Regulatory Compliance & Quality - Section 2: Evidence Binder, RHC App and Certification Process

Question 1

The practice should maintain current documents to provide evidence of ___ at all times

Answer 1

Compliance

Question 2

True or False:

The surveyor will request various documents as evidence of compliance for all regulations only as a part of the initial survey

Answer 2

False; as part of the initial and any follow-up survey

Question 3

It is recommended that all documents be housed where?

Answer 3

In one central location or binder

Question 4

How often should the RHC evidence binder be reviwed?

Answer 4

Quarterly

Question 5

Why should the RHC evidence binder be reviewed quarterly?

Answer 5

To update any new or outdated information

Question 6

True or False:

The RHC evidence binder can be combined with your policy and procedure manual

Answer 6

False; it should be a separate binder that is not part of your policy and procedure manual

Question 7

The evidence binder should include
Copy of current ___
Copy of CMS initial/final tie-in ___
Copy of last ___ document (if available)
___ preventive maintenance log/documentation, calibration, etc.
___ of all current staff (including providers) that includes hire date, job titles, FTE status, and any hospital privileges
Evidence of yearly staff ___ (ex: hazardous waste, infection control, etc)
All providers and clinical staff ___ certification
For ___ and ___staff - copies of all licenses, DEAs, resumes, and application
___, disinfectant logs, contract
Spore check reports/___ reports, if applicable

Answer 7

HPSA
Notice
Survey
Annual
Roster
Training
BLS
Providers and licensed
Cleaning
Radiation

Question 8

___ documentation on fire, tornado, inclement weather, emergency evacuation, safety, AED, etc.

Answer 8

Training

Question 9

___ plan of clinic/identify routes of escape

Answer 9

Floor

Question 10

Current organizational chart (be sure it reflects and includes the position of ___ ___. Must include ___ of who fill the positions)

Answer 10

Medical Director

Names

Question 11

Posted ___ hours/___ hours

Answer 11

Provider hours/clinic hours

Question 12

Documentation to evident ___ review and fulfillment of oversight requirements

Answer 12

Chart

Question 13

Copies of completed/signed ___ agreements, waivers, contracts, guidelines of practice limitations

Answer 13

Collaborative

Question 14

Document stating all ___ rendered within the clinic, list all ___ offered, and list name of outside ___

Answer 14

Services
Labs
Lab

Question 15

Copy of ___ certificate and waste management agreement

Answer 15

CLIA

Question 16

Below is additional documentation and/or evidence of compliance that the surveyor will request. This can also be placed in your evidence binder but it is recommended that you create a separate binder for easy reference:

Sample medication logs should be kept where?
Safety Data Sheets book should be kept where?
Lab manual should house what?

Answer 16

Placing in or near the sample medication storage area
Placing near the eye wash station
House all your lab policies and control logs placed in the lab area

Question 17

How should the evidence binder be organized?

Answer 17

In the way that works best for you

Question 18

How should you keep track of when the quarterly updates are to take place?

Answer 18

Schedule calendar reminders to review the data quarterly for updates

Question 19

Why is it important to identify key staff and educate them on what is in the binder and where it’s located?

Answer 19

A surveyor can come at any time unannounced

Question 20

True or False:

A surveyor will only come if the manager is present

Answer 20

False; the survey will take place regardless if the manager is present or not

Question 21

Staff should be ___ and feel ___ that they can assist the surveyor with the requested documentation

Answer 21

Educated, confident

Question 22

Keep only the most ___ documents in the binder and archive old documents to separate files, if needed

Answer 22

Current

Question 23

The RHC is expected to maintain compliance at what frequency?

Answer 23

At all times

Question 24

What are great tools that can be used to monitor continued compliance and help identify areas that become non-compliance?

Answer 24

Checklists, rounding tools, and logs

Question 25

When completing review of patient exams rooms/care areas, why is it important for staff to initial after completing the review?

Answer 25

To ensure accountability

Question 26

At what frequency should review for all exam room, procedure rooms, and lab/medication areas be completed?

Answer 26

Either weekly or monthly

Question 27

Examples of items listed for review in exam rooms, procedure rooms, and lab/medication areas:
___ medications/supplies
Medications are ___
Sharps/chemicals supplies are out of the reach of ___
Plug protectors in all ___
Closed-lid ___ containers in patient care areas
Area is ___

Answer 27

Expired
Locked
Children
Outlets
Trash
Clean

Question 28

It is recommended that management complete ___ clinic walk throughs to spot check patient care areas for patient safety and infection control concerns

Answer 28

Monthly

Question 29

What could you be at risk for if someone is not spot checking that staff are truly utilizing the tools and completing the work they are attesting to?

Answer 29

Could be at risk for issues and non-compliance

Question 30

How often should management complete a full mock survey?

Answer 30

At least annually

Question 31

What should a full mock survey consist of?

Answer 31

A full review of all the regulations and documentation

Question 32

There are many benefits to completing a full mock survey including:

1) Complete assessment of RHC ___
2) Identification of issues that could impact patient and staff ___
3) Identification of additional ___/___ needs of staff
4) Data that can be shared as part of your ___ reports at the Annual Advisory Meeting

Answer 32

Compliance
Safety
Education/training
Quality

Question 33

Tips to be successful at a mock survey:

1) Distribute a copy of the mock survey tool to all staff so they under what is ___
2) Discuss ___ rounding and mock survey results at staff meetings
3) Educate staff on what to do if a ___ were to arrive for an unannounced survey

Answer 33

Expected
Monthly
Surveyor

Question 34

True or False:

Each RHC practice is a separate practice and must go through the full certification process

Answer 34

True

Question 35

A satellite-clinic of another RHC IS or IS NOT allowed

Answer 35

Is not

Question 36

Each RHC practice is a separate practice and must go through the full certification process. this means that each RHC must have its own ___ and will be assigned its own unique CCN number upon successful certification

Answer 36

NPI

Question 37

Each RHC practice is a separate practice and must go through the full certification process. this means that each RHC must have its own NPI and will be assigned its own unique ___ number upon successful certification

Answer 37

CCN

Question 38

You must first validate that the new practice address meets the ___ requirements that are listed on the Federal Register

Answer 38

Location

Question 39

A practice is eligible for initial RHC certification if it is located in an area “___” designated as Medically Underserved Area (MUA) or Health Professional Shortage Area (HPSA) either by population or geopgraphic

Answer 39

Currently

Question 40

___ are authorized to designate areas with a shortage of personal health services for the purposes of obtaining RHC status

Answer 40

Governors

Question 41

In order for a shortage area designation to be considered “current”, it cannot be more than ___ years old

Answer 41

4 years

Question 42

If an existing RHC practice would like to move to a new location, the new address must meet the ___ requirements as well

Answer 42

Location

Question 43

True or False:

It is safe to assume that the new address is in a HPSA area if it is in the same city or county

Answer 43

False; don’t assume that

Question 44

True or False:

Even if you are moving across the street, there could be potential for that new address to not meet the location requirements or may have not been updated in the past 3 years

Answer 44

True

Question 45

You can obtain an RHC application packet from the ___ agency responsible for administering the RHC program for CMS in the state in which the clinic is located

Answer 45

State

Question 46

If you are applying as an independent RHC, you will request the CMS ___ Medicare Federal Health Care Provider/Supplier Enrollment Application from one of the independent RHC fiscal intermediaries

Answer 46

855A

Question 47

If you are applying as a provider-based RHC, you will request the CMS ___ Medicare Federal Health Care Provider/Supplier Enrollment Application from the host provider’s current fiscal intermediary

Answer 47

855A

Question 48

Many clinics choose to utilize a deeming agency to complete the initial RHC certification site visit for what reason?

Answer 48

To not have to wait for the state to complete the certification visits due to the state’s delayed timing in completing surveys

Question 49

The timeline from submission to full certification CAN or CANNOT vary greatly depending on many factors, such as state agency, MAC, regional office processing time, and state timeliness of survey visit

Answer 49

Can

Question 50

The application process can take as little as ___ months up to ___ months

Answer 50

6 - 12 months

Question 51

Once the applications are processed and the site survey has taken place, what will happen?

Answer 51

The CMS Regional Office will assign the billing CCN number

Question 52

The certification date will be the date the survey took place if what?

Answer 52

No deficiencies were noted at the time of survey

Question 53

If there are deficiencies noted at the time of survey, what is the official RHC date?

Answer 53

The date that the plan of correction is accepted by the state or deeming agency