Rural Health ClinicSurvey and Recertification

Presented by: BethAnn Perkins, RN, Principal

IRHAJune 11,2014

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

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.

Standard vs. ConditionsQuad A Standards

CMS Conditions

Description

100 491.1 Purpose and Scope

200 491.2 Definitions

300 491.3 Certification Procedures

400 491.4 Compliance with Federal, State, and Local Laws

500 491.5 Location of Clinic

600 491.6 Physical Plan and Environment

700 491.7 Organizational Structure

800 491.8 Staffing and Staff Responsibilities

900 491.9 Provision of Services

1000 491.10 Patient Health Records

1100 491.11 Program Evaluation

Top Cited DeficienciesAgency Citation Description

1CMS 491.6(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 conditionQuad A 600.010.15

2CMS 491.9(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 A 900.010.065

3

CMS 491.9(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 A 900.010.050

Top Cited DeficienciesAgency Citation Description

4

CMS 491.6(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 A 900.010.035

5

CMS 491.9(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 A 900.010.065

Top Cited DeficienciesAgency Citation Description

6CMS 491.6(b)(2) The clinic keeps the drugs and biologicals appropriately

stored.Quad A 600.010.20

7

CMS 491.9(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 A 900.010.115

8

CMS 491.8(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 A 800.010.075

Top Cited DeficienciesAgency Citation Description

9CMS 491.8(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 A 800.010.85

10

CMS 491.10(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 A 1000.010.020

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

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.

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.

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.

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.

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

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

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

Thank You!Indiana Rural Health Association

BethAnn Perkins, RNHealth Consulting Strategies,

Inc.www.healthconsultingstrategie

s.com