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HealthWorx Unlimited

HealthWorx Unlimited. Nancy Staffeld , RN, MHCA Certified RHC Surveyor AAAASF. RHC CERTIFICATION PROCESS. Standards Interpretation Mock Survey Tips for a successful survey. INTERPRETING THE STANDARDS 491.4. Compliance with Federal, State, & local laws.

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HealthWorx Unlimited

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  1. HealthWorx Unlimited Nancy Staffeld, RN, MHCA Certified RHC Surveyor AAAASF

  2. RHC CERTIFICATION PROCESS • Standards Interpretation • Mock Survey • Tips for a successful survey.

  3. INTERPRETING THE STANDARDS 491.4 • Compliance with Federal, State, & local laws. • Clinic is licensed pursuant to applicable State & local laws. • All professional licenses are current, personnel files & certifications. • If not kept on site, they must be made available to the surveyor.

  4. INTERPRETATION 491.5 • Determined by ratio of primary care physicians to the general population in that area. • HPSA ( Health Professional Shortage Area) • Clinic must be located in designated area. • Rural, not urbanized as of most recent US census.

  5. INTERPRETATION 491.6 • The clinic is constructed, arranged, and maintained to ensure access to a safety of the patients and provides adequate space for the provision of direct services. • Mechanical & electrical equipment is maintained in safe operating condition. • Exit signs with maps strategically located throughout the clinic.

  6. INTERPRETATION 491.6 • Drugs & biologicals are appropriately stored. • Sample drugs. Labels, log book. • Premises are clean and orderly. • Staff are trained to handle emergency conditions.

  7. INTERPRETATION 491.7 • The clinic is under the medical direction of a physician. • Names & addresses of clinic’s owner. • Organizational chart must include positions and staff assigned to each position with Medical Director at the top.

  8. INTERPRETATION 491.8 • There must be at least 1-2 physicians and 1-2 mid levels ( NP or PA-C) who meet all the credentialing criteria. • A mid-level provider must work at least 50% of the clinic hours available to see patients. • Evidence of collaboration between the Medical Director & mid levels at least every two (2) weeks.

  9. INTERPRETATION 491.9 • Advisory Board importance. • Rules for storing, handling & administration of drugs. • Basic labs are available – urine dip, pregnancy test, hemoglobin, blood sugar, stool for occult blood & primary culturing. • List of services provided and referral protocol as necessary.

  10. INTERPRETATION 491.10 • Who is designated overseer of records? • Confidentiality, release of records – policies to support. • Chart to include consents, consults, lab results, med reconciliation, history & physical, response to treatment. • 491.11 Advisory Board discussion.

  11. MOCK SURVEY • A learning experience, not a survey of record. • Identifies problems, offers solutions. • Educational, not punitive. • Clinic manager and/or clinical staff member to accompany mock surveyor. • Ask questions if you don’t understand. • See Mock Survey handouts.

  12. RHC CERTIFICATION SURVEY • Surveyor will check outside of building for building street number and handicap accessibility. • 1-2 surveyors will present with letter of introduction and/or identification tag. • Surveyor will ask that Medical Director be called to site. • Clinic Manager to accompany surveyor and designate clinical staff member if 2.

  13. RHC Certification Survey • Be prepared to take notes and ask questions as needed. • Don’t be confrontational if you do not agree with surveyor. • Survey usually begins in morning and could last up to eight (8) hours. • Exit interview with Medical Director, Clinic Manager, mid-levels, and staff if available.

  14. Actual Survey Deficiencies • No number on outside of building to identify clinic. None at Subway next door. • Urine specimen found in door of vaccine refrigerator. • Toys found in waiting room with no process to clean them. • Duck tape holding corners of vinyl exam table and other has open slits.

  15. Survey Deficiencies • Air fresheners & other cleaning products being used – not in MSDS book. • Outdated supplies. Check in advance with Materials Management. Some things start to outdate when they are opened rather than the date on the package. • Organizational chart was the hospital’s only. OK but need an organizational chart for the clinics chain of command.

  16. Survey Deficiencies • Policies need to be specific to clinic. Hospital policies may be sufficient for Human Resources for example but not for dog bite notification/treatment. • Remember the policy must reflect the practice. • If equipment is broken and not useable, it should be removed from the clinic.

  17. Deficiencies • Charity Care policy must be in place with evidence that the patients are aware of the process. • Reusable blanket in Pediatric room. • Chipped paint on metal exam table providing rough surface. • About AAAA SF

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