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Penalty for willful failure to file this report when the requirements are met is found at this link
Section 805 of the California Business and Professions Code
805. (a) As used in this section, the following terms have the following definitions: (1) "Peer review body" includes: (A) A medical or professional staff of any health care facility orclinic licensed under Division 2 (commencing with Section 1200) ofthe Health and Safety Code or of a facility certified to participatein the federal Medicare Program as an ambulatory surgical center. (B) A health care service plan registered under Chapter 2.2(commencing with Section 1340) of Division 2 of the Health and SafetyCode or a disability insurer that contracts with licentiates toprovide services at alternative rates of payment pursuant to Section10133 of the Insurance Code. (C) Any medical, psychological, marriage and family therapy,social work, dental, or podiatric professional society having asmembers at least 25 percent of the eligible licentiates in the areain which it functions (which must include at least one county), whichis not organized for profit and which has been determined to beexempt from taxes pursuant to Section 23701 of the Revenue andTaxation Code. (D) A committee organized by any entity consisting of or employingmore than 25 licentiates of the same class that functions for thepurpose of reviewing the quality of professional care provided bymembers or employees of that entity. (2) "Licentiate" means a physician and surgeon, doctor ofpodiatric medicine, clinical psychologist, marriage and familytherapist, clinical social worker, or dentist. "Licentiate" alsoincludes a person authorized to practice medicine pursuant to Section2113. (3) "Agency" means the relevant state licensing agency havingregulatory jurisdiction over the licentiates listed in paragraph (2).(4) "Staff privileges" means any arrangement under which alicentiate is allowed to practice in or provide care for patients ina health facility. Those arrangements shall include, but are notlimited to, full staff privileges, active staff privileges, limitedstaff privileges, auxiliary staff privileges, provisional staffprivileges, temporary staff privileges, courtesy staff privileges,locum tenens arrangements, and contractual arrangements to provideprofessional services, including, but not limited to, arrangements toprovide outpatient services. (5) "Denial or termination of staff privileges, membership, oremployment" includes failure or refusal to renew a contract or torenew, extend, or reestablish any staff privileges, if the action isbased on medical disciplinary cause or reason. (6) "Medical disciplinary cause or reason" means that aspect of alicentiate's competence or professional conduct that is reasonablylikely to be detrimental to patient safety or to the delivery ofpatient care. (7) "805 report" means the written report required undersubdivision (b). (b) The chief of staff of a medical or professional staff or otherchief executive officer, medical director, or administrator of anypeer review body and the chief executive officer or administrator ofany licensed health care facility or clinic shall file an 805 reportwith the relevant agency within 15 days after the effective date ofany of the following that occur as a result of an action of a peerreview body: (1) A licentiate's application for staff privileges or membershipis denied or rejected for a medical disciplinary cause or reason. (2) A licentiate's membership, staff privileges, or employment isterminated or revoked for a medical disciplinary cause or reason. (3) Restrictions are imposed, or voluntarily accepted, on staffprivileges, membership, or employment for a cumulative total of 30days or more for any 12-month period, for a medical disciplinarycause or reason. (c) The chief of staff of a medical or professional staff or otherchief executive officer, medical director, or administrator of anypeer review body and the chief executive officer or administrator ofany licensed health care facility or clinic shall file an 805 reportwith the relevant agency within 15 days after any of the followingoccur after notice of either an impending investigation or the denialor rejection of the application for a medical disciplinary cause orreason: (1) Resignation or leave of absence from membership, staff, oremployment. (2) The withdrawal or abandonment of a licentiate's applicationfor staff privileges or membership. (3) The request for renewal of those privileges or membership iswithdrawn or abandoned. (d) For purposes of filing an 805 report, the signature of atleast one of the individuals indicated in subdivision (b) or (c) onthe completed form shall constitute compliance with the requirementto file the report. (e) An 805 report shall also be filed within 15 days following theimposition of summary suspension of staff privileges, membership, oremployment, if the summary suspension remains in effect for a periodin excess of 14 days. (f) A copy of the 805 report, and a notice advising the licentiateof his or her right to submit additional statements or otherinformation pursuant to Section 800, shall be sent by the peer reviewbody to the licentiate named in the report. The information to be reported in an 805 report shall include thename and license number of the licentiate involved, a description ofthe facts and circumstances of the medical disciplinary cause orreason, and any other relevant information deemed appropriate by thereporter. A supplemental report shall also be made within 30 days followingthe date the licentiate is deemed to have satisfied any terms,conditions, or sanctions imposed as disciplinary action by thereporting peer review body. In performing its dissemination functionsrequired by Section 805.5, the agency shall include a copy of asupplemental report, if any, whenever it furnishes a copy of theoriginal 805 report. If another peer review body is required to file an 805 report, ahealth care service plan is not required to file a separate reportwith respect to action attributable to the same medical disciplinarycause or reason. If the Medical Board of California or a licensingagency of another state revokes or suspends, without a stay, thelicense of a physician and surgeon, a peer review body is notrequired to file an 805 report when it takes an action as a result ofthe revocation or suspension. (g) The reporting required by this section shall not act as awaiver of confidentiality of medical records and committee reports.The information reported or disclosed shall be kept confidentialexcept as provided in subdivision (c) of Section 800 and Sections803.1 and 2027, provided that a copy of the report containing theinformation required by this section may be disclosed as required bySection 805.5 with respect to reports received on or after January 1,1976. (h) The Medical Board of California, the Osteopathic Medical Boardof California, and the Dental Board of California shall disclosereports as required by Section 805.5. (i) An 805 report shall be maintained by an agency fordissemination purposes for a period of three years after receipt. (j) No person shall incur any civil or criminal liability as theresult of making any report required by this section. (k) A willful failure to file an 805 report by any person who isdesignated or otherwise required by law to file an 805 report ispunishable by a fine not to exceed one hundred thousand dollars($100,000) per violation. The fine may be imposed in any civil oradministrative action or proceeding brought by or on behalf of anyagency having regulatory jurisdiction over the person regarding whomthe report was or should have been filed. If the person who isdesignated or otherwise required to file an 805 report is a licensedphysician and surgeon, the action or proceeding shall be brought bythe Medical Board of California. The fine shall be paid to thatagency but not expended until appropriated by the Legislature. Aviolation of this subdivision may constitute unprofessional conductby the licentiate. A person who is alleged to have violated thissubdivision may assert any defense available at law. As used in thissubdivision, "willful" means a voluntary and intentional violation ofa known legal duty. (l) Except as otherwise provided in subdivision (k), any failureby the administrator of any peer review body, the chief executiveofficer or administrator of any health care facility, or any personwho is designated or otherwise required by law to file an 805 report,shall be punishable by a fine that under no circumstances shallexceed fifty thousand dollars ($50,000) per violation. The fine maybe imposed in any civil or administrative action or proceedingbrought by or on behalf of any agency having regulatory jurisdictionover the person regarding whom the report was or should have beenfiled. If the person who is designated or otherwise required to filean 805 report is a licensed physician and surgeon, the action orproceeding shall be brought by the Medical Board of California. Thefine shall be paid to that agency but not expended until appropriatedby the Legislature. The amount of the fine imposed, not exceedingfifty thousand dollars ($50,000) per violation, shall be proportionalto the severity of the failure to report and shall differ based uponwritten findings, including whether the failure to file caused harmto a patient or created a risk to patient safety; whether theadministrator of any peer review body, the chief executive officer oradministrator of any health care facility, or any person who isdesignated or otherwise required by law to file an 805 reportexercised due diligence despite the failure to file or whether theyknew or should have known that an 805 report would not be filed; andwhether there has been a prior failure to file an 805 report. Theamount of the fine imposed may also differ based on whether a healthcare facility is a small or rural hospital as defined in Section124840 of the Health and Safety Code. (m) A health care service plan registered under Chapter 2.2(commencing with Section 1340) of Division 2 of the Health and SafetyCode or a disability insurer that negotiates and enters into acontract with licentiates to provide services at alternative rates ofpayment pursuant to Section 10133 of the Insurance Code, whendetermining participation with the plan or insurer, shall evaluate,on a case-by-case basis, licentiates who are the subject of an 805report, and not automatically exclude or deselect these licentiates.
805.1. (a) The Medical Board of California, the Osteopathic MedicalBoard of California, and the Dental Board of California shall beentitled to inspect and copy the following documents in the record ofany disciplinary proceeding resulting in action that is required tobe reported pursuant to Section 805: (1) Any statement of charges. (2) Any document, medical chart, or exhibits in evidence. (3) Any opinion, findings, or conclusions. (b) The information so disclosed shall be kept confidential andnot subject to discovery, in accordance with Section 800, except thatit may be reviewed, as provided in subdivision (c) of Section 800,and may be disclosed in any subsequent disciplinary hearing conductedpursuant to the Administrative Procedure Act (Chapter 5 (commencingwith Section 11500) of Part 1 of Division 3 of Title 2 of theGovernment Code).
805.2. (a) It is the intent of the Legislature to provide for acomprehensive study of the peer review process as it is conducted bypeer review bodies defined in paragraph (1) of subdivision (a) ofSection 805, in order to evaluate the continuing validity of Section805 and Sections 809 to 809.8, inclusive, and their relevance to theconduct of peer review in California. (b) The Medical Board of California shall contract with anindependent entity to conduct this study that is fair, objective, andfree from bias that is directly familiar with the peer reviewprocess and does not advocate regularly before the board on peerreview matters or on physician and surgeon disciplinary matters. (c) The study by the independent entity shall include, but not belimited to, the following components: (1) A comprehensive description of the various steps of anddecisionmakers in the peer review process as it is conducted by peerreview bodies throughout the state, including the role of otherrelated committees of acute care health facilities and clinicsinvolved in the peer review process. (2) A survey of peer review cases to determine the incidence ofpeer review by peer review bodies, and whether they are complyingwith the reporting requirement in Section 805. (3) A description and evaluation of the roles and performance ofvarious state agencies, including the State Department of HealthServices and occupational licensing agencies that regulate healingarts professionals, in receiving, reviewing, investigating, anddisclosing peer review actions, and in sanctioning peer review bodiesfor failure to comply with Section 805. (4) An assessment of the cost of peer review to licentiates andthe facilities which employ them. (5) An assessment of the time consumed by the average peer reviewproceeding, including the hearing provided pursuant to Section 809.2,and a description of any difficulties encountered by eitherlicentiates or facilities in assembling peer review bodies or panelsto participate in peer review decisionmaking. (6) An assessment of the need to amend Section 805 and Sections809 to 809.8, inclusive, to ensure that they continue to be relevantto the actual conduct of peer review as described in paragraph (1),and to evaluate whether the current reporting requirement is yieldingtimely and accurate information to aid licensing boards in theirresponsibility to regulate and discipline healing arts practitionerswhen necessary, and to assure that peer review bodies function in thebest interest of patient care. (7) Recommendations of additional mechanisms to stimulate theappropriate reporting of peer review actions under Section 805. (8) Recommendations regarding the Section 809 hearing process toimprove its overall effectiveness and efficiency. (9) An assessment of the role of medical professionals, usingprofessionals who are experts and are actively practicing medicine inthis state, to review and investigate for the protection ofconsumers, allegations of substandard practice or professionalmisconduct. (10) An assessment of the process to identify and retain a medicalprofessional with sufficient expertise to review allegations ofsubstandard practice or professional misconduct by a physician andsurgeon, if the peer review process is discontinued. (d) The independent entity shall exercise no authority over thepeer review processes of peer review bodies. However, peer reviewbodies, health care facilities, health care clinics, and health careservice plans shall cooperate with the independent entity inproviding raw data, information, and case files as requested in amutually agreeable timeframe. (e) The case files and other information obtained by theindependent entity shall be confidential. The independent entityshall not release the case files or other information it obtains toany individual, agency, or entity, including the board, except asaggregate data, examples, or in the final report submitted to theboard and the Legislature, but in no case shall information releasedunder these exemptions be identifiable in any way or associated with,or related to, a specific facility, individual, or peer review body.
(f) Notwithstanding any other provision of law, informationobtained by the independent entity from a peer review body or fromany other person or entity and information otherwise generated by theindependent entity, including, but not limited to, raw data, patientinformation, case files or records, interviews and records ofinterviews, proceedings of a peer review body, and analyses orconclusions of the independent entity, shall not be subject todiscovery or to a subpoena or a subpoena duces tecum and shall not beadmissible as evidence in any court of law in this state. Theinformation described in this subdivision shall be subject to allother confidentiality protections and privileges otherwise providedby law. The independent entity and its employees and contractorsshall assert all of the protections for the information described inthis subdivision that may apply in order to protect the informationfrom disclosure. However, nothing in this section shall affectprovisions of law relating to otherwise admissible materialobtainable from sources other than the independent entity. (g) The independent entity shall report to the peer review bodyany information it obtains from the peer review body that theindependent entity determines should have been reported pursuant toSection 805. The independent entity shall include with the report aclear explanation of the reasons it determined that the informationwarrants a report under Section 805. If the peer review body agreeswith the independent entity's determination, the peer review bodyshall report the information pursuant to Section 805 without beingsubject to penalties under subdivision (k) or (l) of Section 805, ifthe peer review body makes the report to the board within 30 days ofthe date the independent entity reported its determination to thepeer review body, unless additional time is required to afford dueprocess or fair hearing rights to the subject of the report asrequired by Section 805 and Sections 809.1 and following. (h) The independent entity shall work in cooperation with andunder the general oversight of the Executive Director of the MedicalBoard of California and shall submit a written report with itsfindings and recommendations to the board and the Legislature nolater than July 31, 2008. (i) Completion of the peer review study pursuant to this sectionshall be among the highest priorities of the Medical Board ofCalifornia, and the board shall ensure that it is completed no laterthan July 31, 2008.
805.5. (a) Prior to granting or renewing staff privileges for anyphysician and surgeon, psychologist, podiatrist, or dentist, anyhealth facility licensed pursuant to Division 2 (commencing withSection 1200) of the Health and Safety Code, or any health careservice plan or medical care foundation, or the medical staff of theinstitution shall request a report from the Medical Board ofCalifornia, the Board of Psychology, the Osteopathic Medical Board ofCalifornia, or the Dental Board of California to determine if anyreport has been made pursuant to Section 805 indicating that theapplying physician and surgeon, psychologist, podiatrist, or dentisthas been denied staff privileges, been removed from a medical staff,or had his or her staff privileges restricted as provided in Section805. The request shall include the name and California licensenumber of the physician and surgeon, psychologist, podiatrist, ordentist. Furnishing of a copy of the 805 report shall not cause the805 report to be a public record. (b) Upon a request made by, or on behalf of, an institutiondescribed in subdivision (a) or its medical staff, which is receivedon or after January 1, 1980, the board shall furnish a copy of anyreport made pursuant to Section 805. However, the board shall notsend a copy of a report (1) if the denial, removal, or restrictionwas imposed solely because of the failure to complete medicalrecords, (2) if the board has found the information reported iswithout merit, or (3) if a period of three years has elapsed sincethe report was submitted. This three-year period shall be tolledduring any period the licentiate has obtained a judicial orderprecluding disclosure of the report, unless the board is finally andpermanently precluded by judicial order from disclosing the report.In the event a request is received by the board while the board issubject to a judicial order limiting or precluding disclosure, theboard shall provide a disclosure to any qualified requesting party assoon as practicable after the judicial order is no longer in force.
In the event that the board fails to advise the institution within30 working days following its request for a report required by thissection, the institution may grant or renew staff privileges for thephysician and surgeon, psychologist, podiatrist, or dentist. (c) Any institution described in subdivision (a) or its medicalstaff that violates subdivision (a) is guilty of a misdemeanor andshall be punished by a fine of not less than two hundred dollars($200) nor more than one thousand two hundred dollars ($1,200).
805.6. (a) The Medical Board of California, the Osteopathic MedicalBoard, and the Dental Board of California shall establish a systemof electronic notification that is either initiated by the board orcan be accessed by qualified subscribers, and that is designed toachieve early notification to qualified recipients of the existenceof new reports that are filed pursuant to Section 805. (b) The State Department of Health Services shall notify theappropriate licensing agency of any reporting violations pursuant toSection 805. (c) The Department of Managed Health Care shall notify theappropriate licensing agency of any reporting violations pursuant toSection 805.
805.7. (a) The Medical Board of California shall work withinterested parties in the pursuit and establishment of a pilotprogram, similar to those proposed by the Citizens Advocacy Center,of early detection of potential quality problems and resolutionsthrough informal educational interventions. (b) The Medical Board of California shall report to theLegislature its evaluation and findings and shall includerecommendations regarding the statewide implementation of this pilotprogram before April 1, 2004.
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