2016 Kentucky Rural Health Clinic Summit. Kate Hill, RN VP Clinical Services

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1 2016 Kentucky Rural Health Clinic Summit Kate Hill, RN VP Clinical Services

2 Operational excellence leads to clinical excellence Focusing on day-to-day operations can DECREASE COSTS while INCREASING QUALITY OF CARE

3 Exemplary Provider TM Accreditation Program Every patient deserves exemplary care. The provider must focus on what matters most to patients. Safety, Honesty & Caring

4 The Compliance Team, Inc. Accrediting since 1998 Owned and operated by a Registered Nurse Accrediting DME Companies, Pharmacies, Infusion Centers, Private Duty Agencies, Sleep Labs, Immediate Care Clinics and Rural Health Clinics. CMS Approved for DME and Rural Health Clinics

5 On-site meeting with the management staff and providers, as many as are available. Review of required policies and personnel files. Tour the entire facility. Observation of infection control practices. Inspection of medicine/supplies storage area. Review of patient medical records. Interviews with staff members conducted throughout the day. Patient interactions: Two or three patients will be interviewed Exit meeting.

6 It Starts Here!

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9 Administration Disclosure of ownership Free from Medicare sanctions OIG exclusion list Standards of conduct (includes a non-retaliation statement) Training of employees (what is involved and documentation)

10 Medical Director provides oversight and performs chart review No patients beyond the waiting room when provider not in the clinic Policy for referring patients and follow up process being used Evidence that records are maintained for at least 6 years (some states require 7 years). Pediatric patient records are addressed if applicable.

11 Patient medical records must contain: Identification and social data Consent forms (treatment and procedure is performed) Medical history Assessment of health care status Summary of episode Report of exams, diagnostic tests, lab results and general findings All physicians orders Signature (written or electronic) of clinician

12 Evidence of safety of patients in non-medical emergencies Training staff in handling emergencies Lighted EXIT signs at appropriate locations Preventative maintenance program in place Premises clean and orderly

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15 Human Resources Training documented & competency updated annually Signed Job Descriptions in personnel files Files on all employees and independent contractors: Application, Resume, References, W-4s I-9 (employees only) kept on-site TB and Hepatitis B status information Signed standards of conduct Copy of license/certification with verification

16 Equipment Management Written equipment management policy: Equipment organized, labeled, tested Clean/dirty areas clearly labeled and separated Equipment off the floor Equipment cleaned/disinfected prior to each patient use Equipment testing log and or checklist

17 Infection Control Hand washing (sinks, alcohol based gels, signs) Utilization of gloves Standard precautions in use and documented training Handling and disposal of infectious waste Preventing cross contamination Patient and care-giver education

18 Infection Control ü If reusable surgical instruments are used, recognized standards must be followed (CDC, AORN, AAMI) Staff must be trained by someone qualified to assess their competency. Table-top autoclaves must be cleaned following manufacturer s IFU.

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20 Infection Control ü Supplies for sterilization should be utilized following manufacturer s IFU. If the peel pouches have a manufacturer expiration date, the pouch must be labeled with this expiration date. Instruments open/unlocked when being sterilized Peel pouches should be labeled to track the load Sterility must be verified (bio indicators or mail service) and results kept in a log.

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23 Patient Services Complete patient care policy: List and description of services provided List of services by arrangement, agreement or referral posted Written information to all patients at first appointment: Rights and Responsibilities Medicare patient s notice of non-coverage Process for handling patient grievances handled within 7 days

24 Patient Services Scope of treatment by an NP, PA or CNM Policy for oversight of NP, CNP or PA MD/PA/NP Collaborative agreement Guidelines for medical mgmt (what requires referral) Criteria for diagnosing & treating health conditions Patient follow up process

25 Pharmaceutical Management Logs of the receipt and disposition of all controlled substances. Controlled substances double-locked ü Sample Log in place Process for complete and legible labeling of Multi Dose Vials No MDVs stored in patient care areas No expired drugs in cabinets Refrigerated drugs are properly stored Emergency Medications are stored appropriately

26 CDC Recommendation Multiple-Dose Vials (MDVs) Store multiple-dose vials outside the immediate patient treatment area. This includes treatment & exam rooms. Best Practice: dedicating a medication storage and prep area for MDVs. LINK:

27 Multi Dose Vial (MDV)

28 A hot mess The staff at this RHC were treating all medication vials as MDVs. The doctor was taking partially used SDV Marcaine from the ER and bringing it back to the clinic so it didn t get wasted.

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30 Survey Process Diagnostic Services Evidence of the following lab services: Urine, ketones Hemoglobin or Hematocrit Glucose Pregnancy tests Exam of stool for occult blood Primary culturing for transmittal to lab Controls being performed and in date per manufacturer s IFU. CLIA license posted and up to date!

31 RISK MANAGEMENT Evidence of Compliance: Evidence that incidents are documented (Variance Form) Evidence of follow-up, investigation, and resolution of incidents Evidence of corrective action taken Evidence of handling employees incidents The work environment is safe

32 RISK MANAGEMENT List of all equipment by manufacturer, model and serial number Oxygen Policy for oxygen handling and being patient ready E-Cylinders are stored properly (cart, chain, etc)

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34 Survey Process Quality Improvement Evaluate results to determine: Is our utilization of services appropriate? Were our established policies followed? What changes are needed? What follow-up is needed for corrective action?

35 Annual Evaluation *****Clinics being surveyed to become Rural Health Clinics: Must have an annual evaluation policy.

36 Annual Evaluation Evidence of annual program evaluation meeting Evaluation performed by the clinic, professional personnel One member must not be a member of the clinic staff Must include: Utilization Review of all services Clinic overall organization Review of active policies for admin, personnel, fiscal areas Number of patients served Review of open and closed patient records Review of all policies affecting patient care Guidelines for medical management of health problems

37 All licenses displayed Regulatory All exit signs marked and illuminated Fire extinguishers mounted, checked, tagged Evidence of fire safety training TB status and Hepatitis B vaccinations or declination Personal protective equipment available

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40 Regulatory All current year mandatory posters posted Organized process for handling an on-site emergency Organized process for handling an off-site emergency Evidence of emergency preparedness training in personnel files Contingency plan for alternative provider if clinic can t service to patients

41 Postings

42 Other Deficiencies No preventative maintenance policy Clinic not under the supervision of an MD or DO i.e. charts not signed, no evidence of review Policies and procedures are not up-to-date, generic, or nonexistent Staff training not documented Emergency Preparedness of drugs during power outages

43 Thoughts If the clinic purchases a generic policy binder, it must be personalized Clinic staff must know what s in the policies Clinic must know and follow the state s physician on-site and chart review regulations Clinic must perform medical record review, even if the state doesn t require

44 Scoring/ Statement of Deficiency 100% compliance is necessary for certification and re-certification Statement of Deficiency (SOD) within 10 business days The clinic has 10 calendar days to submit a Plan of Correction on the SOD form If the clinic received Condition level deficiencies then a revisit must occur within 45 calendar days from the survey date (if you already have a billing number) Standard level deficiencies must be corrected within 60 calendar days from survey

45 Improving Quality Through Measurement 1 Calling patients vs. mailing 2 Focus questions on what matters to patients 3 Sends POWERFUL message to patients that you care

46 Our newest program about to be released: PCMH: Offering a framework for well focused, physician guided, patient centered Continuous and coordinated care. ü Better operation in the clinic ü Streamlined by incorporating PCMH into your ü Current practices ü Focus on improvement not transformation

47 The Compliance Team, Inc. Exemplary Provider TM Accreditation Program Our accreditation advisors work with you every step of the way! Conference call series with advisor Q&A via TCT website access for resources Kate Hill, RN Vice President of Clinical Services

48 Thank You!