Overview
BORIM did not effectively monitor and control compliance reporting by PHS related to 27 physicians with BORIM PAs. BORIM was able to account for 432 out of 437 quarterly reports that PHS was required to send to it for 27 physicians with PAs; the other 5 reports were not submitted. Of the 432 that were submitted, 1 was incomplete and 13 were not submitted on time. Twelve of the 13 untimely reports involved two people for whom BORIM did not notify PHS that PAs had been approved and that quarterly compliance reporting should begin. For one of these two people, it was two years before PHS compliance reporting occurred.
In addition, BORIM did not keep past data in the tracking spreadsheet that logs the dates the monthly and quarterly compliance reports are received. Instead, BORIM only kept information for the current year on the spreadsheet.
As a result of these issues, BORIM could not ensure the public’s safety related to physicians returning to active practice. Without adequate controls and oversight, BORIM cannot achieve its mission, stated in its 2018 annual report, of ensuring “that only qualified and competent physicians of good moral character are licensed to practice in the Commonwealth of Massachusetts.”
Authoritative Guidance
According to Section II(f) of the PHC Unit’s procedures,
An essential task of the PHC Unit is to ensure that any monitoring reports . . . are filed on time. In order to effectuate this, the PHC Manager will coordinate with the PHC Program Coordinator in reviewing the submission of reports. The Program Coordinator will keep a spreadsheet tracking the submission of reports. The Program Coordinator will log the date that the report was received and the PHC Manager will review for any issues and sign off on it, logging it in the tracking system.
Reasons for Lack of Monitoring
BORIM management stated that the lack of notification regarding two physicians who were required to be monitored was a communication oversight. Also, BORIM personnel stated that the monthly and quarterly monitoring spreadsheet used to track receipt of compliance reports was a live document and that therefore information from prior years was not kept on the spreadsheet.
Recommendations
- BORIM should implement controls over monitoring activities to ensure policy compliance, timely submission of complete required reports, and prompt notification to PHS of physicians who require monitoring reports.
- BORIM should maintain records of all data for all years on the monthly and quarterly monitoring spreadsheet.
Auditee’s Response
As we discussed with your audit team, prior to this audit, in 2018, the Board conducted a self-audit of its Physician Health and Compliance Unit to ensure monitoring reports were provided in a timely manner. The recommendations referenced in this finding were adopted prior to the commencement of OSA Audit.
The Board measures PHS’ effectiveness and adherence to the Board’s performance standards by reviewing, among other measures, the quality of its recommendations, monitoring reports, results of body fluid sampling, inpatient and outpatient reports and in-depth psychiatric evaluations. When warranted, the Board will request that PHS provide additional reports and supporting documentation before the Board adjudicates a matter, and may also make recommendations to PHS regarding its business practices.
The Board also measures PHS’ effectiveness using the clinical expertise of its Board members. A past Board member, who was a psychiatrist, and a current Board member, who is a Licensed Alcohol and Drug Counselor and Certified Interventionist, reviewed and confirmed PHS’s effectiveness as matters were brought to the Board on a case by case basis. The Board also recognizes PHS' Board of Directors includes diverse representation and leaders from the medical community, including its Medical Director who is highly respected in the field of addiction medicine. PHS' effectiveness is also measured by the successful transition of many physicians back into the workplace.
Additionally, to ensure patient safety, the Board implemented procedures to confirm the reported information regarding impaired physicians is complete and brought forward in a timely manner.
BORIM's protocols require its Executive Director promptly (the same-day) to review statutory reports received by the Board, and refer those reports to the Complaint Committee for prompt review at the next Complaint Committee meeting, or for urgent matters to contact the Chair of the Board and perhaps hold an emergency board meeting.
Auditor’s Reply
In its response, BORIM states that it “conducted a self-audit of its Physician Health and Compliance Unit to ensure monitoring reports were provided in a timely manner” and, as a result of this audit, implemented changes to better ensure the timeliness of reporting. Despite this, we still found problems with PHS’s submission of quarterly monitoring reports to BORIM during the audit period. Timely reporting on physicians who have PAs is essential to keeping BORIM informed about physician progress and ensuring patient safety. Therefore, OSA made recommendations for improvements to both recordkeeping and internal controls, which we believe would be effective in resolving the problems we identified with the quarterly reporting process. Based on its response, BORIM is taking measures to address our concerns on this matter; however, we urge BORIM to implement all our recommendations.
| Date published: | April 7, 2020 |
|---|