1. Surviving Survey and Re-certification

3. Rural Mississippi Mississippi Stats ◦116 Hospitals ◦154 RHC’s (MSDH website) ◦28 CAH’s (35miles or “necessary provider”) Recertifying approximately 6-7 years Survey will be unannounced Survey will be during RHC posted hours Usually 1 surveyor 4 to 8 hours

4. What to expect upon arrival Frequently Requested Items ◦Providers hours ◦Proof of Physician review of mid-level charts ◦Personnel list and licenses ◦Proof of Mid level involvement in policies ◦Policy and Procedure Manual ◦Fire Marshall Inspection ◦Medical Director ◦Clinic owner demographics ◦Lab tests available at the clinic

5. Conditions for Certification Compliance with laws Location Physical Plant Organizational Structure Staffing and Staff Responsibilities Provision of Services Health Records QAPI – Program Evaluation

6. Compliance with Laws Compliance with State practice acts concerning mid-levels PA’s -The supervising physician shall review all patient encounters not later than 24 hours after the physician assistant has seen the patient.

7. Compliance with Laws NP’s – 1. Review by collaborative physician of a random sample of charts that represent 10% or 20 charts, whichever is less, of patients seen by the nurse practitioner every month. Charts should represent the variety of patient types seen by the nurse practitioner. Patients that the nurse practitioner and collaborating physician have consulted on during the month will count as one chart review. 2. The nurse practitioner shall maintain a log of charts reviewed which include the identifier for the patient’s charts, reviewers’ names, and dates of review. 3. Each nurse practitioner shall meet face to face with a collaborating physician once per quarter for the purpose of quality assurance and this meeting should be documented.

8. Location of Clinic

9. Physical Plant Safety ◦Exit signs ◦Evacuation routes ◦Fire Extinguishers ◦Covered outlets Preventive Maintenance ◦Bioengineering logs ◦Drugs and Biologicals Non-Medical Emergencies ◦Things likely to occur in your location ◦Documentation

10. Organizational Structure Medical Direction Written Policies ◦Administrative (authority and responsibilities) ◦Patient Care ◦Personnel ◦Fiscal ◦Maintenance Disclosure of Names/Addresses

11. Staffing and Staff Responsibilities Sufficient Staffing ◦Reasonable time to discharge responsibilities ◦Loss of mid-level or physician (waiver) Must be available to furnish services all times the clinic is operating as an RHC (posted administrative hours) Mid level must be present 50% of the operating hours of the RHC Written documentation of physician review

12. Provision of Services Primarily engaged in providing RHC services at least 51% of the total operating schedule Patient Care Policies – (written guideline for medical management) Referral Policies Description of Services Additional Services furnished through referral Drugs and Biologicals ◦Storage – Outdated – deteriorated - security

13. Patient Health Records Records kept at the clinic Record retention (6 year) RHC reg… Appropriate release of information Protection of Record Information ◦Ensure confidentiality ◦Provide safeguards against loss or unauthorized use

14. Program Evaluation Annual Evaluation ◦Total operations including  Organization  Administration  Policies and Procedures  Personnel  Fiscal  Patient care areas

15. Quality Assurance Performance Improvement (QAPI) Quality Assessment Performance Indicator (QAPI) system in place that is appropriate to the complexity of the RHC operations, data driven, and focused on improving outcomes in patient safety, quality of care and patient satisfaction. The QAPI program must include objective measures for at least four organizational processes and clinic utilization. The key requirement is documenting that a system is in place.

16. Contact Information Joanie.Perkins@northsunflower.com