Welcome to the 2011 Annual Evaluation Session This session’s trainer is:

1. Welcome to the 2011 Annual Evaluation Session This session’s trainer is: J. E. Estes, President, Consultant Healthcare Horizon Bartlesville, Oklahoma 800-399-0874 E-Mail: hlthcarehorizons@mindspring.com www.healthcarehorizon.com

2. ANNUAL EVALUATION: YA’ GOTTA DO IT ! So why not make it a helpful process ?

3. The annual evaluation is required to be in compliance with Federal Medicare regulations for RHC's.

5. In particular the CFR cites the following regulations that the annual evaluation process must fulfill:

6. Code J77— • The clinic carries out • or arranges • for an annual evaluation • of it's total program. 

7. Code J78— • The evaluation includes • review of specific areas • including utilization, review of • clinic records • and policies and • procedures • among other things.

8. Utilization: Encounters by Type Medicare Medicaid All other Review of Clinic Records: Actual chart review performed by staff must include a representative sample of both open and closed charts

9. Typical Chart Review Outline: 1) Patient Name 2) Ins. Class 3) Vitals 4) Signatures 5) SOAPS 6) Pt. Info. 7) Consent Form 8) Release of Info. Form 9) HIPAA Notice 10) Medicare Lifetime Sig. Form

10. 11) Rx Log • 12) Problem Log • 13) History Form • 14) History Updated • 15) Allergy Info. • 16) No-Shows noted • MSP Long Form • 18) MSP Per Encounter • 19) Comments

11. Review of Policies and Procedures Should include a review by the Medical Director and at least one PA/NP/CNM as well as the Office Manager/Administrator All of these staff persons should “sign-off” on the Annual Evaluation Report.

12. Code J82— • The purpose of the evaluation • is to determine whether • the utilization of services was appropriate; the established • policies and procedures were • followed; and any changes • are needed.

13. Code J86— • The clinic staff • considers the findings of the evaluation and takes • corrective action if necessary.

14. There are specific requirements of who is to be included in the group • of clinic employees and governors • that "sign off" on the annual • evaluation. This evaluation can be • done by the clinic or through • arrangements with other • appropriate professional • consultants.

15. This “Review Committee” • must include one person • that is not on the • staff of the clinic.

16. TYPICAL CONTENTS OF AN ANNUAL EVALUATION:

17. Overview of the RHC • 2) Location: Market Area • 3) Scope of Services

18. Disclosure of Ownership • 5) Listing of all physicians, • NP, PA, CNM (billable Providers)

19. 6) Review of encounters by payer class 7) CPT coding analysis by provider (helpful)

20. 9) Review of Policies & Procedures Manual (checklist or report) with recommendations

21. 10) Listing of those on the Review Committee 11) Signatures of Review Committee accepting the Evaluation Report

22. 12) Recommendations for changes/improvements 13) Timeline for those recommendations

23. 14) Confirmation of changes having been made, with signature of Medical Director

24. The Annual Evaluation is a great opportunity to also conduct an “inspection” of the clinic, similar to what the State performs during the RHC re-certification inspections. This inspection often reveals area of non-compliance that have been over- looked in the day-to-day operation of the clinic.

25. SURVEY COMPLIANCE ISSUES: J3 Fed, State & Local laws J4 Licensed if required J5 Personnel licensed J6 Clinic located in Rural/Shortage area J8 Equip/supplies sufficient J20 Adequate space/Patient safety J21 Preventive Maint. Program on: Mechanical, electrical, Pt-care equip. Drugs/biologicals storage Facility clean & orderly

26. J25-28 Emergency Procedures: Staff trained Exit signs Clinic-specific conditions J29-36 Organizational Structure Owners disclosed Clinic manager named Medical Director responsibilities

27. J37-51 Staffing/Responsibilities MD/DO and PA or NP Qualified as per 481.2(b)(c)(d) NP or PA present 50% Staff sufficient Physician is Med. Dir. Physician involved in PPM Physician reviews records, PPM & provides medical care Phys. Present every 2 wks.

28. J50 PA/NP responsibilities PA/NP assist in PPM development Abides by those policies Refers patients as needed Maintains med. Rec. Meets with Phys. in review of records J52 PRIMARY CARE is primary scope J54 Pt. care policies PPM is accurately reflected in actual patient care PPM developed with input from Cmtg

29. PPM includes scope of practice Guidelines for med. Mgmnt Rules for storage of drugs, biologicals Reviewed annually by Cmtg. J62: Emergency Emerg. Proced, 1st resp. and kit with: Analgesics - ASA, Tylenol, Aleve Anesthetics - Xylocaine, Lidocaine Antibiotics - Rocephin Anticonvulsants - Valium, Cerebyx Antidotes – Epinephrine, Benydryl Emetics - Activated Charcoal Serums/toxoids - Vaccines, Tetanus

30. J63-65 Services thru arrangement Referral doctors Hospital access (letter) J66-75 Health Records Med. Rec. follows clinic PPM A staff member resp. for Med. Rec. Records include: Demog. Info.; Consent forms Med. Hist.; Assessments Reports; labs; orders Signature of providers

31. Rec. kept confidential and safe PPM policy on removal of records Pt consent required for release of info Rec. kept (6) years (Majority) J76-86 Program Evaluation

32. QUESTIONS ?

33. Thank You !