1. Surviving Survey and Re- certification By: Joanie Perkins, CPC

2. Face your deficiencies and acknowledge them; but do not let them master you. Let them teach you patience, sweetness, insight. Helen Keller (1880 – 1968) American Writer

3. Objectives How to decide if you’re eligible for RHC designation Know when you’re due for an announced or unannounced survey Know what to expect from your surveyor Know the conditions for certification and how to meet them

4. Conditions of Certification Regs published ‘78 1.Compliance with Federal, State and Local Laws (42 CFR 491.4) a.)Licensure of clinic b.)Licensure, certification or registration of personnel c.) State law supersedes Federal Law on who can provide services

5. Location of Clinic (42 CFR491.5) The clinic must be located in a non- urbanized area that is designated as a shortage area, and may be a permanent or a mobile unit. –Each RHC will be considered independently –Mobile Units need to have fixed scheduled locations which meet the rural and shortage area designations –Your regional office will make this determination

6. Know this guy?

7. Physical Plant and Environment (42 CFR 491.6) Construction –Maintained to ensure access and safety of patients and adequate space Maintenance –Equipment is in safe operating order –Drugs and Biologicals are appropriately stored –Premises are clean and orderly

8. Physical Plant and Environment (42 CFR 491.6) Emergency Procedures –The clinic assures the safety of patients in case of non-medical emergencies by: Training Staff Exit signs Taking other appropriate measures that are consistent with the area the clinic is located

9. The Buck Stops Here

10. Organizational Structure (42 CFR 491.7) Basic Requirements –The clinic is under the medical direction of a physician, and staffing meets the mid level requirement –Clinic has clear lines of authority in writing Disclosure –Name/Address –Clinic Administrator –Medical Director

11. Staffing and Staff Responsibilities (42 CFR 491.8) One or more Physician and/or NP, PA must be available to furnish services at all times the clinic operates as an RHC. –Indiana surveyor stated the following: Inadequate staffing is the most common citation RHC surveyors give out. RHC’s must have a “back up” in case the mid- level or medical director take any type of leave for any duration.

12. Staffing and Staff Responsibilities (42 CFR 491.8) A provider must be on site to perform services during all times RHC operates RHC's may allow beneficiary entry to the waiting room or other non-patient care areas to handle billing inquiries or to get out of the weather when the mid-level practitioner as defined in §493.2, clinical social worker, clinical psychologist or physician member of the staff is not present under the following circumstances:

13. Staffing (CFR 491.8) Cont Solely for administrative purposes or to allow patients to get out of inclement weather No health care services may be provided Administrative hours should be posted State Law supersedes this regulation if it does not allow patients in the building

14. Staffing and Staff Responsibilities (42 CFR 491.8) Physician and mid-level must participate jointly in the development of new policies. Each staff member must review, agree with and adhere to clinic policies. There should be sufficient written documentation that this is carried out.

15. Physician Responsibilities Must provide and document oversight for mid- level Must provide direct care services in the RHC Must spend “sufficient time” at a minimum of once every two weeks to discharge their duties. –Indiana Regulations require 5% review weekly of NP’s records for prescriptive authority 100% review PA’s

16. Mid-level Responsibilities Participate in development, execution and review of written policies Provide services in accordance with those policies Arrange for referrals as needed Assure that adequate health records are maintained and transferred as required when patients are referred Participate with physician in a periodic review of health records.

17. Provision of Services

18. Provision of Services (42 CFR 491.9) The clinic must be primarily engaged in providing outpatient health services Patient Care Policies –Services must be furnished in accordance with written policies that are consistent with State law –Policies must be developed with a group of professional personnel that include a physician, mid-level and someone that is not a member of the clinic staff

19. Provision of Services (42 CFR 491.9) Policies must include –Description of services provided and provided through arrangement –Guidelines for medical management which include Conditions requiring referral/consultation Maintenance of health records Periodic review of services furnished Storage/Handling of drugs and biologicals

20. Provision of Services (42 CFR 491.9) –Policies must be reviewed annually by a group of professional personnel Direct Services –Services typically provided in a physician’s office –Six lab tests U/A Hbg or Hct Blood sugar Fecal occult blood Pregnancy Primary culturing for transmittal to a certified lab

21. Provision of Services (42 CFR 491.9) Emergency –Life saving drugs/biologicals Analgesics, anesthetics (local), anticonvulsants, antidotes and emetics, serums and toxins Services provided through agreements or arrangements –Inpatient hospital care –Physician services in NH/hospital patients home/office –Additional diagnostic laboratory

22. Medical Records

23. Patient Health Records (42 CFR 491.10) Records must be kept in accordance with written policies A staff member must be designated as responsible for the records and ensuring they are accurate, readily accessible and systematically organized.

24. Patient Health Records (42 CFR 491.10) Records must include –ID and social data, consent forms, medical history, health status, health care needs, summary of visit, disposition and instructions to the patient. –Reports of physical exams, diagnostic lab test results, consults –Physician orders, reports of treatment and medications –Signatures

25. Patient Health Records (42 CFR 491.10) Protection of record information –Maintains confidentiality –Safeguards against loss, destruction or unauthorized use –Written policy governing the use and removal of records and release of information –Patients written consent is required for release of information Retention – 6 years

26. Program Evaluation (42 CFR 491.11) Annually the evaluation must include: Utilization of clinic services (at least the number of patients served) and number of total visits A review of both active and closed medical charts (10 open 5 closed) A review of the policy and procedure manual

27. Program Evaluation - (42 CFR 491.11) Surveyors will decide if the services you provided were: –Appropriate –In alignment with your current policies –If any changes are necessary

28. QAPI Program 491.11 a Rural Health Clinic must have a Quality Assessment and Performance Improvement (QAPI) program that is appropriate for the complexity of its organization and services and focuses on maximizing outcomes by improving patient safety, quality of care, and patient satisfaction.

29. Questions?