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 [email protected]
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