59A-12.012. Internal Risk Management Program

(1) Every health maintenance organization certified under Part III of Chapter 641, F.S., shall, as a part of its administrative function, establish an internal risk management program as defined in Section 641.55, F.S:

(2) The risk management program shall be the ultimate responsibility of the governing body of the HMO.

(3) Every Staff Model and Mixed Model HMO certified under this part which has an annual premium volume of $10 million or more shall employ or contract with a risk manager who shall be responsible for implementation and oversight of the organization’s internal risk management program. A part-time risk manager shall not be responsible for risk management programs in more than four organizations or facilities. Every IPA Model and every HMO with an annual premium volume of less than $10 million shall designate an officer or employee of the HMO to serve as risk manager.

(4) As part of the internal risk management program an incident reporting system shall be established for each HMO. Procedures shall be detailed in writing and disseminated to all employees of the HMO. Within 30 days of employment all new employees shall be instructed in the operation and responsibilities of the incident reporting system. All non-physician personnel who provide direct patient care in clinical areas of a Staff or Mixed Model HMO shall receive 1 hour annually of risk management and risk prevention education and training including the importance of accurate and timely incident reporting. The incident reporting system shall include the prompt, within 3 business days, reporting of incidents to the risk manager. Incident reports shall be on a form developed by the HMO for the purpose and shall contain at least the following information:

(a) The patient’s name, date of birth, sex, physical findings or diagnosis and, if hospitalized; locating information, admission time and date, and the facility’s name;

(b) A clear and concise description of the incident including time, date, exact location, and coding elements as needed for the annual report based on ICD-10-CM;

(c) Whether or not a physician was called and, if so, a brief statement of said physician’s recommendations as to medical treatment, if any;

(d) A listing of all persons known to be involved directly in the incident, including witnesses, along with locating information for each; and,

(e) The name, signature and position of the person completing the report, along with date and time that the report was completed.

(5) The HMO shall be responsible for regular and systematic review of all incident reports and written patient grievances for the purpose of identifying trends or patterns as to time, place or persons and, upon emergence of any trend or pattern in incident occurrence, shall develop recommendations for appropriate corrective action and risk management prevention education and training. Summary data shall be systematically maintained for 3 years.

(a) At least quarterly or more often as may be required by the governing body, the risk manager shall provide a summary report to the governing body which includes information about activities of risk management.

(b) Evidence of the incident reporting and analysis system and copies of summary reports and evidence of recommended and accomplished corrective actions shall be made available for review by the Agency upon request during normal business hours.

(6) Annual reports must be submitted to the Agency summarizing the incident reports that were filed in the organization during the preceding calendar year pertaining to services rendered on the premises of the organization as as defined in Section 641.55, F.S. Annual reports must be submitted electronically to the Agency as required in Section 641.55, F.S., on Annual Report, AHCA Form 3140-5002 OL, May 2018, https://www.flrules.org/Gateway/reference.asp?No=Ref-12147, which is hereby incorporated by reference and may be obtained from the Agency’s annual reporting system located at: https://apps.ahca.myflorida.com/adverseincidentreport/.

(7) All adverse or untoward incidents, whether occurring in the facilities of the Staff Model or Mixed Model organization or arising from health care prior to admission to the facilities of the organization or in the facility of one of its providers must be reported to the Agency as defined in Section 641.55, F.S. Adverse incident reports must be submitted electronically to the Agency within 3 working days after its occurrence, with a more detailed followup within 10 days of the first report as required in Section 641.55, F.S., on Health Maintenance Organization Adverse Incident Report, HMO Adverse Incident, AHCA Form 3140-5003 OL, April 2017, which is hereby incorporated by reference and available at: https://www.flrules.org/Gateway/reference.asp?No=Ref-08776, and may be obtained from the Agency’s adverse incident reporting system which can only be accessed through the Agency’s Single Sign On Portal located at https://apps.ahca.myflorida.com/SingleSignOnPortal.

Rulemaking Authority 641.55, 641.56 FS. Law Implemented 641.55 FS. History–New 1-28-88, Amended 3-11-92, Formerly 10D-100.012, Amended 11-13-17, 10-7-20.