The information on this page was last updated by Horty, Springer & Mattern on January 26, 2024.
NEW JERSEY
REPORTING REQUIREMENTS
N.J. Stat. Ann. §26:2H-12.2b. Notification to division by health care entity relating to status of professionals employed or under contract; incompetence, professional misconduct and unprofessional conduct
a. A health care entity shall notify the division in writing if a health care professional who is employed by, under contract to render professional services to, or has privileges granted by, that health care entity, or who provides such services pursuant to an agreement with a health care services firm or staffing registry:
(1) for reasons relating to the health care professional’s impairment, incompetency or professional misconduct, which incompetency or professional misconduct relates adversely to patient care or safety: (a) has full or partial privileges summarily or temporarily revoked or suspended, or permanently reduced, suspended or revoked; (b) has been removed from the list of eligible employees of a health services firm or staffing registry; (c) has been discharged from the staff; or (d) has had a contract to render professional services terminated or rescinded;
(2) has conditions or limitations placed on the exercise of clinical privileges or practice within the health care entity for reasons relating to the health care professional’s impairment, incompetency or professional misconduct or, which incompetency or professional misconduct relates adversely to patient care or safety, including, but not limited to, second opinion requirements, non-routine concurrent or retrospective review of admissions or care, non-routine supervision by one or more members of the staff, or the completion of remedial education or training;
(3) voluntarily resigns from the staff if: (a) the health care entity is reviewing the health care professional’s patient care or reviewing whether, based upon its reasonable belief, the health care professional’s conduct demonstrates an impairment or incompetence or is unprofessional, which incompetence or unprofessional conduct relates adversely to patient care or safety; or (b) the health care entity, through any member of the medical or administrative staff, has expressed an intention to do such a review;
(4) voluntarily relinquishes any partial privilege or authorization to perform a specific procedure if: (a) the health care entity is reviewing the health care professional’s patient care or reviewing whether, based upon its reasonable belief, the health care professional’s conduct demonstrates an impairment or incompetence or is unprofessional, which incompetence or unprofessional conduct relates adversely to patient care or safety; or (b) the health care entity, through any member of the medical or administrative staff, has expressed an intention to do such a review;
(5) while under, or subsequent to, a review by the health care entity of the health care professional’s patient care or professional conduct, is granted a leave of absence for reasons relating to a physical, mental or emotional condition or drug or alcohol use which impairs the health care professional’s ability to practice with reasonable skill and safety, except that no report is required for pregnancy-related leaves of absence or if the health care professional has sought assistance from a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the health care professional and is following the treatment regimen or monitoring as that program requires; or
(6) is a party to a medical malpractice liability suit, to which the health care entity is also a party, and in which there is a settlement, judgment or arbitration award.
As used in this subsection, incompetence, professional misconduct and unprofessional conduct shall not include personal conduct, such as tardiness, insubordination or other similar behavior, which does not relate to patient care or safety.
b. A health care entity shall notify the division in writing if it is in possession of information that indicates that a health care professional has failed to comply with a request to seek assistance from a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the health care professional, or has failed to follow the treatment regimen or monitoring program required by that program to assure that the health care professional’s physical, mental or emotional condition or drug or alcohol use does not impair the health care professional’s ability to practice with reasonable skill and safety.
c. A health care entity shall notify the division in writing if any health care professional who has been the subject of a report pursuant to this section, has had conditions or limitations on the exercise of clinical privileges or practice within the health care entity altered, or privileges restored, or has resumed exercising clinical privileges that had been voluntarily relinquished.
d. In the case of a health care professional who is providing services at a health care entity pursuant to an agreement with a health care services firm or staffing agency and is the subject of a notice pursuant to this section, the health care entity shall, when it submits a notice to the division concerning that health care professional, provide a copy of the notice to the health care services firm or staffing agency.
e. The form of notification shall be prescribed by the Commissioner of Health, in consultation with the Commissioner of Human Services in the case of psychiatric facilities and developmental centers, and shall contain such information as may be required by the division and shall be made within seven days of the date of the action, settlement, judgment or award.
f. A health care entity which fails to provide such notice to the division or fails to cooperate with a request for information by the division, the board or the Medical Practitioner Review Panel established pursuant to section 8 of P.L.1989, c. 300 (C.45:9-19.8) shall be subject to such penalties as the Department of Health may determine pursuant to sections 13 and 14 of P.L.1971, c. 136 (C.26:2H-13 and 26:2H-14).
g. A health care entity, or any employee thereof, which provides information to the division, the board, the Medical Practitioner Review Panel, a health care services firm or staffing agency, or the Department of Health, in good faith and without malice, regarding a health care professional pursuant to the provisions of this section or section 3 of P.L.1989, c. 300 (C.26:2H-12.2a), is not liable for civil damages in any cause of action arising out of the provision or reporting of the information.
h. A health care entity shall provide the health care professional who is the subject of a notice pursuant to paragraphs (1), (2), (4) and (5) of subsection a. of this section and subsection c. of this section with a copy of the notice provided to the division, when the health care entity submits the notice to the division.
i. For the purposes of this section, section 3 of P.L.1989, c. 300 (C.26: 2H-12.2a) and section 15 of P.L.2005, c. 83 (C.26:2H-12.2c):
“Board” means a professional and occupational licensing board within the Division of Consumer Affairs in the Department of Law and Public Safety which licenses or otherwise authorizes a health care professional to practice a health care profession.
“Division” means the Division of Consumer Affairs in the Department of Law and Public Safety.
“Health care entity” means a health care facility licensed pursuant to P.L.1971, c. 136 (C.26:2H-1 et seq.), a health maintenance organization authorized to operate pursuant to P.L.1973, c. 337 (C.26:2J-1 et seq.), a carrier which offers a managed care plan regulated pursuant to P.L.1997, c. 192 (C.26:2S-1 et seq.), a State or county psychiatric hospital, a State developmental center, a staffing registry, and a home care services agency as defined in section 1 of P.L.1947, c. 262 (C.45: 11-23).
“Health care professional” means a person licensed or otherwise authorized pursuant to Title 45 or Title 52 of the Revised Statutes to practice a health care profession that is regulated by the Director of the Division of Consumer Affairs or by one of the following boards: the State Board of Medical Examiners, the New Jersey Board of Nursing, the New Jersey State Board of Dentistry, the New Jersey State Board of Optometrists, the New Jersey State Board of Pharmacy, the State Board of Chiropractic Examiners, the Acupuncture Examining Board, the State Board of Physical Therapy, the State Board of Respiratory Care, the Orthotics and Prosthetics Board of Examiners, the State Board of Psychological Examiners, the State Board of Social Work Examiners, the State Board of Veterinary Medical Examiners, the State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians, the Audiology and Speech-Language Pathology Advisory Committee, the State Board of Marriage and Family Therapy Examiners, the Occupational Therapy Advisory Council and the Certified Psychoanalysts Advisory Committee. Health care professional also includes a nurse aide and a personal care assistant certified by the Department of Health.
§26:2H-12.2c. Inquiry from another health care entity; disclosure of job performance information; definition; immunity from civil liability; failure to disclose; penalties
a. A health care entity, upon the inquiry of another health care entity, shall truthfully:
(1) disclose whether, within the seven years preceding the inquiry, it provided any notice to the division pursuant to section 2 of P.L.2005, c. 83 (C.26:2H-12.2b), or to the review panel, as required by section 3 of P.L.1989, c. 300 (C.26:2H-12.2a), with respect to the health care professional about whom the inquiry has been made, providing a copy of the form of notification and any supporting documentation that was provided to the division, a professional or occupational licensing board in the Division of Consumer Affairs in the Department of Law and Public Safety, or the review panel; and
(2) provide information about a current or former employee’s job performance as it relates to patient care, as provided in this section, and, in the case of a former employee, the reason for the employee’s separation.
b. For the purposes of this section, “job performance” shall relate to the suitability of the employee for re-employment at a health care entity, and the employee’s skills and abilities as they relate to suitability for future employment at a health care entity. Information about a current or former employee’s job performance pursuant to this paragraph shall be based on the employee’s performance evaluation, and provided to another health care entity only if: (1) the evaluation has been signed by the evaluator and shared with the employee; (2) the employee has had the opportunity to respond; and (3) the employee’s response, if any, has been taken into consideration when providing the information to another health care entity.
Job performance as it relates to patient care shall not include the current or former employee’s participation in labor activities pursuant to the “National Labor Relations Act,” 29 U.S.C. s.151 et seq.
c. A health care entity, or any employee designated by the entity, which, pursuant to this section, provides information in good faith and without malice to another health care entity concerning a health care professional, including information about a current or former employee’s job performance as it relates to patient care, is not liable for civil damages in any cause of action arising out of the provision or reporting of the information.
d. A health care entity which fails to truthfully disclose information to another health care entity making an inquiry pursuant to this section or fails to cooperate with such request for information by the other health care entity shall be subject to such penalties as the Department of Health may determine pursuant to sections 13 and 14 of P.L.1971, c. 136 (C.26:2H-13 and 26:2H-14) and section 16 of P.L.1997, c. 192 (C.26:2S-16), or the director shall determine pursuant to P.L.1989, c. 331 (C.34:8-43 et seq.), as applicable.
§26:2H-12.2d. Reporting of possession of information relating to impairment, gross incompetence or unprofessional conduct of another health care professional; immunity from civil liability
a. A health care professional employed by or practicing at a health care entity shall promptly notify the person at the entity, who is designated by that entity, if the health care professional is in possession of information which reasonably indicates that another health care professional who is employed by or practicing at the entity has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare.
b. A health care professional who provides information pursuant to this section, in good faith and without malice, shall not be liable for civil damages in any cause of action arising out of the provision of such information.
c. The reporting requirement in this section shall be in addition to the reporting requirement for health care professionals established in section 12 of P.L.2005, c. 83 (C.45:1-37).
§45:1-35. Immunity from civil liability relating to provision of information
A health care entity, health care professional or any other person who provides to the division, a board or the review panel, in good faith and without malice, any information concerning an act by a health care professional which the person has reasonable cause to believe involves misconduct that may be subject to disciplinary action by the division, board or review panel, as applicable, or any information relating to such conduct requested by the division, board or review panel in the exercise of its statutory responsibilities or which may be required by statute, shall not be liable for civil damages in any cause of action arising out of the provision of such information or services.
§45:1-37. Reporting requirement; failure to comply; immunity from civil liability relating to notification; exception
a. A health care professional shall promptly notify the division if that health care professional is in possession of information which reasonably indicates that another health care professional has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare. A health care professional who fails to so notify the division is subject to disciplinary action and civil penalties pursuant to sections 8, 9 and 12 of P.L.1978, c. 73 (C.45:1-21, 45:1-22 and 45:1-25).
b. A health care professional shall be deemed to have satisfied the reporting requirement concerning another health care professional’s impairment by promptly providing notice to the division, the board or a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the licensee.
c. (1) There shall be no private right of action against a health care professional for failure to comply with the notification requirements of this section.
(2) There shall be no private right of action against a health care entity if a health care professional who is employed by, under contract to render professional services to, or has privileges granted by, that health care entity, or who provides such services pursuant to an agreement with a health care services firm or staffing registry, fails to comply with the notification requirements of this section.
d. A health care professional who provides notification to the division, board or review panel, in good faith and without malice, about a health care professional who is impaired or grossly incompetent or who has demonstrated unprofessional conduct, pursuant to this section, is not liable for civil damages to any person in any cause of action arising out of the notification.
e. Notwithstanding the provisions of this section to the contrary, a health care professional is not required to provide notification pursuant to this section about an impaired or incompetent health care professional if the health care professional’s knowledge of the other health care professional’s impairment or incompetence was obtained as a result of rendering treatment to that health care professional.
§45:1-38. Notification to licensing authority; investigation; notification to health entity of limits on license
a. Upon receipt of notice from a health care entity, or any employee thereof, pursuant to section 2 of P.L.2005, c. 83 (C.26:2H-12.2b), notice from a health care professional pursuant to section 12 of P.L.2005, c. 83 (C.45:1- 37) or information concerning the conduct of a health care professional pursuant to section 10 of P.L.2005, c. 83 (C.45:1-35), the division shall promptly notify the board that issued the license or other authorization to practice to the person to whom the notice relates.
The division or board, as applicable, shall initiate an investigation concerning the information received and obtain any additional information that may be necessary in order to determine if disciplinary charges should be pursued or if an application to temporarily suspend or otherwise limit the health care professional’s license or other authorization to practice should be initiated.
b. The division or the board may seek the assistance of a consultant or other knowledgeable person in evaluating the information and may request the board or the Attorney General to exercise investigative powers pursuant to section 5 of P.L.1978, c. 73 (C.45:1-18) in the conduct of its investigation.
c. If the Attorney General files charges based on information derived from the notice from a health care entity or if the board revokes or permanently or temporarily suspends or otherwise limits the license or other authorization to practice of a health care professional, the board shall notify each health care entity with which the health care professional is affiliated.
NJ Admin. Code §8:43G-16.1 Medical staff structural organization
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(j) The clinical privileges of all individuals shall be fully reviewed periodically. Actions which result in reduction or restriction of staff privileges based on this review shall be reported to the New Jersey Board of Medical Examiners in accordance with N.J.S.A. 26:2H-12.2.
(k) The hospital shall notify the New Jersey State Board of Medical Examiners, or a medical practitioner review panel created by legislation and subordinate to the Board, if a practitioner who is employed by, under contract to render professional services to, or has privileges at the hospital:
1. Voluntarily resigns from the staff while the facility is reviewing the practitioner’s conduct or patient care or has through any member of the medical or administrative staff expressed an intention to do so;
2. Voluntarily relinquishes any partial privileges to perform a specific procedure while the hospital is reviewing the practitioner’s conduct or patient care or has, through any member of the medical or administrative staff, expressed an intention to do so;
3. Has full or partial privileges summarily or temporarily revoked or suspended, permanently reduced, suspended or revoked, has been discharged from the staff or has had a contract to render professional services terminated or rescinded for reasons relating to the practitioner’s incompetency misconduct, or impairment;
4. Agrees to the placement of conditions or limitations on the exercise of clinical privileges or practice within the health care facility including, but not limited to: second opinion requirements, non-routine concurrent or retrospective review of admissions or care, non-routine supervision by one or more members of the staff, or the completion of remedial education or training;
5. Is granted a leave of absence pursuant to which he or she may not exercise clinical privileges or practice within the hospital if the reasons provided in support of the leave relate to any physical, mental, or emotional condition or drug or alcohol use, which might impair the practitioner’s ability to practice with reasonable skill and safety;
6. Is a party to a medical malpractice liability suit in which the hospital is also a party, in which there is a settlement, judgement, or arbitration award; or
7. Has privileges, conditions or limitations reinstated or a leave of absence concluded where the results of the investigation clear the practitioner from all allegations of misconduct, impairment, or incompetence.
(l) Notifications required by (k) above shall be provided within seven days of the reported event and shall be submitted on forms approved by the Department of Health for that purpose.
(m) The hospital shall provide upon request to the State Board of Medical Examiners, or to a practitioner review panel created by legislation and reporting to the board, such additional information on individual instances of loss or change of physician privileges, possible impairments, and medical malpractice liability as the board or panel requests in accordance with law.
(n) The hospital shall provide to the following:
Office of the Assistant Commissioner
Division of Health Facility Survey and Field Operations
Department of Health
PO Box 367
Trenton, N.J. 08625-0367
copies of all reports regarding physician hospital privileges sent to the New Jersey State Board of Medical Examiners, or to the practitioner review panel created by legislation and reporting to the board. All records regarding such copies shall be made available to the Department of Health personnel for official purposes and, for each report, to the specific facility mentioned in the report.
(o) For the purposes of (k) through (n) above, “practitioner” means only a person licensed to practice: medicine and surgery under N.J.S.A. 45:9-1 et seq. or a medical resident or intern; or podiatry under N.J.S.A. 45:5-1 et seq.
13:45E-3.1 Notification to the Clearing House Coordinator by a health care entity
(a) Except as provided in (c) below, a health care entity shall file a report with the Clearing House Coordinator concerning a health care professional who is employed by, under contract to render professional services to, or has clinical privileges granted by that health care entity, or who provides such services pursuant to an agreement with a health care services firm or staffing registry if:
1. For reasons relating to the health care professional’s impairment, incompetency or professional misconduct, which incompetency or professional misconduct relates adversely to patient care or safety, the health care entity:
i. Summarily or temporarily revokes or suspends or permanently reduces, suspends or revokes the health care professional’s full or partial clinical privileges or practice;
ii. Removes the health care professional from the list of eligible employees of a health services firm or staffing registry;
iii. Discharges the health care professional from the staff of the health care entity; or
iv. Terminates or rescinds a contract with the health care professional to render professional services;
2. The health care entity places conditions or limitations on the health care professional’s exercise of clinical privileges or practice within the health care entity for reasons relating to the health care professional’s impairment, incompetency or professional misconduct, which incompetency or professional misconduct relates adversely to patient care or safety, including, but not limited to, second opinion requirements, non-routine concurrent or retrospective review of admissions or care specifically tailored after a preliminary review of care, non-routine supervision by one or more members of the staff, or the completion of remedial education or training;
3. The health care professional voluntarily resigns from the staff if:
i. Whether or not known to the health care professional, the health care entity is undertaking an investigation or a review of:
(1) The quality of patient care rendered by the health care professional to determine if the care could have had adverse consequences to the patient;
(2) Conduct by the health care professional that demonstrates an impairment;
(3) Conduct by the health care professional that demonstrates incompetence that relates adversely to patient care or safety; or
(4) Unprofessional conduct by the health care professional that relates adversely to patient care or safety; or
ii. A body within the health care entity that has the authority to initiate an investigation that may lead to disciplinary action, has expressed an intention through any member of the medical or administrative staff, reflected in the records of the health care entity or expressed directly to the health care professional, to conduct such a review of the health care professional’s patient care or conduct and the healthcare entity notifies the health care professional that the health care entity is conducting or intends to conduct the review or investigation.
4. The health care professional voluntarily relinquishes any partial clinical privilege or authorization to perform a specific procedure if:
i. Whether or not known to the health care professional, the health care entity is undertaking an investigation or a review of:
(1) The quality of patient care rendered by the health care professional to determine if the care could have had adverse consequences to the patient;
(2) Conduct by the health care professional that demonstrates an impairment;
(3) Conduct by the health care professional that demonstrates incompetence that relates adversely to patient care or safety; or
(4) Unprofessional conduct by the health care professional that relates adversely to patient care or safety; or
ii. A body within the health care entity that has the authority to initiate an investigation that may lead to disciplinary action has expressed an intention, through any member of the medical or administrative staff, reflected in the records of the health care entity or expressed directly to the health care professional, to conduct such a review of the health care professional’s patient care or conduct and the healthcare entity notifies the health care professional that the health care entity is conducting or intends to conduct the review or investigation.
5. The health care entity grants a leave of absence to the health care professional for reasons relating to a physical, mental or emotional condition or drug or alcohol use which impairs the health care professional’s ability to practice with reasonable skill and safety while the health care professional is under, or subsequent to, a review by the health care entity of the health care professional’s patient care or professional conduct, except that no report is required for pregnancy-related leaves of absence; or
6. The health care professional is a party to a medical malpractice liability suit, to which the health care entity is also a party, and in which there is a settlement, judgment or arbitration award.
(b) The initiation of an investigation under (a)3i or 4i above shall have been reflected contemporaneously in the records of the health care entity.
(c) A health care entity is not obligated to file a report under (a)5 above if the health care professional is participating, or agrees to participate, in an intervention program approved by the Division or the relevant licensing board and agrees to follow, and then does follow the treatment regimen or monitoring required by the program.
1. The health care entity shall confirm with the intervention program that the health care professional has agreed to participate and is participating in the program and has agreed to follow and continues to follow the treatment regimen or monitoring required by the program.
2. The health care entity shall notify the health care professional that the health care entity would have filed a report under (a)5 above but for the health care professional’s participation in, and compliance with the treatment regimen or monitoring required by, an approved intervention program.
3. The health care entity shall file the report under (a)5 above within seven days after obtaining knowledge that the health care professional is not in compliance with the requirements of the program.
(d) When a health care entity is required to notify the Clearing House Coordinator under (a)l, 2 or 5 above about a health care professional who has exhibited conduct relating adversely to patient care or safety, the action to be reported to the Clearing House Coordinator is action taken by the health care entity that limits, curtails or prevents a health care professional from performing the full scope of his or her duties or places conditions on that performance.
(e) A health care entity shall file an additional report if the entity’s due process review or the passage of time results in the health care entity taking other action that results in the full or partial restoration of the duties that had been limited, curtailed or prevented, or further limits, curtails or prevents a health care professional from performing the full scope of his or her duties.
(f) A health care entity shall file a report with the Clearing House Coordinator pursuant to this section if the action taken by the health care entity is to require the health care professional to undergo remedial education or training.
(g) A report required by this section shall be filed with the Clearing House Coordinator within seven calendar days of:
1. The date action under (a)1, 2 or 5 or (e) above was taken by the health care entity;
2. The entry of a final order or judgment on an arbitration award; settlement by the parties in a litigated matter either by stipulation of the parties or the entry of a final order to dismiss; or entry of a final judgment or order on a motion under (a)6 above; or
3. The date the health care professional voluntarily resigns under the conditions provided in (a)3 above or voluntarily relinquishes any partial privilege or authorization to perform a specific procedure under the conditions provided in (a)4 above.
13:45E–3.2 Notification to the Clearing House Coordinator by a health care professional
(a) A health care professional shall file a report with the Clearing House Coordinator if that health care professional is in possession of information which reasonably indicates that another health care professional has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare.
(b) The health care professional shall file the report required under (a) above if he or she has personal knowledge of the information required to be reported, unless the health care professional is only aware of that information as a result of participation in a review or other proceeding conducted by or for a health care entity.
(c) A health care professional, who would otherwise be required to file a report under (a) above, may discharge his or her duty by joining with the entity in filing a report with the Clearing House Coordinator, evidenced by his or her signature on the report or by receiving written assurance from the health care entity notified that it has fulfilled its reporting requirement.
(d) A health care professional who has signed a report to be filed jointly with the entity and received the acknowledgement and undertaking shall have satisfied his or her duty to file a report.
(e) A health care professional who signs a joint report shall retain a copy of the acknowledgement and undertaking for a period of seven years.
13:45E–3.3 Duty of health care entity to a health care professional subject to N.J.S.A. 45:1–37
(a) A health care entity shall execute and deliver to the health care professional signing the report an acknowledgment of such signing and an undertaking to file the joint report with the Clearing House Coordinator.
(b) A health care entity that is reporting the conduct of a health care professional on behalf of a health care professional who has reported the conduct to the health care entity as set forth in N.J.A.C. 13:45E–3.2(c), shall provide notice and a copy of the filed report to the reporting health care professional within seven calendar days that the health care entity has notified the Clearing House Coordinator.