National Association of Rural Health Clinics A Virtual Walk Through of a Rural Health Clinic October 17, 2017 Kate Hill, RN VP Clinical Services Inc. Tom Terranova Chief Operating Officer
Who Is In The Room Today? Already a certified Rural Health Clinic? Preparing for Initial RHC Survey? In the Exploratory Phase?
RHC Survey Is An Open-Book Test There Should Be No Surprises 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 Conditions for Certification
RHC Conditions for Certification Want a little Extra 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 Policies Reports Other 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 Certificates State Postings Federal Postings Provider 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 Preventing Access to Hazards
Facility Tour Equipment 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 Tour Equipment 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 Storage Vaccination 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 Practices Training 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 Prevention OSHA training upon hire and annually PPEs are available and accessible Hand Hygiene when appropriate Clean/Dirty Segregation in work and storage areas Avoid Cross-Contamination (disinfecting environment, cleaning patient equipment, sterile processing) No Reuse of Meds/Supplies Designated for Single Use Safe 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 plastic side of pouch Labeled with the correct information for the load log Internal chemical indicator Hinged instruments opened position
Patient Health Records Common 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.
Emergency Preparedness Survey Procedures for Risk Assessment and Planning 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.
Emergency Preparedness Survey Procedures for Risk Assessment and Planning 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.
Emergency Preparedness Survey Procedures for Risk Assessment and Planning 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.
Emergency Preparedness Survey Procedures for Risk Assessment and Planning 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 RHCbased 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.
Emergency Preparedness Survey Procedures for Communication Plan 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.
Emergency Preparedness Survey Procedures for Communication 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.
Emergency Preparedness Survey Procedures for Provider Based Clinics 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).
Emergency Preparedness Survey Procedures for Provider Based Clinics 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 You Kate Hill, RN Vice President of Clinical Services khill@thecomplianceteam.org Tom Terranova Chief Operation Officer tterranova@aaaasf.org