1. Rural Health Clinic Survey and Recertification Presented by: BethAnn Perkins, RN, Principal IRHA June 11,2014

2. Objectives Able to identify 5 of the top ten survey deficiencies Identify ISDH recertification pitfall that can cost you the most Name 3 processes that you must have in place to keep you from a condition level deficiency

3. AAAASF/RHC & ISDH American Academy for Accredited Ambulatory Surgical Facilities – Perform Initial RHC Certification surveys on behalf of the State. – You submit an accreditation application to AAAASF and your RHC State application to ISDH – Survey results are forwarded to ISDH for review and submission to CMS. ISDH does not do any initial RHC surveys but they are responsible for recertification surveys if they performed your initial certification survey. – Process initial survey package once results are received from AAAASF/RHC.

4. Standard vs. Conditions Quad A Standards CMS Conditions Description 100491.1Purpose and Scope 200491.2Definitions 300491.3Certification Procedures 400491.4Compliance with Federal, State, and Local Laws 500491.5Location of Clinic 600491.6Physical Plan and Environment 700491.7Organizational Structure 800491.8Staffing and Staff Responsibilities 900491.9Provision of Services 1000491.10Patient Health Records 1100491.11Program Evaluation

5. Top Cited Deficiencies AgencyCitationDescription 1 CMS491.6(b)(1)The clinic has a preventive maintenance program to ensure that all essential mechanical, electric and patient- care equipment is maintained in safe operating condition Quad A600.010.15 2 CMS491.9(b)(4)The clinic’s policies are reviewed at least annually by the group of professional personnel and reviewed as necessary by the clinic. Quad A900.010.065 3 CMS491.9(b)(3)(iii)The clinic’s policies include guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic. Quad A900.010.050

6. Top Cited Deficiencies AgencyCitationDescription 4 CMS491.6(b)(2)The clinic’s policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners, and at least one member that is not a member of the clinic staff. Quad A900.010.035 5 CMS491.9(c)(2)The clinic laboratory services which implements the provisions of Section 353 of the Public Health Service Act wherein the RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including chemical examination of urine, hemoglobin or hematocrit, blood glucose, examination of stool specimens for occult blood, pregnancy tests, and primary culturing for transmittal to a certified laboratory. Quad A900.010.065

7. Top Cited Deficiencies AgencyCitationDescription 6 CMS491.6(b)(2)The clinic keeps the drugs and biologicals appropriately stored. Quad A600.010.20 7 CMS491.9(3)The clinic provides medical emergency procedures as a first response to common life threatening injuries and acute illness and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids. Quad A900.010.115 8 CMS491.8(c)(i)The physician assistant and the nurse practitioner members of the clinic’s staff participate in the development, execution and periodic review of the written policies governing the services the clinic furnishes. Quad A800.010.075

8. Top Cited Deficiencies AgencyCitationDescription 9 CMS491.8(c)(v)The physician assistant and the nurse practitioner members of the clinic’s staff participate with the physician in a periodic review of the patient’s health records. Quad A800.010.85 10 CMS491.10(a)(3)The clinic maintains a record for each patient receiving health care services, identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient. Quad A1000.010.020

9. Re-certification Citations from ISDH 491.6(b) Maintenance 491.8 Staffing and Staff Responsibilities 491.9(b) Patient Care Policies 491.10 Records System 491.11 Program Evaluation

10. Top Citation from ISDH 491.6 Physical plant and environment – (b) Maintenance – The clinic has a preventive maintenance program to ensure that: (1)All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition; (2)Drugs and biologicals are appropriately stored; and (3)The premises are clean and orderly. 491.8 Staffing and staff responsibilities – (b) Physician responsibilities – (c) Physician assistant and nurse practitioner responsibilities.

11. Top Citation from ISDH 491.9 Provision of services – (b) Patient care policies – The clinic has a preventive maintenance program to ensure that: (1) The clinic’s health care services are furnished in accordance with appropriate written policies which are consistent with applicable law. (2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic staff. (3) The policies include: – (i) A description of the services the clinic furnishes directly and those furnished through agreement or arrangement. – (ii) Guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health are records, and procedures for the periodic review and evaluation of the services furnished by the clinic. (4) These policies are reviewed at least annually by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary.

12. Top Citation from ISDH 491.10 Patient health records – (a) Records system. (1) The clinic maintains a clinical record system in accordance with written policies and procedures. (2) A designated member of the professional staff is responsible for maintaining the records and for insuring that they are completely and accurately documented, readily accessible, and systematically organized.. (3) For each patient receiving health care services, the clinic maintains a record that includes, as applicable: – (i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the status and health care needs of the patients, and a brief summary of the episode, disposition, and instructions to the patient. – (ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings; – (iii) All physician’s orders, reports of treatments and medication, and other pertinent information necessary to monitor the patient’s progress.

13. Top Citation from ISDH 491.10 Patient health records – (b) Protection of record information. (1) The clinic maintains the confidentiality of record information ad provides safeguards against loss, destruction or unauthorized use 491.11 Program evaluation – (a) The clinic carries out, or arranges for, an annual evaluation of its total program. – (b) The evaluation includes review of: (1) The utilization of clinic services, including at least the number of patients served and the volume of services. (2) A representative sample of both active and closed clinical records; and (3) The clinic’s health care policies – (c) The purpose of the evaluation is to determine whether: (1) The utilization of services was appropriate; (2) The established policies were followed; and (3) Any changes are needed. – (d) The clinic staff considers the findings of the evaluation and takes corrective action if necessary.

14. 5 Processes to Implement Develop a comprehensive Preventative Maintenance Program that includes: Management of equipment (annual inspection, calibration, daily inspection, process of repair and removal) Develop Bi-directional Physician Review process. – Process is written and includes an accounting of the nurse practitioner’s prescribing DOS

15. 5 Processes to Implement Establish annual review of all policies – Staff review (initially the nurse practitioner/physician assistant must participate in the development of the policies or at the very least have the opportunity to provide input and comment on existing policies. – For provider-based practices, policies must reflect the operations of the clinic. – Professional Advisory Group approval of reviewed policies Management of equipment (annual inspection, calibration, daily inspection, process of repair and removal) Develop annual review of medical records including inactive records (patients who have transferred, died, or not seen in the clinic with the past 3 years); develop ongoing compliance audit

16. 5 Processes to Implement Develop written Program Evaluation – Ensure completed annually – Utilize Road Map, ensure that all components are reviewed and commented on – Professional Advisory Group must include: Medical Director Physician Assistant/Nurse Practitioner Community Member

17. Thank You! Indiana Rural Health Association BethAnn Perkins, RN Health Consulting Strategies, Inc. www.healthconsultingstrategies.com