioner has violated any laws or rules of the board.

(F) Each report shall include:

(1) The name and address of the facility reporting;

(2) The practitioner's name and license number;

(3) The action taken by the facility;

(4) The date of the action taken by the facility;

(5) The effective date of the action taken by the facility; and

(6) A summary of the underlying facts leading to the action.

(G) A facility's timely filing with the board of a copy of the national practitioner data bank adverse action report shall satisfy the reporting requirement of this rule when, upon contact by the board, the reporting facility verifies that the filing of the report has been approved by the peer review committee which reviewed the case or by the governing board of the facility.

(H) Any request for patient records by the board as provided under division (A) of section 4730.32 of the Revised Code, division (A) of section 4731.224 of the Revised Code, division (A) of section 4760.16 of the Revised Code, division (A) of section 4762.16 of the Revised Code, or division (A) of section 4774.16 of the Revised Code shall be directed to the chief administrator or executive officer of the facility. Failure to provide the board with the requested certified copies of patient records within thirty days of receipt of that request shall constitute a failure to comply with the applicable reporting requirements unless the board has granted a prior extension in writing.

Last updated November 30, 2023 at 8:22 AM

Supplemental Information

Authorized By: 4730.07, 4731.05, 4759.05, 4760.19, 4761.03, 4762.19, 4774.11, 4778.12
Amplifies: 4730.25, 4730.32, 4731.22, 4731.224, 4731.25, 4731.251, 4759.07, 4759.13, 4760.13, 4760.16, 4761.09, 4761.19, 4762.13, 4762.16, 4774.13, 4774.16, 4778.14, 4778.17
Five Year Review Date: 11/30/2028
Prior Effective Dates: 2/28/2004

Rule 4731-15-03 | Malpractice reporting requirement.

• Effective: November 30, 2023
• Promulgated Under: 119.03

(A) Any insurer providing professional liability insurance or any other entity that seeks to indemnify the professional liability of any person holding a valid license shall notify the board within thirty days after the final disposition of any written claim for damages where such disposition results in a payment which exceeds twenty-five thousand dollars.

(B) For purposes of the malpractice reporting statutes and this rule:

(1) The amount of payment shall mean the aggregate gross settlement, not including court costs or other litigation costs;

(2) The present value of future payments shall be utilized in calculating the aggregate gross settlement in cases of structured payments;

(3) In cases involving multiple defendants where payment exceeds twenty-five thousand dollars but no specific allocation is made in the disposition of the claim, a report shall be filed with the board for each of the defendants upon whose behalf the payment is made;

(4) Payments made solely for damages not arising from patient care need not be reported;

(5) The waiver of an outstanding debt is not construed as a payment.

(C) Each notification to the board shall include the following:

(1) The name and address of the person submitting the notification;

(2) The identity of the insurer or other indemnifying entity;

(3) The name and address of the insured who is the subject of the claim;

(4) The name of the person filing the written claim;

(5) The date of final disposition;

(6) The amount of payment;

(7) If applicable, the identity of the court in which the final disposition took place.

(D) An insurer that reports a medical malpractice payment to the national practitioner data bank may satisfy the reporting requirement of this rule by timely filing a copy of the national practitioner data bank medical malpractice report with the board.

(E) The reports received under the malpractice reporting statutes, and this rule may be investigated for possible violations of any law or rule of the board.

Last updated November 30, 2023 at 8:22 AM

Supplemental Information

Authorized By: 4730.07, 4731.05, 4760.19, 4762.19, 4774.11
Amplifies: 4730.32, 4731.224, 4760.16, 4762.16, 4774.16
Five Year Review Date: 11/30/2028

Rule 4731-15-04 | Professional society reporting.

• Effective: November 30, 2023
• Promulgated Under: 119.03

(A) Any professional association or society composed primarily of doctors of medicine and surgery, doctors of osteopathic medicine and surgery, doctors of podiatric medicine and surgery, practitioners of the limited branches of medicine, dietitians, anesthesiologist assistants, respiratory care professionals, physician assistants, acupunctruists, radiologist assistants, or genetic counselors that suspends or revokes an individual's membership in that society for violations of professional ethics or for reasons of professional incompetence or professional malpractice shall report that action to the board within sixty days after a final decision.

(B) Each report shall include:

(1) The licensee's name and license number;

(2) The action taken; and

(3) A summary of the underlying facts leading to the action.

(C) A professional association or society that reports an adverse action to the national practitioner data bank (NPDB) may satisfy the reporting requirement of this rule by timely filing a copy of the NPDB adverse action report with the board.

Last updated November 30, 2023 at 8:22 AM

Supplemental Information

Authorized By: 4730.07, 4731.05, 4759.05, 4760.19, 4761.03, 4762.19, 4774.11, 4778.12
Amplifies: 4730.32, 4731.224, 4759.13, 4760.16, 4761.19, 4762.16, 4774.16, 4778.17
Five Year Review Date: 11/30/2028
Prior Effective Dates: 9/1/1991