Surviving Survey and Re-certification

Rural Mississippi

Mississippi Stats◦116 Hospitals◦163 RHC’s (MSDH website)◦28 CAH’s (35miles or “necessary provider”)

Recertifying approximately 6-7 yearsSurvey will be unannouncedSurvey will be during RHC posted hoursUsually 1 surveyor4 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 lawsLocationPhysical PlantOrganizational StructureStaffing and Staff ResponsibilitiesProvision of ServicesHealth RecordsQAPI – 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 – 1. Review by collaborative physician of a random sample of charts that

represent 10% or 20 charts, whichever is less, of patients seen by the nurse

practitioner every month. Charts should represent the variety of patient types seen by

the nurse practitioner. Patients that the nurse practitioner and collaborating

physician have consulted on during the month will count as one chart review. 2. The nurse practitioner shall maintain a log of charts reviewed which

include the identifier for the patient’s charts, reviewers’ names, and dates of review. 3. Each nurse practitioner shall meet face to face with a collaborating

physician once per quarter for the purpose of quality assurance and this meeting should be documented.

Location of Clinic

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 DirectionWritten 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 PoliciesDescription of ServicesAdditional Services furnished through referralDrugs and Biologicals

◦Storage – Outdated – deteriorated - security

Patient Health Records

Records kept at the clinicRecord retention (6 year) RHC reg…Appropriate release of informationProtection of Record Information

◦Ensure confidentiality◦Provide safeguards against loss or unauthorized

use

Program Evaluation

Annual Evaluation ◦Total operations includingOrganizationAdministrationPolicies and ProceduresPersonnelFiscal 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.

Contact InformationJoanie.Perkins@northsunflower.com