Ambulatory Services Management Group

1. Ambulatory Services Management Group Glena Jarboe Ambulatory Compliance Manager Office of corporate Compliance 859-323-3217 Comply-Line 1-877-898-6072 July 17, 2014

2. Single Dose Vials • The Joint Commission issued a Sentinel Event Alert “Preventing Infection from the Misuse of Vials” http://www.jointcommission.org/assets/1/6/SEA_52.pdf • Primarily from the reuse of single-dose vials, which are intended to be used once for a single patient • Single-dose vials lack preservatives, therefore, using the vials more than once carries substantial risk for bacterial contamination, growth and infection • CDC is aware of at least 19 bloodborne or bacterial infection outbreaks since 2007 associated with the misuse of single-dose vials—all in outpatient settings

3. KASPER Update Hospital or Physician Clinic Protocol WBT completion eKASPER Delegate Request Form completed and emailed to Dana Thomas @ danathomas@uky.edu Until communication from Glena Jarboe—your process stays the same

4. Training Material HIPAA allows for the use of patient information for treatment, payment, and operations If you are developing any type of training material—make every effort to avoid actual patients If you must work from a live system—do not screen shot and print material that could be inadvertently left in the wrong place Be mindful of material that you save to list serv or upload for future teaching purposes

5. Iron Port • If anyone in your area sends or receives PHI (outside uky.edu or kmsf.org domains) it must be done so securely • Iron Port is the only UK approved means by which to do so • Must request application be installed on your desktop • Current process in undergoing transition. If you need access please call the help desk

6. Clinical Trials If anyone in your area is performing a clinical trial—an Institutional Coverage Analysis must be completed per UKHC Policy A07-055 Per UKHC Policy A05-045 “A medical record shall be maintained for every patient evaluated or treated at a UK HealthCare facility” For additional education or help with clinical trials questions, please contact Rebecca Scott in the Office of Corporate Compliance @ 323-1478

7. Privacy All suspected breaches must be reported to the Office of Corporate Compliance—Privacy Officer is the only person at UKHC that can make the determination if a breach has occurred If you submit an incident to the SI system that involves suspected breach of patient information please also notify the Privacy Office at the Office of Corporate Compliance

8. Contracts • If you do business with anyone outside UK—there must be an agreement in place • Is the vendor on the approved list? • If satellite services—is there a properly executed contract? • Are you living up to the terms of the contract? • Amount of time committed • Space • Reconciliation if terms of contract require

9. Compliance Mindedness Fill in the blank: You knew or should have known______________ You notice that a billed procedure that normally take 2 hours was done in 15 minutes Your standard practice is to display PHI on a whiteboard—that may be visible to patients Patients are by-passing registration and therefore billing Performing procedures they are not qualified to perform—or passing themselves off as more qualified than they actually are

10. Whistleblower • The serial complainer….. • Repeatedly raising issues that may or may not have validity • Know enough to raise valid concerns (i.e., have a level of education in certain area that would make them credible • Feel they are being ignored • Protection from retaliation is expanding

11. Documentation Detail • Are you asked to add modifiers to accounts? • Do you understand the difference between separate and distinct for RVU purposes vs. separate and distinct for billing purposes? • Have you noticed notes that are identical to previous ones? Copy/Paste can be a great thing for spreadsheets and PowerPoints—Not necessarily for chart documentation. Colleen King will discuss at our August ASMG what is and is not acceptable for copy/paste chart documentation.

12. Questions?