PURPOSE: This rule establishes procedures for the voluntary evaluation of human immunodeficiency virusand hepatitis B virusinfected health care professionals who perform invasive procedures in order to determine whether practice restrictions or 19 CSR 20-26

limitations should be applied, as defined in section 191.700, RSMo.

1. (1) The definitions in 19 CSR 20-26.050 shall be used in the interpretation of this rule.
2. (2) Any health care professional who performs invasive procedures is advised to know his/her human immunodeficiency virus
3. (HIV) antibody status and hepatitis B surface antigen (HBsAg) status. If HBsAg is present, the presence or absence of hepatitis B e antigen (HBeAg) shall be determined. If a significant occupational exposure occurs which could place the health care professional at risk of acquiring HIV or hepatitis B virus
4. (HBV) infection, appropriate post-exposure evaluation should be undertaken.

5. (3) HIV- or HBV-infected health care professionals who perform invasive procedures may be voluntarily evaluated by an expert review panel appointed by the department according to section 191.700, RSMo. This panel shall follow subsections (3)(A)–(P) of this rule.

   1. (A) Health care professionals infected with HIV or HBV who perform invasive procedures and who choose to be evaluated by an expert review panel appointed by the department according to section 191.700, RSMo shall apply for the evaluation in writing to the director. Directors of health care facilities (chief administrative officers or equivalents) allowed by 191.700.2(1), RSMo to seek evaluation of infected health care professionals who perform invasive procedures shall, with the consent of the infected health care professional and after consultation with the professional’s private physician, apply in writing to the director of the Department of Health.

   2. (B) Upon receipt of a written request for evaluation, the director shall appoint an expert review panel by utilizing the following criteria:

      1. 1. The panel shall include those individ-

uals specified by 191.700.2(2)(a)–(d), RSMo and may include additional individuals if the director determines this is necessary; and

1. 2. The director shall seek input from

appropriate professional organizations in making his/her appointments.

1. (C) The subject of the evaluation shall provide the director with a list of all health care facilities and community-based practices, regardless of location, where the subject performs invasive procedures.

2. (D) The expert review panel shall utilize the following to evaluate the health care professional’s practice:

   1. 1. Criteria specified in 191.700.2(3),

RSMo; AND SENIOR SERVICES

1. 2. Verification of the health care profes-

sional’s licensure status;

1. 3. Current, scientific evidence that is

available; and

1. 4. Panel members’ professional judg-

ments.

1. (E) Panel members shall be subject to the requirements of section 191.656, RSMo regarding the confidentiality of information on an HIV-infected health care professional’s infection status.
2. (F) The health care professional shall be allowed to appear before the panel and present any information which s/he believes to be pertinent to the panel’s task. The health care professional’s personal physician(s) and any other individual(s) the health care professional believes can provide pertinent input into the process shall be allowed to appear before the panel.
3. (G) The panel may recommend that restrictions or limitations be placed on the practice of the health care professional.
4. (H) The panel shall require the health care professional to notify any affected patient in a timely manner whenever a parenteral or mucous membrane exposure to the health care professional’s blood occurs.
5. (I) The panel’s findings and recommendations shall be conveyed in writing to the health care professional and to the director.
6. (J) The director shall disclose to the chief administrative officer or equivalent individual in each health care facility or communitybased practice where the health care professional is performing invasive procedures any restrictions or limitations placed on his/her practice by the panel.
7. (K) If the health care professional seeks to affiliate with an additional health care facility or community-based practice, regardless of its location, where s/he will be performing invasive procedures, s/he shall disclose to the chief administrative officer or equivalent individual in that facility or practice the findings of the review panel, and any restrictions or limitations placed on his/her practice by the panel, prior to the affiliation and the provision of patient care. S/he shall also advise the department of the new practice location.
8. (L) If the health care professional plans to begin performing invasive procedures at a health care facility or community-based practice where s/he is currently affiliated but not presently performing those procedures, s/he shall disclose to the chief administrative officer or equivalent individual in that facility or practice the findings of the review panel, and any restrictions or limitations placed on his/her practice by the panel, prior to the performance of any invasive procedures, and report his/her intention to begin performing invasive procedures in writing to the director prior to beginning to perform these procedures.
9. (M) If the review panel places restrictions or limitations on the health care professional’s practice, it shall be the responsibility of each health care facility where s/he is employed and performing invasive procedures to monitor him/her for compliance at appropriate intervals, at least annually, based on his/her medical status and the types and frequencies of invasive procedures s/he performs. If a facility finds the health care professional to be noncompliant, it shall report this in writing to the appropriate state board, as provided under Chapters 330, 332, 334 or 335, RSMo, and to the director.
10. (N) If the review panel places restrictions or limitations on the practice of a health care professional who performs invasive procedures in a community-based setting, it shall be the responsibility of the department to monitor him/her for compliance in this setting at appropriate intervals, at least annually, based on his/her medical status and the types and frequencies of invasive procedures s/he performs. If the department finds the health care professional to be noncompliant, it shall report this in writing to the appropriate state board, as provided under Chapters 330, 332, 334 or 335, RSMo, and to the director.
11. (O) If the director becomes aware that the infected health care professional is noncompliant with practice restrictions or limitations at any location where s/he is performing invasive procedures, the director shall report this noncompliance to the chief administrative officer or equivalent individual in each health care facility and community-based practice where the health care professional performs invasive procedures.
12. (P) The panel shall require, as necessary, that the infected health care professional undergo periodic reviews to determine if the decision to place or not to place restrictions or limitations on his/her practice needs to be modified because of changes in his/her medical condition or some other relevant circumstance. If a review results in the panel making such a modification, this modification shall be conveyed in writing to the health care professional and the director. If the modification results in restrictions or limitations, or further restrictions or limitations, being placed on the health care professional, the director shall disclose this modification to the chief administrative officer or equivalent individual in each health care facility or community-based practice where the health care professional is performing invasive procedures.
13. (Q) If restrictions or limitations have been Public Health

placed on a health care professional’s practice by the panel and if later there is a change in the individual’s medical condition or some other relevant circumstance, and as a result s/he believes that the restrictions or limitations should be modified, s/he may request in writing to the director that the panel consider such a modification. A similar written request may also be made by the director or chief administrative officer of a health care facility with the consent of the infected health care professional and after consultation with his/her private physician. The panel shall review the information and determine whether modification is necessary. If a modification is made, this shall be conveyed in writing to the health care professional and the director. If the modification results in further restrictions or limitations being placed on the health care professional, the director shall disclose this modification to the chief administrative officer or equivalent individual in each health care facility or community-based practice where the health care professional is performing invasive procedures.

1. (4) As described in 191.700.2(5)(d), RSMo, a health care facility peer review panel may evaluate HIV- or HBV-infected health care professionals who perform invasive procedures. This evaluation process may be accessed directly by an infected health care professional, or by the director of a health care facility with the consent of the infected health care professional and after consultation with his/her private physician. This evaluation shall take place as follows:

   1. (A) If a health care facility regulated under sections 197.010–197.120, RSMo maintains or establishes an internal peer review panel for the evaluation of HIV- or HBV-infected health care professionals who perform invasive procedures, this panel shall—

      1. 1. Maintain the confidentiality of the

infected health care professional. Panel members shall be subject to the requirements of section 191.656, RSMo regarding the confidentiality of information on an HIV-infected health care professional’s infection status;

1. 2. Conduct an evaluation of the infected

health care professional and his/her practice. This evaluation and any recommendations shall be based on the premise that HIV or HBV infection alone does not justify limiting the health care professional’s duties;

1. 3. Allow the health care professional to

appear before the peer review panel and present any information which s/he believes to be pertinent to the panel’s task. The health care professional’s personal physician(s), as well as any other individual(s) the health care professional believes can provide input into the process, shall be allowed to appear before the panel;

1. 4. Establish, utilizing the criteria speci-

fied in subsection (3)(D) of this rule, whether restrictions or limitations shall be placed on the practice of the health care professional. If the panel is uncertain about whether a specific procedure may pose some risk of HIV or HBV transmission, it may recommend that this procedure be performed only after the patient has been informed of the health care professional’s infection status;

1. 5. Require the health care professional

to notify any affected patient in a timely manner whenever a parenteral or mucous membrane exposure to the health care professional’s blood occurs;

1. 6. Report its findings and recommenda-

tions in writing to the health care professional;

1. 7. Report its findings and recommenda-

tions in writing to the director including how the evaluation process was conducted. The department shall review the report to determine concurrence with 191.700.2(5)(d), RSMo and this rule. Results of the department’s review shall be reported back to the facility. In the event the health care professional later seeks an evaluation by a department-appointed panel, the findings and recommendations of the facility’s peer review panel shall be included as part of this evaluation; and

1. 8. Require, as necessary, that the infect-

ed health care professional undergo periodic reviews to determine if the decision to place or not to place restrictions or limitations on his/her practice needs to be modified because of changes in his/her medical condition or some other relevant circumstance. If a review results in the panel making such a modification, this modification shall be conveyed in writing to the health care professional and the director; and

1. (B) When a facility’s internal peer review panel conducts a review in concurrence with 191.700.2(5)(d), RSMo and this rule, the following shall be performed:

   1. 1. The infected health care professional

shall provide a list to the director of all other health care facilities and community-based practices, regardless of location, where s/he performs invasive procedures. The director shall disclose to the chief administrative officer or equivalent individual in each of these other facilities and practices any restrictions or limitations placed on the health care professional’s practice by the panel;

1. 2. If the health care professional seeks to

affiliate with an additional health care facility or community-based practice, regardless of its location, where s/he will be performing invasive procedures, s/he shall disclose to the chief administrative officer or equivalent individual in that facility or practice the findings of the peer review panel, and any restrictions or limitations placed on his/her practice by the panel, prior to the affiliation and the provision of patient care, and notify the department of the new practice location;

1. 3. If the health care professional plans to

begin performing invasive procedures at a health care facility or community-based practice where s/he is currently affiliated but not presently performing those procedures, s/he shall disclose to the director or chief administrative officer in that facility or practice the findings of the peer review panel, and any restrictions or limitations placed on his/her practice by the panel, prior to the performance of any invasive procedures, and report the change in practice to the department;

1. 4. It shall be the responsibility of each

health care facility where the health care professional is employed and performing invasive procedures to monitor him/her for compliance with the practice restrictions or limitations at appropriate intervals, at least annually, based on his/her medical status and the types and frequencies of invasive procedures s/he performs. If a facility finds the health care professional to be noncompliant, it shall report this in writing to the appropriate state board, as provided under Chapters 330, 332, 334 or 335, RSMo, and to the director;

1. 5. If the health care professional also

performs invasive procedures in a community-based setting, it shall be the responsibility of the department to monitor him/her for compliance with the restrictions or limitations in this setting at appropriate intervals, at least annually, based on his/her medical status and the types and frequencies of invasive procedures s/he performs. If the department finds the health care professional to be noncompliant, it shall report this in writing to the appropriate state board, as provided under Chapters 330, 332, 334 or 335, RSMo, and to the director;

1. 6. If the director becomes aware that the

infected health care professional is noncompliant with practice restrictions or limitations at any location where s/he is performing invasive procedures, the director shall report this noncompliance to the director or chief administrator in each health care facility and community-based practice where the health care professional performs invasive procedures;

1. 7. If the peer review panel, as a result of

a periodic review of the infected health care professional’s status, makes a modification in its recommendations that results in restric- 19 CSR 20-26

tions or limitations, or further restrictions or limitations, being placed on the health care professional, the director shall disclose this modification to the chief administrative officer or equivalent individual in any other health care facilities or community-based practices where the health care professional is performing invasive procedures; and

1. 8. If restrictions or limitations have been

placed on a health care professional’s practice by the peer review panel and if later there is a change in the health care professional’s medical condition or some other relevant circumstance, and as a result s/he believes that the restrictions or limitations should be modified, s/he may request that the panel consider the modification. The panel shall review the pertinent evidence and determine whether such modification shall be made. If a modification is made, this shall be conveyed in writing to the health care professional and the director. If the modification results in further restrictions or limitations being placed on the health care professional, the director shall disclose the modification to the chief administrative officer or equivalent individual in any other health care facilities or communitybased practices where the health care professional is performing invasive procedures.

AUTHORITY: section 191.700.2, RSMo 2000.* Original rule filed April 17, 1995, effective Nov. 30, 1995. Emergency amendment filed May 10, 2002, effective July 1, 2002, expired Dec. 28, 2002. Amended: Filed May 10, 2002, effective Nov. 30, 2002.

*Original authority: 191.700.2, RSMo 1992.