Surviving Survey and Re-certification

1. Surviving Survey and Re-certification

3. Mississippi Stats • 116 Hospitals • 163 RHC’s (MSDH website) • 28 CAH’s (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 Rural Mississippi

4. 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 What to expect upon arrival

5. Compliance with laws • Location • Physical Plant • Organizational Structure • Staffing and Staff Responsibilities • Provision of Services • Health Records • QAPI – Program Evaluation Conditions for Certification

6. 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

7. 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. Compliance with Laws

8. Location of Clinic

9. 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 Physical Plant

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

11. 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 Staffing and Staff Responsibilities

12. 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 Provision of Services

13. 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 Patient Health Records

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

15. 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. Quality Assurance Performance Improvement (QAPI)

16. Contact InformationJoanie.Perkins@northsunflower.com