Chapter Five
Preparing for the RHC Certification Inspection
There is a saying with runners, "the race is easy, it's the
preparation that will kill you." The same can be said for preparing
for the RHC Certification Survey. If you prepare thoroughly, then
the survey can be uneventful. This chapter is designed to assist
you in the preparation. We believe you will find this information
useful, but it is not possible to address every situation that may
arise during the survey. There are four key elements to preparing
for the RHC Certification Survey they are: 1) Policy and Procedure
Manual Review, 2) Medical Records Review, 3) Facility Inspection,
and 4) Program Evaluation.
The RHC Policy and Procedure Manual
The policy and procedure manual should cover key human resource
policies, administrative policies, clinical procedures and protocols,
and medical guidelines per RHC Code of Federal Regulations (CFR)
§491.7(a)(2). A sample Policy and Procedure manual has been
included in Appendix D. It should be noted that this is an example.
Each clinic's policy and procedures manual should be drafted with
that clinic in mind. This document should be an accurate reflection
of how the clinic truly intends to operate.
The Policy and Procedures Manual section of the RHC Interpretive
Guidelines States, "Written policies should consist of both
administrative and patient care policies. Patient care policies
are discussed under 42 CFR 491.9(b). In addition to including lines
of authority and responsibilities, administrative policies may cover
topics such as personnel, fiscal, purchasing, and maintenance of
building and equipment. Topics covered by written policies may have
been influenced by requirements of the founders of the clinic, as
well as agencies that have participated in supporting the clinic's
operation."
When looking at developing human resource policies, there are several
laws, administrative rules, acts, and regulations that must be considered:
RHC Code of Federal Regulations, RHC Interpretative Guidelines,
State and Federal Laws, State Public Health Code, and Professional
Practice Standards.
The Human Resource policies should include:
- job descriptions
- benefits, compensation and pay practice
- employment criteria and conditions of employment
- smoking, drug use/possession and distribution
- appointment of providers/credentialing
- confidentiality
- personnel files (organization, management, and access)
- harassment, and employee privacy
The Code of Federal Regulations for the RHC program and the RHC
Interpretive Guidelines (both are available on the website of the
National Association of Rural Health Clinics - www.narhc.org)
are often the best place to start when developing RHC policies.
CFR Section 491.8 Staffing and staff responsibilities, outlines
some of the program requirements for physician assistants, nurse
practitioners and certified nurse midwives. The regulations State
that, "A nurse practitioner or a physician assistant is available
to furnish patient care services at least 50 percent of the time
the clinic operates." When developing the job description of
the PA/NP/CNM, part of their responsibilities should include the
following: "The PA/NP/CNM will be scheduled in the clinic and
available to provide patient care services for at least 50 percent
of the time the clinic operates."
As you develop your Administrative section, you will want to consider
the following resources: RHC Code of Federal Regulations and Interpretative
Guidelines, State and
Federal Laws, State Court Rules, Federal and State OSHA Standards,
Medicare and Medicaid reimbursement policy, State Public Health
Code, Administrative rules, and the Freedom of Information Act.
Administrative policies should include:
Life safety
Confidentiality
Exposure control plan
Hazardous materials
Health services
Informed consent
Medical records (storage, release of information, documentation
standards)
Reporting of suspected child neglect/abuse and abandonment
TB screening for health care workers |
Medical waste management
Organizational structure
Personal accident/incident
Physical plant and environment
Patient compliant-grievance procedure
Performance improvement plan
Preventative maintenance
Patient rights and responsibilities
Quality assurance
Medicare bad debt
Cleaning |
Again when developing your Administrative section, the best place
to start is with the Code of Federal Regulations (CFR). An example
of an Administrative policy would be Preventive Maintenance. CFR
Section 491.6(b) States, "The clinic has a preventive maintenance
program to ensure that: (1) All essential mechanical, electrical
and patient-care equipment is maintained in safe operating condition."
The RHC Interpretive Guideline for this regulation defines the requirement
further, "A program of preventive maintenance should be followed
by the clinic. This includes inspection of all clinic equipment
at least yearly, or as the type, use, and condition of equipment
dictates." By using these two resources the preventive maintenance
policy could contain the following
Statements:
- All Clinic equipment will be inspected at least yearly, or as the type, use, and
condition of equipment dictates. Each time an inspection or repair occurs, an entry will be made in the Inspection and Maintenance Log and signed by the service person to verify the event.
- The medical/clinical assistant prior to each use must inspect all equipment.
- An electrician or bio-medical engineer will inspect each piece of bio-medical equipment. The inspection will ensure that the equipment is in proper operating condition, is safe to use, and is calibrated properly.
When developing clinical procedures/protocols, it is helpful to
keep in mind that this section refers to those procedures that are
performed by support personnel, e.g., nurse, certified medical assistant,
registered radiologic technologist, clinical assistant, etc. Resources
that you would want to consider as you develop this section are:
RHC Regulations and Interpretive Guidelines, manufacturer recommendations,
professional practice standards, pharmacy regulations and administrative
rules, American Heart Association, Federal and State OSHA standards,
CLIA regulations, CDC, State Public Health Code, American Academy
of Pediatrics, and PHS Standards for Pediatric Immunization Practices.
Clinical policies should include:
- Administration of Sub-Q, IM, or IV Medications
- Policies for all invasive procedures performed
- Vaccine administration, handling and storage
- Procedures for the operation of all medical equipment
- Medications (stock and sample)
- Laboratory services
- Communicable disease care
- HIV testing
- Universal Precautions
- Diagnostic tracking
- Adverse drug reactions
- Policies that address the testing and quality control of all lab/diagnostic test(s) performed
- Storage of sterile supplies, sterilization of sterile supplies and instruments
As with the Human Resources and Administrative sections, the first
resources to consider are the Code of Federal Regulations and the
Interpretive Guidelines. Using the Code you can easily start to
put together your clinical procedures/protocol section. For example,
CFR Section 491.6(b)(2) States, "The clinic has a preventive
maintenance program to ensure that drugs and biologicals are appropriately
stored." Based on this regulation, the medication policy could
contain the following Statements (among others):
- Medications will be refrigerated as necessary and will be kept separate from any food substances. Refrigerator and freezer temperatures will be obtained and recorded on a daily basis.
- On a monthly basis, medications will be checked for expiration dates and those which are outdated will be discarded in the following manner: Given back to drug representative or discarded via the biohazard container. A log will be maintained to indicate when monthly checks are done and by whom.
- All medications stored on the Clinic premises will be kept in cabinets, shelves, drawers, and/or refrigerators and locked during non-patient care hours.
Finally, the RHC program requires that the clinic have guidelines
for the medical management of health problems which include the
conditions requiring medical consultation and/or patient referral,
the maintenance of health care records, and procedures for the periodic
review and evaluation of the services furnished by the clinic. Acceptable
guidelines may follow various formats.
Some guidelines are collections of general protocols, arranged
by presenting symptoms; some are Statements of medical directives
arranged by the various systems of the body (such as disorders of
the gastrointestinal system); some are standing orders covering
major categories such as health maintenance, chronic health problems,
common acute self-limiting health problems, and medical emergencies.
Even though approaches to describing guidelines may vary, acceptable
guidelines for the medical management of health problems must include
the following essential elements:
- They are comprehensive enough to cover most health problems that patients usually see a physician about;
- They describe the medical procedures available to the nurse practitioner, certified nurse-midwife, and/or physician assistant; and
- They are compatible with applicable State laws.
The professional organizations of the health professionals typically
found in an RHC (physician, PA, NP and CNM) have published a number
of patient care guidelines. Should a clinic choose to adopt such
guidelines (or adopt them essentially with noted modifications),
this would be acceptable if the guidelines include the aforementioned
essential elements.
Often the regulations will over lap and you need to be aware of
the areas where this occurs. Policy and procedure development is
one area. The physician and PA, NP or CNM responsibilities include
participation in developing, executing, and periodic reviewing of
the clinic's written policies. Additionally, the policies are developed
with the advice of a group of professional personnel that includes
one or more physicians and one or more physician assistants or nurse
practitioners. At least one member of the advisory group must not
be a member of the clinic staff.
Medical Records
The RHC program has been recognized for its emphasis on documented
patient care. This is the direct result of the requirements and
expectations clearly stated in the Code of Federal Regulations.
The clinic has written policies and procedures of how it will maintain
confidentiality of patient health records and provide a safeguard
against: loss, destruction, or unauthorized use of patients' health
record. CFR Section 491.10 Patient health records of the Code, outlines
expectations for medical record confidentiality, maintenance, organization,
content, protection, release and retention. As part of the Certification
Survey process, a representative sample of the clinic's medical
records will be reviewed. The focus should be on Medicare and Medicaid
records only. The clinic may have the opportunity to select the
records for review. If not,
it will be the surveyor who determines the records to be reviewed.
Documentation must include but is not limited to:
- Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition and instructions to the patient;
- Reports of physical examinations, diagnostic and laboratory test results and consultative findings;
- All provider orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress; and
- Signatures of the provider and other health care professionals.
In addition to these program expectations, the clinic must also
comply with reimbursement policy, legal expectations, and standard
of practice guidelines. Remember, if it wasn't documented, it wasn't
done.
Facility
Preparing the facility is not only a requirement of the RHC program
but may also be a requirement for compliance with local, State and
Federal laws. An inspection of the physical plant is one of the
key elements of the survey process. Some of the regulations,
laws, rules, and standards that impact the facility are: RHC Code
of Federal Regulations, Clean Indoor Air Act, OSHA Hazardous Communication
Standard, local building, zoning and, fire ordinances, and State
laws for storage and disposal of medical waste.
To insure the safety of patients, personnel, and the public, the
physical plant should be maintained consistent with appropriate
State and local building, fire, and safety codes. Reports prepared
by State and local personnel responsible for insuring that the appropriate
codes are met should be available for review. The facility must
have safe
access and be free from hazards that may affect the safety of patients,
personnel, and the public. The clinic must also be constructed,
arranged, and maintained to insure access to and safety of patients,
and provide adequate space for the provision of direct services.
The clinic must provide laboratory services directly to its patients.
Each clinic must have, at a minimum, its own CLIA certificate of
waiver. Provider-based RHCs may not use the CLIA certificate of
the parent hospital. The clinic must have a preventive maintenance
program to ensure that all essential mechanical, electrical, and
patient-care equipment is maintained in safe operating condition.
The clinic must make provisions for the appropriate storage of drugs
and biologicals and the premises must be clean and orderly. The
clinic is responsible for assuring the safety of patients in case
of non-medical emergencies that include, placing exit signs in appropriate
locations and taking other appropriate measures that are consistent
with the particular conditions of the area in which the clinic is
located.
Program Evaluation
An evaluation of the clinic's total operation including the overall
organization, administration, policies and procedures covering personnel,
fiscal and patient care areas must be done at least annually. This
evaluation may be done by the clinic; an outside group of professional
personnel that includes one or more physicians and one or more physician
assistants or nurse practitioners and at least one individual who
is not part of the clinic staff; or through arrangement with other
appropriate professionals. The State survey does not constitute
any part of this program evaluation.
The total evaluation does not have to be done all at once or by
the same individuals. It is acceptable to do parts of it throughout
the year, and it is not necessary to have all parts of the evaluation
done by the same staff person. However, if the evaluation is not
done all at once, no more than one year should elapse between evaluating
the same parts. For example, a clinic may have its organization,
administration, and personnel and fiscal policies evaluated by a
health care administrator(s) at the end of the fiscal year; and
its utilization of clinic services, clinic records, and health care
policies evaluated six months later by a group of health care professionals.
If the facility has been operational for at least a year at the
time of the survey and has not completed an evaluation of its total
program, the surveyor must report this as a deficiency. If the facility
has been operational for less than one year or is in the start-up
phase, it is not required to complete a program evaluation. However,
the clinic should have a written plan that specifies who is to do
the evaluation, when it is to be done, how it is to be done, and
what will be covered in the evaluation.
The evaluation must include a review of the following:
- Utilization of clinic services (including at least the number of patients served and the volume of services)
- A representative sample of both active and closed clinical records, and
- The clinic's health care policies
The purpose of the evaluation is to determine whether: the utilization
of services was appropriate; the established policies were followed;
and whether any changes are needed.
The clinic staff or a group of professional personnel must consider
the findings of the
evaluation and take corrective action if necessary. The Balanced
Budget Act of 1997 requires RHCs to have a clinical quality assurance
plan. However as of the writing of this manual, CMS had not published
the rules outlining how RHCs can meet this requirement. Many State
surveyors expect to see such a plan in the policy and procedures
manual.
Once the clinic submits its Letter of Readiness to the State agency,
the State agency has 90 days in which to schedule the RHC Certification
Survey. Some clinics may experience a delay in the process depending
on national initiatives and budget constraints.
The State agency does have the option, under certain conditions,
of giving clinics a 48-hour notice of the scheduled survey. Some
States, however, will not exercise this option and the survey will
be unannounced. To ensure a successful survey, have a plan and prepare
ahead. The following documents should be prepared and available
to the surveyor.
Policy and Procedure Manual |
MSDS Manual |
All Professional Group, Staff,
and Provider mtg. minutes |
Minimum of 10 medical records
(Medicare/Medicaid only) mix of all life cycles and providers |
Fire and Evacuation Training
logs |
CLIA Certificate
|
Exposure Control and Blood borne
Pathogen Training |
Quality Assurance and Performance
Improvement Activity |
Personnel Files |
Preventative Maintenance Reports |
X-ray Certificate (if applicable)
|
Laboratory Control Logs |
Sample Drug Log |
Diagnostic Results Tracking System |
When the Certification Survey results in no deficiencies, the State
agency has ten (10) calendar days to prepare the Survey Packet for
the CMS Regional Office (RO) with a recommendation of approval.
The RO has 60 days to review and approve the survey packet and issue
the Medicare Provider Letter to the clinic. For those clinics that
file their application as a Provider-based entity, the provider-based
request must be submitted to the RO with the survey packet. The
RO will make the Provider-based determination and will notify the
appropriate Fiscal Intermediary via the Medicare Tie-In Notice.
Should the survey result in deficiencies or citations, a Statement
of Deficiencies will be sent to the clinic by the State agency within
ten (10) days of the survey. The clinic will have 10 days to develop
a Plan of Correction (POC) and submit the POC back to the State
agency. An initial applicant to the Medicare program cannot be certified
or approved unless they are in compliance with the Conditions for
Coverage. If in the judgement of the surveyor, the deficiencies
evince non-compliance at the Condition level, then the applicant
cannot be approved until those deficiencies have been corrected
and the corrections have been verified through a follow-up survey.
If there are deficiencies but they do not constitute non-compliance
at the condition level, then the facility can be approved for participation
with an approved plan of correction in place. A sample "Plan
of Correction with Deficiencies" appears at the end of this
chapter. The State agency will then review the POC for completeness.
Key elements to a POC include: it must be doable or realistic,
it must have completion dates, it must specifically address the
citation, and if appropriate, the clinic must be able to document
proof of compliance. There are no time constraints placed on the
State agency when reviewing a POC. Once the State agency has found
the POC to be acceptable, they will submit the survey packet with
recommendations to the RO. The RO has 60 days to review and approve
the survey packet and issue the Medicare Provider Letter to the
clinic. For those clinics that file their application as a Provider-based
entity, the provider-based request must be submitted to the RO with
the survey packet. The RO will make the Provider-based determination
and will notify the Fiscal Intermediary via the Medicare Tie-In
Notice.
Once the Medicare Provider Letter has been received by the clinic,
the clinic is eligible to file a projected cost report and have
their Medicare Rate determined. This will be covered in greater
detail in the next chapter.
30 Most Common RHC Survey/Certification Deficiencies
Surveyor Code |
CFR Section |
Summary of Requirement |
J20 |
491.6(a) |
The clinic is constructed, arranged,
and maintained to ensure access to and safety of patients, and
provides adequate space for the provision of direct services. |
J22 |
491.6(b)(1) |
The clinic has a preventive maintenance
program to ensure that all essential mechanical, electrical
and patient-care equipment is maintained in safe operating condition. |
J23 |
491.6(b)(2) |
The clinic has a preventive maintenance
program to ensure that drugs and biologicals are appropriately
stored. |
J24 |
491.6(b)(3) |
The clinic has a preventive maintenance
program to ensure that the premises are clean and orderly. |
J26 |
491.6(c)(1) |
The clinic assures the safety
of patients in case of non-medical emergencies by training staff
in handling emergencies. |
J28 |
491.6(c)(3) |
The clinic assures the safety
of patients in case of non-medical emergencies by taking other
appropriate measures that are consistent with the particular
conditions of the area in which the clinic is located. |
J32 |
491.7(a)(2) |
The organization's policies and
it's lines of authority and responsibilities are clearly set
forth in writing. |
J41 |
491.8(a)(6) |
A physician, nurse practitioner,
or physician's assistant is available to furnish patient care
services at all times during the clinic's regular hours of operation.
A nurse practitioner or a physician's assistant is available
to furnish patient care services during at least 50 percent
of the clinic's regular hours of operation. |
J47 |
491.8(b)(2) |
Physician responsibilities: In
conjunction with the physician assistant and/or nurse practitioner
member(s), the physician participates in developing, executing
and periodically reviewing the clinic's written policies and
the services provided to Federal program patients. |
J48 |
491.8(b)(3) |
Physician responsibilities: The
physician periodically reviews the clinic's patient records,
provides medical orders, and provides medical care services
to the patients of the clinic. |
J51 |
491.8(c) |
Physician assistant and the nurse practitioner responsibilities.
The physician assistant and the nurse practitioner members
of the clinic's staff:
- Participate in the development, execution and periodic
review of the written policies governing the services the
clinic furnishes;
- Provide services in accordance with those policies;
- Arrange for, or refer patients to, needed services that
cannot be provided at the clinic;
- Assure that adequate patient health records are maintained
and transferred as required when patients are referred;
and
- Participate with a physician in a periodic review of
the patient's health records.
|
J55 |
491.9(b)(1) |
The clinic's health care services
are furnished in accordance with appropriate written policies,
which are consistent with applicable State law. |
J56 |
491.9(b)(2) |
The patient care policies are
developed with the advice of a group of professional personnel
that includes one or more physicians and one or more physician's
assistants or nurse practitioners. At least one member of the
group is not a member of the clinic's staff. |
J57 |
491.9(b)(3)(iii) |
The policies include guidelines
for the medical management of health problems, which include
the conditions requiring medical consultation and/or patient
referral, the maintenance of health care records, and procedures
for the periodic review and evaluation of the services furnished
by the clinic. |
J58 |
491.9(b)(4) |
These policies are reviewed at
least annually by the group of professional personnel as required
under 491.9(b)(2), and reviewed as necessary by the clinic. |
J61 |
491.9(c)(2) |
The clinic provides basic laboratory services essential to
the immediate diagnosis and treatment of the patient, including:
- Chemical examinations of urine by stick or tablet methods or both (including urine ketones);
- Hemoglobin or hematocrit;
- Blood sugar;
- Examination of stool specimens for occult blood;
- Pregnancy tests; and
- Primary culturing for transmittal to a certified laboratory.
|
J62 |
491.9(3) |
The clinic provides medical emergency
procedures as a first response to common life-threatening injuries
and acute illness, and has available the drugs and biologicals
commonly used in life saving procedures, such as analgesics,
anesthetics (local), antibiotics, anticonvulsants, antidotes
and emetics, serums and toxoids. |
J70 |
491.10(a)(3) |
For each patient receiving health care services, the clinic
maintains a record that includes, as applicable:
- Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and brief summary of the episode, disposition, and instructions to the patient;
- Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;
- All physician's orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress;
- Signatures of the provider or other health care professional.
|
J72 |
491.10(b)(1) |
The clinic maintains the confidentiality
of record information and provides safeguards against loss,
destruction, or unauthorized use. |
J76 |
491.11 |
Program evaluation |
J77 |
491.11(a) |
The clinic carries out, or arranges
for, an annual evaluation of its total program. |
J78 |
491.11(b) |
Reviews included in evaluation |
J79 |
491.11(b)(1) |
The evaluation includes review
of the utilization of clinic services, including at least the
number of patients served and the volume of services. |
J80 |
491.11(b)(2) |
The evaluation includes review
of a representative sample of both active and closed clinical
records. |
J81 |
491.11(b)(3) |
The evaluation includes review
of the clinic's health care policies.
|
J82 |
491.11(c) |
Purpose of the evaluation |
J83 |
491.11(c)(1) |
The purpose of the evaluation
is to determine whether the utilization of services was appropriate. |
J84 |
491.11(c)(2) |
The purpose of the evaluation
is to determine whether the established policies were followed. |
J85 |
491.11(c)(3) |
The purpose of the evaluation
is to determine whether any changes are needed. |
J86 |
491.11(d) |
The clinic staff considers the
findings of the evaluation and takes corrective action if necessary. |
For examples of Forms see the pdf
version.
|