National Association of Rural Health Clinics Preparedness Survey Procedures for Risk Assessment and...

A Virtual Walk Through of a Rural Health Clinic

October 17, 2017Kate Hill, RN

VP Clinical ServicesThe Compliance Team Inc.

Tom TerranovaChief Operating Officer

AAAASF

National Association of Rural Health Clinics

AAAASF The Compliance Team

Who Is In The Room Today? • Already a certified Rural Health Clinic? • Preparing for Initial RHC Survey? • In the Exploratory Phase?

• Title 42 Code of Federal Regulations (CFR) Part 491 Rural Health Clinics Conditions for Certification

• Any State Regulations Affecting the Provision of Healthcare Services

• Any Accreditation Organization Standards that Exceed the CFR

Note: Be mindful of the strictest requirement

RHC Survey Is An Open-Book Test…There Should Be No Surprises


RHC Conditions for Certification


RHC Conditions for CertificationWant a littleExtra insight?

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf


Interpretive Guidelines Example


Roadmap to Success• RHC Training for Providers and Staff• Making/Completing the “To Do” list• Fine-tuning Provider and Staff education• Adoption of RHC policies • Ensuring processes are in place to keep

the clinic ready for day of survey


Survey Planning Tips• Develop a Survey Readiness Binder

PoliciesReportsOther evidence of compliance

• Keep the Clinic “Company Ready”


Day of Survey Agenda• On-site Meeting with Key Leadership• Review of RHC policies• Tour the entire Facility• Observe Medication Storage • Observe Infection Prevention Practices• Interview Staff and Providers• Patient Health Record review• Personnel Files• Exit interview


What The Surveyor Will Request• P&P and Other Manuals • Evidence of Annual Program Evaluation/Template• Copy of RHC Organization Chart• Equipment List and Maintenance Report• HR Files• Staffing Schedule (to calculate provider hours)• Evidence of PA/NP Records reviewed by Physician• Patient Records to Review (10 random files)


Clinic Policies & Procedures• P&P personalized, not generic templates• Staff should be familiar with policies• Must follow the state’s physician on-site and chart

review regulations• Must have evidence of adoption and annual review by

an advisory group that includes, at a minimum, a physician, NP or PA, and one person not on staff


Required Policies & Procedures• Lines of Authority• Categories of Practitioners• Periodic Review of Policies by MD, NP/PA/CNMW• Maintenance of Medical Records• Protection and Release of PHI• Annual Program Evaluation • Scope of Patient Care Services


Other Policies & Procedures• Corporate Compliance• Contents of the Emergency Box• Environmental Cleaning and Waste• HR Policies and Training• Complaint Policy• Equipment Management• Infection Control • Specific Pharmaceutical Requirement


Facility Tour• The name physically on the clinic must match one of the

two names on your 855A form.• If you have changed it over the years, you must notify CMS

and the State.• All changes require coordination between Accreditors and

CMS/State

Signage Consistent with CMS 855A Application


Facility Tour

Hours of Operation Outside of the Clinic


Facility Tour

ADA Accessible and Free from Obstacles


Facility Tour

Clean and Maintained


Facility Tour

Local Licenses or CertificatesState PostingsFederal PostingsProvider Licenses

State and Federal Posters are required to be in Visible Places


Facility Tour

Clinic Practices Secure Protected Health Information


Facility Tour

Fire Safety Process per State Regulations


Facility Tour

Securing Hazards


Facility Tour

PreventingAccess to Hazards


Facility TourEquipment Maintenance Best Practices• All equipment resides on an Inventory List • Policy determines need for Inspection vs Preventive Maintenance• PM based on Manufacturer’s IFUs• Process in place for tracking due dates for PM• Evidence of initial inspection BEFORE use in patient care• Annual Bio-Med inspection is evident with stickers or report• Equipment not in use is labeled as such and stored away• Equipment brought back into use must be inspected

BEFORE resuming use


Facility TourEquipment Management Best Practices• Manufacturer’s IFUs determine cleaning process• Healthcare Disinfectant is used • Staff follows directions on the Disinfectant• Dirty equipment is stored away from Clean• Equipment stored off of the floor


Facility Tour

Secured/Organized In Original Containers, Not Expired/Past BUD, No MDV in Immediate Treatment Areas, SDV contents Not Saved


Facility Tour

DANGER: Unlabeled Vaccines in Pre-Drawn Syringes


Facility Tour: Medication StorageVaccination Storage Best Practices

• Temperature monitoring should alert staff to a temperature variance in the past 48 hours• Clinic should have a process to be notified when the power goes off at the clinic (power grid call list, alarm with alerts, etc.)• Bottled water stored in the doors• No medications stored in the doors• Expired medications MUST be identified• No food or lab supplies stored in the

med fridge or freezer


Facility Tour: Medication Storage

Controlled Substances (CS) in a Substantial Cabinet Recordkeeping Logs for Ordering / Dispensing

Dilemmas: MDVs, Storage in Sample Closet, Med Fridge, or ER Boxes


Facility Tour: Medication Storage

Sample Medications Secured Logged to Track In the Event of a Recall


Free Medication Storage Training

CDC Safe Injection PracticesTraining Videos on You Tube


Facility Tour LAB Compliance• 6 Required tests must be able to be performed in the Clinic

•Urine Analysis•Hemoglobin or Hematocrit •Blood Glucose Testing•Urine Pregnancy Test•Occult Fecal Blood Test•Primary Culturing

• Clinic follows all Manufacturer’s IFU for equipment and supplies• Staff should have training/verification of competency

(BEST PRACTICE)


Infection PreventionOSHA training upon hire and annuallyPPEs are available and accessibleHand Hygiene when appropriateClean/Dirty Segregation in work and storage areasAvoid Cross-Contamination (disinfecting environment,

cleaning patient equipment, sterile processing)No Reuse of Meds/Supplies Designated for Single UseSafe Injection Practices


Infection Prevention Best Practices“Clean to Dirty” Process to Avoid Cross-Contamination

Clean Area (Meds) Dirty Area (Labs)


Infection Prevention Best Practices

Disposable Instrumentation Is The Easiest Way To Meet Compliance


Infection Prevention Best Practices

Labeled on the plasticside of pouch

Internalchemicalindicator

Labeled with the correctinformation forthe load log

Hingedinstrumentsopened position


Patient Health RecordsCommon Chart Deficiency:

• Lack of complete consent forms

• Lack of date

• Lack of relationship to patient for minors


Emergency Preparedness


Emergency Preparedness 30 Days to be Compliant!

EP Requirements for Medicare and Medicaid Participating Providers/Suppliers• Published September 16, 2016• Applies to all 17 provider/supplier types• Compliance required for participation in Medicare

Implementation Date November 15, 2017


Emergency Preparedness Survey Procedures for Risk Assessment and Planning

1. Interview the RHC leadership and ask them to describe the RHC’s emergency preparedness program.

2. Ask RHC leadership to identify hazards (e.g. natural, man-made, geographic, etc.) that were identified in the RHC’s risk assessment, why they were included and how the risk assessment was conducted, and succession plans.



3. Interview RHC leadership and ask them to describe the following: a. The RHC’s patient population that would be at risk during an emergency;b. Services the RHC would be able to provide during an emergency; how it continues to provide operations during an emergency; and delegations of authority and succession plans.

4. Verify that the RHC has an emergency preparedness plan by asking to see a copy of the plan.



5. Verify plan contains the following required elements:a. A documented, clinic-based and community-based risk assessment. b. Strategies for addressing emergency events identified by the risk assessment. c. Addresses patient population, including, but not limited to, the type of services the clinic has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.



5. d. A process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness official’s efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the clinic’s efforts to contact such officials and when, applicable, of its participation in collaborative and cooperative planning efforts.



6. Ensure the word “comprehensive” in the RHC’s emergency preparedness program considers a multitude of events (not one potential emergency) and the RHC can demonstrate that they have considered this during their development of the emergency preparedness plan.

7. Verify that the plan is reviewed and updated annually.


Emergency Preparedness Survey Procedures for Policies and Procedures

1. Review the written policies and procedures which address the RHC’s emergency plan and verify the following:

a. Policies and procedures were developed based on the RHC-based and community- based risk assessment and communication plan, utilizing an all-hazards approach.b. Verify the RHC’s policies and procedures:

1. Provide for the safe evacuation of patients from the RHC.


Emergency Preparedness Survey Procedures for Policies and Procedures

2. Include how it will provide a means to shelter in place for patients, staff and volunteers who remain in the RHC.3. Ensures the medical record documentation system preserve patient information, protects confidentiality of patient and secures and maintains availability of records.4. Includes the use of volunteers and other staffing strategies in its emergency plan.

When surveying the RHC, verify that all exit signs are placed in the appropriate locations to facilitate a safe evacuation.


Emergency Preparedness Survey Procedures for Communication Plan

1. Verify that the RHC has a written communication plan by asking to see the plan.2. Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.3. Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.



4. Verify the communication plan includes primary and alternate means for communicating with RHC staff, Federal, State, tribal, regional and local emergency management agencies by reviewing the communication plan (i.e., pagers, cellular telephones, walkie-talkies, HAM radio, etc.)

5. Ask to see the communications equipment or communication systems listed in the plan.



6. Verify the RHC has developed policies and procedures that address the means the RHC will use to release patient information to include the general condition and location of patients, by reviewing the communication plan.

7. Verify the communication plan includes a means of providing information about the RHC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.


Emergency Preparedness Survey Procedures for Training and Testing

1. Verify the RHC has an emergency preparedness training and testing program.2. Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made. 3. Ask for copies of the RHC’s initial emergency preparedness training and annual emergency preparedness training offerings.4. Interview various staff and ask questions regarding the RHC’s initial and annual training course, to verify staff knowledge of emergency procedures.


Emergency Preparedness Survey Procedures for Provider Based Clinics

1. Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.

2. Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.



3. Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.

4. Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).



5. Ask facility leadership to describe how the unified and Integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.


Thank YouKate Hill, RNVice President of Clinical ServicesThe Compliance [email protected]

Tom TerranovaChief Operation [email protected]


mailto:[email protected]

mailto:[email protected]

National Association of Rural Health Clinics Preparedness Survey Procedures for Risk Assessment and...

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