TACHC Conference on Family Planning

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TACHC ConferenceonFamily Planning

• October 17, 2006
• Houston, Texas

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Family Planning Documentation and Confirmation of
Compliance

• Lolly Lockhart Ph D RN
• TACHC Consultant

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Family Planning Documentation and Confirmation of
Compliance

• Objectives Participants are able to
• 1. Identify requirements for documentation
  regarding family planning services
• 2. Identify processes and forms that may be used
  to confirm compliance with family planning
  services and documentation

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Policies to Comply with Federal/State

• Civil Rights (non-discrimination P/P and survey)
• B. Americans with Disabilities (ADA)
• C. Limited English Proficiency (LEP)

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Policies to Comply with Federal/State

• D. Child Abuse Screening
• Including Domestic Violence issues

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Policies to Comply with Federal/State

• E. Consent
• F. Privacy and confidentiality
• G. Patient health care/medical records

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Policies to Comply with Federal/State

• H. Grievance procedures
• I. Infection Control

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Policies to Comply with Federal/State

• J. Credentialing and competencies of staff
• K. Standing Delegation Orders/Clinical
• Protocols
• L. Staff identification by name tags

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Policies to Comply with Federal/State

• M. CLIA Certification/Waivers
• N. Pharmacy license or provisions

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Policies to Comply with Federal/State

• O. CPI (QA) Program (active and documented)
• P. Safety (facility, fire safety, medical
  equipment, hazardous materials)

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Policies to Comply with Federal/State

• Q. Eligibility for Title V, X and XX services
• R. Client Rights Responsibilities signed

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Policies to Comply with Federal/State

• S. Billing logs and co-pays collected
• T. Billing and donations clearly stated

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Policies to Comply with Federal/State

• U. Community information/awareness (marketing)
• V. Information/Education Advisory Committee

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Policies to Comply with Federal/State

• W. Staff development based on needs
• X. Coordination of care
• Y. Client satisfaction

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Monitors to Confirm Compliance

• A. Non-discrimination policies and procedures
  including privacy and confidentiality
• See Patient and Center Rights and
  Responsibilities,
• TACHC MO Manual (2003), (English and
• Spanish), pages 291-306 (includes HIPAA Privacy
• Rights Statement)

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Monitors to Confirm Compliance

• B. Limited English Proficiency (LEP)
• Patient information and forms in English and
  Spanish, including medical and health
• questionnaires, Patient and Center Rights and
• Responsibilities (includes HIPAA privacy rights),
• Client Satisfaction Survey, and educational
• materials

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Monitors to Confirm Compliance

• C. Center policies and practices consistent
• with Americans with Disabilities Act
• provisions for physical access and
• accommodation

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Monitors to Confirm Compliance

• D. Child Abuse Screening
• See TACHC Manual Updates (2005) 7 Child Abuse
• Reporting, Checklist, Record Review Monitor,
  Reporting
• Requirements, TDSHS (TDH) Guidelines for
  Monitoring
• (5/15/04), updates pages 332-340F.
• See also TACHC MO Manual, Domestic Violence P/P,
  
• pages 329-331.

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Monitors to Confirm Compliance

• E. Consent for Family Planning Services
• See TACHC revised and expanded consent forms
  related
• to Family Planning (2006)

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Monitors to Confirm Compliance

• F. Investigate and trend any complaints
• concerning Civil Rights and/or services
• See Client Satisfaction and Complaints, TACHC
• Management and Operations Manual (2003), pages
  307-311
• See also Risk Management Policy on Sentinel Event
  and
• Intensive Investigations, TACHC Management and
• Operations Manual (2003), pages 238-245

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Monitors to Confirm Compliance

• G. Conduct client satisfaction surveys, and
• analyze and report findings for actions
• See Assessing Client Satisfaction in Family
  Planning
• Clinics Lessons Learned by Huckaby and Williams.
  Use
• these forms for Family Planning and standard
  TACHC forms
• (previous slide) for other clients.

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Monitors to Confirm Compliance

• H. Safety (facility, fire, medical equipment,
• hazardous materials) and Infection Control (OSHA
  Exposure Plan)
• See TACHC MO Manual (2003) pages 168-217
• See also Environment of Care (EOC) Safety Plan
  TACHC
• MO Manual pages 261-277 related to infection
  control

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Monitors to Confirm Compliance

• I. Staff Credentialing/Competencies, and Training
• Needs Assessment
• Schedule of Training
• Name tag to identify staff
• In addition to TACHC Human Resources Manual
  (2003)
• regarding credentialing and competencies, refer
  to sample
• Staff Development Plan by CHCs of South Central
  Texas
• (Gonzales)

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Monitors to Confirm Compliance

• J. Laboratory services have CLIA certification or
  waiver
• K. Pharmacy services licensed as pharmacy
• provisions for pharmacy services by
• contract/agreement

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Monitors to Confirm Compliance

• L. Clinical services provide for Standing
  Delegation Orders and Clinical Protocols for
  family planning services
• See TACHC Manual Updates (2005) regarding
  Standing
• Delegation Orders (SDO), pages 79-85.
• See TDSHS Family Planning guidelines for services
  to be
• included in SDO and Clinical Protocols.

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Monitors to Confirm Compliance

• M. Eligibility for Titles V, X and XX
• N. Forms required for Titles V, X and XX
• O. Billing process and documentation
• See BVCAA Family Planning Reference Tool

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Monitors to Confirm Compliance

• P. Record reviews of client record including
  Family Planning forms to document coordination of
  care
• See sample family planning forms by Brazos
  Valley
• Community Health Center for male and female
  medical history in English and Spanish

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Monitors to Confirm Compliance

• Q. Quality Assurance (Compliance/ Performance
  Improvement Program)
• Must have CPI committee and evidence of
  on-going effective CPI activities
• Monitors must include issues addressed in this
  presentation

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Monitors to Confirm Compliance

• R. Administrative Actions
• Review oversight/supervision, and accountability
  for safety measures (staff credentialing,
  facility safety, supervision, corrective actions
  based on CPI monitors and outcomes)

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Monitors to Confirm Compliance

• S. Community information/awareness (marketing)
  and Information/Education Advisory Committee
• Review marketing program and involve IEA
• Committee to ensure public awareness of services

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Monitors to Confirm Compliance

• T. Clinical Record Review
• Assurance of documentation concerning medical
  management and coordination of care including
  family planning services consistent with TDSHS
  and professional standards
• Monitor risk factors and care measures
• Monitor of client outcomes and actions taken)

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Monitors to Confirm Compliance

• U. Monitor Tools
• 1. TDSHS Core tool (2006) (5 pages)
• 2. Title V FP Tool (2006) (5 pages)
• 3. Title V Tool Monitoring Instructions (2006)
  (13 pages)
• 4. Title V MCH, Dysplasia, Family Planning Tool
  (2006) (3 pages)
• 5. Title V FP and X/XX Clinical Record Review
  Tool (2006) (1 page)
• 6. Title X/XX On-Site Evaluation Report(2006)
  (6 pages)
• 7. Title X/XX Tool Monitoring Instructions
  (2006) (11pages)

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Thank you very much!

• Please remember to complete the evaluation forms