Regulatory Compliance & Quality - Section 2: Evidence Binder, RHC App and Certification Process Flashcards
The practice should maintain current documents to provide evidence of ___ at all times
Compliance
True or False:
The surveyor will request various documents as evidence of compliance for all regulations only as a part of the initial survey
False; as part of the initial and any follow-up survey
It is recommended that all documents be housed where?
In one central location or binder
How often should the RHC evidence binder be reviwed?
Quarterly
Why should the RHC evidence binder be reviewed quarterly?
To update any new or outdated information
True or False:
The RHC evidence binder can be combined with your policy and procedure manual
False; it should be a separate binder that is not part of your policy and procedure manual
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
HPSA Notice Survey Annual Roster Training BLS Providers and licensed Cleaning Radiation
___ documentation on fire, tornado, inclement weather, emergency evacuation, safety, AED, etc.
Training
___ plan of clinic/identify routes of escape
Floor
Current organizational chart (be sure it reflects and includes the position of ___ ___. Must include ___ of who fill the positions)
Medical Director
Names
Posted ___ hours/___ hours
Provider hours/clinic hours
Documentation to evident ___ review and fulfillment of oversight requirements
Chart
Copies of completed/signed ___ agreements, waivers, contracts, guidelines of practice limitations
Collaborative
Document stating all ___ rendered within the clinic, list all ___ offered, and list name of outside ___
Services
Labs
Lab
Copy of ___ certificate and waste management agreement
CLIA
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?
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
How should the evidence binder be organized?
In the way that works best for you
How should you keep track of when the quarterly updates are to take place?
Schedule calendar reminders to review the data quarterly for updates
Why is it important to identify key staff and educate them on what is in the binder and where it’s located?
A surveyor can come at any time unannounced
True or False:
A surveyor will only come if the manager is present
False; the survey will take place regardless if the manager is present or not
Staff should be ___ and feel ___ that they can assist the surveyor with the requested documentation
Educated, confident
Keep only the most ___ documents in the binder and archive old documents to separate files, if needed
Current
The RHC is expected to maintain compliance at what frequency?
At all times
What are great tools that can be used to monitor continued compliance and help identify areas that become non-compliance?
Checklists, rounding tools, and logs
When completing review of patient exams rooms/care areas, why is it important for staff to initial after completing the review?
To ensure accountability
At what frequency should review for all exam room, procedure rooms, and lab/medication areas be completed?
Either weekly or monthly
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 ___
Expired Locked Children Outlets Trash Clean
It is recommended that management complete ___ clinic walk throughs to spot check patient care areas for patient safety and infection control concerns
Monthly
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?
Could be at risk for issues and non-compliance
How often should management complete a full mock survey?
At least annually
What should a full mock survey consist of?
A full review of all the regulations and documentation
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
Compliance
Safety
Education/training
Quality
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
Expected
Monthly
Surveyor
True or False:
Each RHC practice is a separate practice and must go through the full certification process
True
A satellite-clinic of another RHC IS or IS NOT allowed
Is not
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
NPI
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
CCN
You must first validate that the new practice address meets the ___ requirements that are listed on the Federal Register
Location
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
Currently
___ are authorized to designate areas with a shortage of personal health services for the purposes of obtaining RHC status
Governors
In order for a shortage area designation to be considered “current”, it cannot be more than ___ years old
4 years
If an existing RHC practice would like to move to a new location, the new address must meet the ___ requirements as well
Location
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
False; don’t assume that
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
True
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
State
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
855A
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
855A
Many clinics choose to utilize a deeming agency to complete the initial RHC certification site visit for what reason?
To not have to wait for the state to complete the certification visits due to the state’s delayed timing in completing surveys
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
Can
The application process can take as little as ___ months up to ___ months
6 - 12 months
Once the applications are processed and the site survey has taken place, what will happen?
The CMS Regional Office will assign the billing CCN number
The certification date will be the date the survey took place if what?
No deficiencies were noted at the time of survey
If there are deficiencies noted at the time of survey, what is the official RHC date?
The date that the plan of correction is accepted by the state or deeming agency
