Surviving Survey and Recertification

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Surviving Survey and Re-certification
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It's easier to go down a hill than up it but the
view is much better at the top. Henry Ward Beecher
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Rural Indiana

• Indiana Stats
• 114 Hospitals / 41 in Rural areas
• 59 RHCs
• 35 CAHs (35miles or necessary provider)
• Recertifying approximately 6-7 years
• Survey will be unannounced
• Survey will be during RHC posted hours
• Usually 1 surveyor
• 4 to 8 hours

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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

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Conditions for Certification

• Compliance with laws
• Location
• Physical Plant
• Organizational Structure
• Staffing and Staff Responsibilities
• Provision of Services
• Health Records
• QAPI Program Evaluation

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Compliance with Laws

• Compliance with State practice acts concerning
  mid-levels
• PAs -The supervising physician shall review all
  patient encounters not later than 24 hours after
  the physician assistant has seen the patient.

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Compliance with Laws

• NPs
• http//www.in.gov/legislative/iac/T08480/A00040.PD
  F\
• NP requirement is 5 weekly random audit
• RHC is going to require some oversight documented

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Location of Clinic
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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

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Organizational Structure

• Medical Direction
• Written Policies
• Administrative (authority and responsibilities)
• Patient Care
• Personnel
• Fiscal
• Maintenance
• Disclosure of Names/Addresses

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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

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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 Policies
• Description of Services
• Additional Services furnished through referral
• Drugs and Biologicals
• Storage Outdated deteriorated - security

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Patient Health Records

• Records kept at the clinic
• Record retention (6 year) RHC reg
• Appropriate release of information
• Protection of Record Information
• Ensure confidentiality
• Provide safeguards against loss or unauthorized
  use

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Program Evaluation

• Annual Evaluation
• Total operations including
• Organization
• Administration
• Policies and Procedures
• Personnel
• Fiscal
• Patient care areas

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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.

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Contact InformationJoanie.Perkins_at_northsunflower.
com