Health Care Department Operations Manual

Chapter 5 – Administrative

Article 6 – Contracts and Procurement

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5.6.6 Direct Health Care Service Contractor and/or Provider Performance Issue Reporting

Policy
- California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) staff shall document and report, in writing, any performance issues concerning a direct health care service contractor and/or provider to the Direct Care Contracts Section (DCCS).
Procedure
- Institution or HQ Staff Responsibilities
  - Institution and HQ staff shall report all contractor and/or provider reportable performance issue(s) by:
    - Utilizing the forms available on Lifeline at the following link: Resources (sharepoint.com) to report identified issues.
      - For non-network provider issues, document the unsatisfactory contractor and/or provider performance issue using the CCHCS-MC-411, Direct Health Care Service Contractor and/or Provider Incident Report available at the following link: CCHCS-MC-411.docx (sharepoint.com).
      - For in-network provider performance issues, utilize the Healthcare Provider Network (HPN) Potential Quality Issue (PQI) Referral Form available at the following link: Direct Care Contracts – Healthcare Provider Network (HPN) Potential Quality Issue (PQI) Referral Form – All Documents (sharepoint.com).
    - Notifying the CCHCS DCCS Help Desk (herein referred to as Help Desk) by e-mailing the completed CCHCS-MC-411 and/or HPN PQI Referral Form to: CCHCSHealthcareContractsHelpdesk@cdcr.ca.gov.
  - Institution and HQ staff may contact the Help Desk with questions about direct health care services contract terms or performance requirements via e-mail, or by telephone at (916) 691-0698.
- DCCS Staff Responsibilities
  - The Help Desk staff shall:
    - Acknowledge receipt of all e-mails received through the Help Desk inbox and inform the submitting party that Specialty Network Administration Program (SNAP) staff will respond within three business days.
    - Notify SNAP via SNAP@cdcr.ca.gov following the receipt of the performance issue and forward the CCHCS-MC-411 and/or HPN PQI Referral Form and all relevant documents to SNAP within one business day.
    - Log and assign a tracking number to all inquiries related to contractor and/or provider reportable performance, and monitor the status of each inquiry.
  - SNAP staff shall:
    - Maintain a listing of incident reports/issues, monitor the status, and track all forms and related documents received from the Help Desk.
    - Communicate with the submitting party for further details/completion of the forms if the forms do not indicate enough details to fully address the incident/issue.
    - Review and determine a recommendation for an appropriate course of action for each performance issue received. If the issue is determined to be a critical incident, all forms and related documents shall be forwarded to DCCS Management.
  - DCCS Management shall:
    - Review and assess the incident report. If the issue is deemed a clinical issue, forward all forms and related documents to Utilization Management (UM) leadership.
    - Follow-up with UM and assess whether a corrective action plan is required.
  - UM shall:
    - Review all forms and related documents of the incident.
    - Notify Health Net if a corrective action plan is needed.
- Unsatisfactory Contractor and/or Provider Performance Monitoring
  - DCCS and/or UM shall follow-up with the institution, as needed, to confirm the contractor and/or provider’s on-going performance is acceptable.
    - If performance remains unsatisfactory and compliance does not occur within the specified timeline in the corrective action plan, DCCS Management may provide the contractor with a Notice of Stop Work, Notice of Contract Suspension, Notification of Breach of Contract, or Notice of Termination Agreement.
    - A Notification of Breach of Contract, Notice of Stop Work, or Notice of Contract Suspension shall be sent to the contractor when the contractor and/or provider fails to comply with the specified terms of the contract or corrective action plan.
      - A Notice to Stop Work or Notice of Contract Suspension may be issued to direct the contractor to suspend performance or stop performing services for a specified period of time. This shall be the contractor and/or provider’s last opportunity to address the unsatisfactory performance and a timeframe in which to comply with contract terms shall be provided. Cancellations, extensions, or modifications and timelines for each notice may vary based on contract language.
    - If performance remains unsatisfactory through the specified timeframe, a Notice of Termination Agreement may be issued. Contract termination with cause may be immediate, or without cause within 30 calendar days from date of Notice of Termination Agreement. However, timelines may vary based on contract language.
    - In the event of contract or provider termination, SNAP staff shall coordinate with the institution or HQ staff to determine if a new contract or provider is needed for the impacted service.
    - Unless and until a Notice of Termination Agreement is issued, the contractor and/or provider shall continue to provide health care services under the contract.
- Contractor and/or Provider Immediate Removal
  - In cases of egregious performances that warrant removing a contractor and/or provider from an institution, the institution or HQ staff shall contact the Help Desk immediately upon removal by telephone or e-mail for instructions on how to proceed.
References
- State Contracting Manual, Volume 1, Chapter 9 https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/State-Contracting
- California Correctional Health Care Services, Direct Care Contracts Section Directives and Procedures Resources (sharepoint.com)
- Health Care Department Operations Manual, Chapter 5, Article 1, Section 5.1.4, Reporting of Actual or Suspected Incidents of Fraud, Errors, and Improper Governmental Activities
Revision History
- Effective: 11/2017
  Revised: 01/2022