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Surviving Survey and Re-certification. It's easier to go down a hill than up it but the view is much better at the top. Henry Ward Beecher. Rural Indiana. Indiana Stats 114 Hospitals / 41 in Rural areas 59 RHC’s 35 CAH’s (35miles or “necessary provider”)
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It's easier to go down a hill than up it but the view is much better at the top. Henry Ward Beecher
Rural Indiana Indiana Stats • 114 Hospitals / 41 in Rural areas • 59 RHC’s • 35 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
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
Conditions for Certification • Compliance with laws • Location • Physical Plant • Organizational Structure • Staffing and Staff Responsibilities • Provision of Services • Health Records • QAPI – Program Evaluation
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.
Compliance with Laws • NP’s – • http://www.in.gov/legislative/iac/T08480/A00040.PDF\ • NP requirement is 5% weekly random audit • RHC is going to require some oversight documented
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
Organizational Structure • Medical Direction • Written Policies • Administrative (authority and responsibilities) • Patient Care • Personnel • Fiscal • Maintenance • Disclosure of Names/Addresses
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
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
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
Program Evaluation • Annual Evaluation • Total operations including • Organization • Administration • Policies and Procedures • Personnel • Fiscal • Patient care areas
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.
