Organizational Structure Program Evaluation

8/11/2019 Organizational Structure Program Evaluation

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Robin VeltKamp

Health Services Associates, Inc2 East Main Street

Fremont, MI 49412PH: 231-924-0244

Email: [email protected]: www.hsagroup.net
mailto:[email protected]:[email protected]://www.hsagroup.net/http://www.hsagroup.net/http://www.hsagroup.net/mailto:[email protected]


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The RHC requirements for theOrganizational Structure Chart for the clinic. Provider based vs. Independent RHC

The RHC requirements for disclosure of theclinic.

The RHC requirements for responsibilitiesof physicians and midlevel providers.


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Subpart A of 42 CFR 491 sets forth theconditions that RHCs must meet in order toqualify for certification under Medicare andMedicaid.

Standards are the clinic operating processes.You may receive deficiencies in Standardssuch as expired medications, etc.

Conditions are severe deficiencies. You may

receive deficiencies in Conditions if you donthave a midlevel 50%, policies are not current.No current annual meeting.


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CMS Form 30 (select the most current) Federal Regulations

Surveyors utilize as tool of measurement

Office must remain compliant to J tags asdaily operation compliance.


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491.7 Organizational structure. J29)

(a) Basic requirements. J30)

(1) The clinic or center is under the medical

direction of a physician, and has a health carestaff that meets the requirements of 491.8.J31)

(2) The organization's policies and its lines of

authority and responsibilities are clearly setforth in writing. J32)


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(b) Disclosure. J33)The clinic or center discloses the names andaddresses of:(1) Its owners, in accordance with section 1124 of

the Social Security Act (42 U.S.C. 132 A3); J34)(2) The person principally responsible fordirecting the operation of the clinic or center; andJ35)

(3) The person responsible for medical direction.J36)

[57 FR 24983, June 12, 1992]


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491.8 Staffing and staff responsibilities. J37)

(a) Staffing. J38)(1) The clinic or center has a health care staff that includesone or more physicians. Rural health clinic staffs must alsoinclude one or more physician's assistants or nursepractitioners. J39)

(2) The physician member of the staff may be the owner ofthe rural health clinic, an employee of the clinic or center, orunder agreement with the clinic or center to carry out theresponsibilities required under this section. J40)(3) The physician assistant, nurse practitioner, nurse-midwife, clinical social worker, or clinical psychologistmember of the staff may be the owner or an employee of theclinic or center, or may furnish services under contract to thecenter. J40)


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(4) The staff may also include ancillary personnel whoare supervised by the professional staff.(5) The staff is sufficient to provide the servicesessential to the operation of the clinic or center. J42)(6) A physician, nurse practitioner, physician assistant,

nurse-midwife, clinical social worker, or clinicalpsychologist is available to furnish patient care servicesat all times the clinic or center operates. In addition, forrural health clinics, a nurse practitioner or a physicianassistant is available to furnish patient care services atleast 60 percent of the time the clinic operates. (has

been changed to 50%) J41)


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(b) Physician responsibilities. J45)(1) The physician:

(i) Except for services furnished by a clinical

psychologist in an FQHC, which State lawpermits to be provided without physiciansupervision, provides medical direction for theclinic's or center's health care activities and

consultation for, and medical supervision of,the health care staff. J46)


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(ii) In conjunction with the physician's assistantand/or nurse practitioner member(s),participates in developing, executing, andperiodically reviewing the clinic's or center's

written policies and the services provided toFederal program patients; and J47)(iii) Periodically reviews the clinic's or center'spatient records, provides medical orders, and

provides medical care services to the patients ofthe clinic or center. J48)


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(2) A physician is present for sufficient periods oftime, at least once in every 2 week period (exceptin extraordinary circumstances), to provide themedical direction, medical care services,consultation and supervision described in

paragraph (b)(1) of this section and is availablethrough direct telecommunication for consultation,assistance with medical emergencies, or patientreferral. The extraordinary circumstances aredocumented in the records of the clinic or center.J49)


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(c) Physician assistant and nurse practitionerresponsibilities. J50)(1) The physician assistant and the nursepractitioner members of the clinic's or

center's staff:(i) Participate in the development, executionand periodic review of the written policiesgoverning the services the clinic or center

furnishes;(ii) Participate with a physician in a periodicreview of the patients' health records.


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(2) The physician assistant or nurse practitioner performsthe following functions, to the extent they are not beingperformed by a physician:(i) Provides services in accordance with the clinic's orcenter's policies;

(ii) Arranges for, or refers patients to, needed services thatcannot be provided at the clinic or center; and(iii) Assures that adequate patient health records aremaintained and transferred as required when patients arereferred. J51)[57 FR 24983, June 12, 1992, as amended at 61 FR 14658,

Apr. 3, 1996; 68 FR 74817, Dec. 24, 2003; 71 FR 55346,Sept. 22, 2006]


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The Medical Director must be identified onthe Organizational Chart and MUST have a

Job Description and/or employment contractthat details their responsibilities.

The Medical Director MUST have a currentLicense to practice in the State.


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The clinic MUST have a health care staffincludes one or more physicians and one ormore non-physician providers.

There MUST be sufficient staff to provide theservices essential to the operation of theclinic (greeting patients as they present to theclinic, assisting the provider, monitoring

patients in the clinical area and answeringincoming calls).


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The clinic MUST have written policies coveringHuman Resources, Operations, ClinicalGuidelines, HIPAA, and Clinic Operations.

The clinic MUST have a written OrganizationalStructure that INCLUDES theOwnership/Control AND the Medical Director.


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If the clinic is Provider-Based (owned by ahospital, etc) this relationship MUST beclearly evident to the public, through signage,letterhead, advertising, etc.


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The clinic MUST also have a currentOrganizational Chart. For largeorganizations, the Organizational Chart MUSTidentify the clinic within the main entity. In

addition, there MUST also be a clinicOrganizational chart that identified positionsand staff at the clinic level.

There MUST be a Job Description for EVERY

position INCLUDING providers. (and MedicalDirector)


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There MUST be a provider of core servicesavailable to furnish patient care services at alltimes the clinic operates. The definition ofprimary care providers are those who are

practicing in General Medicine, FamilyPractice, Internal Medicine, Pediatrics, andOB/GYN.

The clinic MUST post its hours of operation

where they are VISIBLE to the public when theclinic is closed.


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The non-physician provider MUST beavailable to furnish patient care services atLEAST 50% of the time the clinic operates.

If the non-physician provider is not available

to see patients at least 50% of the clinicspatient appointment times, there MUST bedocumentation that the clinic has notified theState and has filed for a waiver if it has been

more than 90 days since they no longer meetthe minimum requirement.


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There MUST be a physician present duringsome clinic hours of operation, providingmedical orders and medical care services tothe patients.


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The provider staff MUST participate in thedevelopment or review of the clinics writtenpolicies.

There MUST be a process in place for theprovider staff to provide input regardingclinic policies.

The clinic MUST also have a written policy for

the review of clinic policies by any newprovider staff.


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The non-physician provider MUST participatein the development, execution, and periodicreview of the written policies governing theservices the clinic furnishes.

The non-physician provider MUST provideservices in accordance with the policies.


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The Medical Director must perform the medicalrecord review in accordance with written policy.If the clinics written policy does not state aspecific frequency, then there MUST be evidenceof a quarterly review.

The review process MUST be initiated by theMedical Director through a random selection ofMedical Records.

The review process MUST provide for writtencommunication between the Medical Director and

the non-physician provider.


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The clinic needs to create a worksheet intable format that includes the followinginformation: Name of staff (including providers)

Position/job title Date of Hire


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The clinic MUST have Human Resourcepolicies that include at a minimum: Job Descriptions

Copies of Licenses

Confidentiality Current CPR certification (clinical staff and

providers)

TB testing

Documented proof of Inservice trainings


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The non-physician provider MUST practice inaccordance with the State Scope of Practice asdefined in the States Nurse PracticeAct/Public Health Code/Administrative Code

and Pharmacy Act. All providers MUST be in possession of a

current and unlimited State license to practicein their discipline, pharmacy license and DEAlicense (as allowed by discipline).


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If there is a lapse in the physician schedule, thereason MUST be documented (illness, weather, travelconditions, delivery, etc)

If there is a recurring lapse in the physician schedule,the reason MUST be documented (detriment tophysicians own practice, excessive distance, closedroads/pass, bridge repair, etc.) The situation MUSTbe reported to the CMS RO and an approval granted.

If the physician is unavailable, there should be awritten plan for remote consultation and transfer ofpatients who require further evaluation and

treatment.


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491.11 Program evaluation. J76)

(a) The clinic or center carries out, or arranges for,an annual evaluation of its total program. J77)

(b) The evaluation includes review of: J78)

(1) The utilization of clinic or center services,including at least the number of patients servedand the volume of services; J79)

(2) A representative sample of both active and

closed clinical records; and J80)(3) The clinic's or center's health care policies. J81)


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(c) The purpose of the evaluation is todetermine whether: J82)(1) The utilization of services was appropriate;J83)

(2) The established policies were followed; andJ84)

(3) Any changes are needed. J85)(d) The clinic or center staff considers the

findings of the evaluation and takes correctiveaction if necessary. J86)[71 FR 55346, Sept. 22, 2006]


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The clinic must have a written ProgramEvaluation Plan that identifies who isresponsible for ensuring that the plan iscompleted, what is to be reviewed, and whatis to be done with the findings.

The full evaluation must be completed every12 months and must include: Review of the processes, functions, services and utilization

of clinic services, including at least the number of patientsserved and the volume of services

Total Medicare encounters Total Medicaid encounters Total third party encounters Total self-pay encounters


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The policy and procedure review must alsobe conducted annually, as well as a chartreview of a representative sample of bothactive and closed clinic records.

The clinics professional advisory groupmust be involved in the annual evaluationprocess.


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If the clinic has implemented a QAPIprogram, the project measures that theclinic has developed and monitoring ofthose measures should be available.

QAPI projects should be based on clinic-specific data related to high-volume, high-risk services, patient safety, coordination of

care, convenience and timeliness ofavailable services, care of acute and chronicconditions, or grievances and complaints.


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If the clinic uses the implementation of aninformation technology system as a QAPIproject, the decision, implementation, andevaluation steps must be documented.

The clinics professional advisory groupshould also provide oversight to the QAPIprojects.


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Robin VeltKamp, VP of Medical Practice Compliance & ConsultingEmail: [email protected]

Health Services Associates, Inc.2 East Main StreetFremont, MI 49412

PH: 231.924.0244 FX: 231.924.4882

www.hsagroup.net
mailto:[email protected]:[email protected]://www.hsagroup.net/http://www.hsagroup.net/mailto:[email protected]

Documents

Organizational Structure Program Evaluation