NARHC Forum

Contributor: Guadalupe Vasquez

Good Afternoon,

Can anyone share their process/policy for the advisory committee?

Thank you.

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Contributor: gvasquez@sierra-view.com

Good Afternoon,

Can anyone remind me where to find the requirements for the Advisory Committee?

Lupe

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Contributor: Guadalupe Vasquez

Update: Found it in the State Operations Manual Appendix G

It is called Annual Evaluation of Program not Advisory Committee

J-0161
(Rev. 177, Issued: 01-26-18, Effective: 01-26-18, Implementation: 01-26-18)
§491.11(a) The clinic . . . carries out, or arranges for, an annual
evaluation of its total program
(b) The evaluation includes review of:
(1) The utilization of clinic . . . services, including at least the number of patients
served and the volume of services;
(2) A representative sample of both active and closed clinical records; and
(3) The clinic's . . . health care policies.
(c) The purpose of the review is to determine whether:
(1) The utilization of services was appropriate;
(2) The established policies were followed; and
(3) Any changes are needed.
Interpretative Guidelines §491.11(a)-(c)
The RHC is required to conduct an evaluation of its total clinical program, at least
annually. This evaluation may be done by RHC staff or through arrangement with other
appropriate professionals. The RHC must have documentation of who conducts the
review or portions of the review, and what their qualifications are to do so.
The evaluation must include, at a minimum, the number of patients served and the volume
of services provided. The evaluation should be able to determine whether the RHC
provides appropriate types and volume of services based upon the needs of its patient
population. It should also be able to evaluate whether RHC patient policies were
followed and whether or not changes to the policies or to procedures are warranted. The
evaluation does not have to be done all at once or by the same individuals. However, if
the evaluation is not performed all at once, no more than one year may elapse between
evaluating the same components.
A RHC that has been certified for less than one year may not have done a program
evaluation. However, the RHC must have a written plan that specifies who is to do the
evaluation, when and how it is to be done, and what will be covered within the
evaluation.
The evaluation must also include a review of a representative sample of both active and
closed clinical records of RHC patients. The sample must also include at least 5 percent
of the RHC's current patients or 50 records, whichever is less. The purpose of the review
is to determine whether utilization of the RHC's services was appropriate, i.e., whether
practitioners adhere to accepted standards of practice and adhere to the RHC's
guidelines for medical management when diagnosing or treating patients. The review
also must evaluate whether all personnel providing direct patient care adhere to the
RHC's patient care policies. The evaluation of practitioners must be conducted by an
MD or DO; if there is only one MD or DO practicing in the RHC, it is expected that the
RHC will arrange for an outside MD/DO to review the selected sample of records of
RHC patients cared for by the RHC's MD/DO. The evaluation of whether the RHC's
patient care policies were followed may be conducted by an MD/DO, a non-physician
practitioner, an RN, or other personnel who meet the RHC's qualifications criteria.
The evaluation findings must be documented in a summary report, and must include
recommendations, if any, for corrective actions to address problems identified in the
evaluation. If a RHC has developed a QAPI program and that program meets/exceeds
the regulatory requirements for a Program Evaluation, the QAPI program would be
acceptable.
Survey Procedures § 491.11(a)-(c)
• Does the RHC have documentation that its clinical program is reviewed at least
annually?
• Is there evidence that the evaluation includes review of the number of patients served
and the volume of services provided?
• Is there evidence of a review of a representative sample of RHC records?
• Does the sample include the required minimum number of records?
• Who conducts which portions of the review? Are they qualified to do so?
• Is there evidence of findings and recommendations from the review, and do the findings
address each required component?
J-0162
(Rev. 177, Issued: 01-26-18, Effective: 01-26-18, Implementation: 01-26-18)
§ 491.11(d) The clinic . . . staff considers the findings of the evaluation
and takes corrective action if necessary.
Interpretative Guidelines § 491.11(d)
The RHC's leadership must consider the evaluation findings and recommendations for
change, if any. It must take corrective actions as necessary, such as changes in policies
or, with respect to clinical personnel, provision of additional training, changes in level of
supervision, or even limiting or terminating clinical privileges. The RHC must document
where and when the evaluation findings and recommendations were considered, and by
whom they were considered. It must also document what corrective actions, if any, were
taken and by whom they were recommended. If the RHC leadership does not take
corrective actions recommended as part of the evaluation, or if it takes corrective actions
different from those recommended, it must document the rationale for its decision.
Survey Procedures § 491.11(d)
• Does the RHC have documentation of leadership review of the evaluation findings
each year?
• Is there evidence of the RHC taking corrective actions?
• If the RHC did not take recommended corrective actions or took corrective actions
different from those recommended, did it document an appropriate rationale
supporting its decision?

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Contributor: Karla Risbeck-Hardin

I am sorry but maybe I am missing something. I read through this section multiple times but can to see where BLS is a requirement of an RHC for all staff including providers.



Last Post By: Guadalupe Vasquez

Update: Found it in the State Operations Manual Appendix G

It is called Annual Evaluation of Program not Advisory Committee

J-0161
(Rev. 177, Issued: 01-26-18, Effective: 01-26-18, Implementation: 01-26-18)
§491.11(a) The clinic . . . carries out, or arranges for, an annual
evaluation of its total program
(b) The evaluation includes review of:
(1) The utilization of clinic . . . services, including at least the number of patients
served and the volume of services;
(2) A representative sample of both active and closed clinical records; and
(3) The clinic's . . . health care policies.
(c) The purpose of the review is to determine whether:
(1) The utilization of services was appropriate;
(2) The established policies were followed; and
(3) Any changes are needed.
Interpretative Guidelines §491.11(a)-(c)
The RHC is required to conduct an evaluation of its total clinical program, at least
annually. This evaluation may be done by RHC staff or through arrangement with other
appropriate professionals. The RHC must have documentation of who conducts the
review or portions of the review, and what their qualifications are to do so.
The evaluation must include, at a minimum, the number of patients served and the volume
of services provided. The evaluation should be able to determine whether the RHC
provides appropriate types and volume of services based upon the needs of its patient
population. It should also be able to evaluate whether RHC patient policies were
followed and whether or not changes to the policies or to procedures are warranted. The
evaluation does not have to be done all at once or by the same individuals. However, if
the evaluation is not performed all at once, no more than one year may elapse between
evaluating the same components.
A RHC that has been certified for less than one year may not have done a program
evaluation. However, the RHC must have a written plan that specifies who is to do the
evaluation, when and how it is to be done, and what will be covered within the
evaluation.
The evaluation must also include a review of a representative sample of both active and
closed clinical records of RHC patients. The sample must also include at least 5 percent
of the RHC's current patients or 50 records, whichever is less. The purpose of the review
is to determine whether utilization of the RHC's services was appropriate, i.e., whether
practitioners adhere to accepted standards of practice and adhere to the RHC's
guidelines for medical management when diagnosing or treating patients. The review
also must evaluate whether all personnel providing direct patient care adhere to the
RHC's patient care policies. The evaluation of practitioners must be conducted by an
MD or DO; if there is only one MD or DO practicing in the RHC, it is expected that the
RHC will arrange for an outside MD/DO to review the selected sample of records of
RHC patients cared for by the RHC's MD/DO. The evaluation of whether the RHC's
patient care policies were followed may be conducted by an MD/DO, a non-physician
practitioner, an RN, or other personnel who meet the RHC's qualifications criteria.
The evaluation findings must be documented in a summary report, and must include
recommendations, if any, for corrective actions to address problems identified in the
evaluation. If a RHC has developed a QAPI program and that program meets/exceeds
the regulatory requirements for a Program Evaluation, the QAPI program would be
acceptable.
Survey Procedures § 491.11(a)-(c)
• Does the RHC have documentation that its clinical program is reviewed at least
annually?
• Is there evidence that the evaluation includes review of the number of patients served
and the volume of services provided?
• Is there evidence of a review of a representative sample of RHC records?
• Does the sample include the required minimum number of records?
• Who conducts which portions of the review? Are they qualified to do so?
• Is there evidence of findings and recommendations from the review, and do the findings
address each required component?
J-0162
(Rev. 177, Issued: 01-26-18, Effective: 01-26-18, Implementation: 01-26-18)
§ 491.11(d) The clinic . . . staff considers the findings of the evaluation
and takes corrective action if necessary.
Interpretative Guidelines § 491.11(d)
The RHC's leadership must consider the evaluation findings and recommendations for
change, if any. It must take corrective actions as necessary, such as changes in policies
or, with respect to clinical personnel, provision of additional training, changes in level of
supervision, or even limiting or terminating clinical privileges. The RHC must document
where and when the evaluation findings and recommendations were considered, and by
whom they were considered. It must also document what corrective actions, if any, were
taken and by whom they were recommended. If the RHC leadership does not take
corrective actions recommended as part of the evaluation, or if it takes corrective actions
different from those recommended, it must document the rationale for its decision.
Survey Procedures § 491.11(d)
• Does the RHC have documentation of leadership review of the evaluation findings
each year?
• Is there evidence of the RHC taking corrective actions?
• If the RHC did not take recommended corrective actions or took corrective actions
different from those recommended, did it document an appropriate rationale
supporting its decision?

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Contributor: Charles James, North American Healthcare Management Services

Kate mentioned in a previous response that BLS certification is not an explicit requirement in the RHC reg or the accreditation standard. Kate mentioned further that surveyors view this as a best practice. Often, a state surveyor may require that BLS is done as part of ensuring the safety of patients and staff, despite the lack of explicit requirement.

OUR recommendation is to have BLS certification for all staff who have patient contact. This usually only excludes billing staff who may be in a different administrative office. My question to them is "what about the parking lot". Do you ever come into contact with patients there?

Charles A. James, Jr.
President and CEO
North American Healthcare Management Services
9245 Watson Industrial Park * St. Louis, Missouri 63126
888.968.0076 Office
314.560.0098 Cell
www.northamericanhms.com

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Contributor: Rhonda Grandi

We are preparing to conduct our Annual Program Evaluation next week actually. We have three separate clinic sites and arrange for the appropriate staff from each clinic to be present and conduct the evaluation together as a group while reviewing all policies to ensure they meet each clinic's needs or revise accordingly, evaluate each clinic's services and the number of patients served (for each clinic) during the previous year, as well as review active and closed clinical records from each clinic to deterimine if the utilization of services was appropriate, if established polices were followed (throughout the year), and to determine if any changes are needed.

From there policy revisions are made and the updated RHC Policy & Procedure Manual is submitted for review and approval through our appropriate hospital committees and our BOD. Additionally, an Annual Evaluation Summary Report is prepared for submission to the Board by the March meeting.

Here is how our policy reads:

PROGRAM EVALUATION
In order to comply with 42 CFR §491.11, the clinic carries out, or arranges for, an annual evaluation of its total program by doing the following:

An Annual Evaluation Review Committee will be formed for each clinic with the following individuals:

Director of Outpatient Clinics
Medical Director
Mid-level Provider
Clinic Staff
Member of the Community

The evaluation will include a review of the following:
The 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,
Any changes are needed.
Clinic staff shall consider the findings of the evaluation and take corrective action as necessary.
Upon completion, the attached Annual Evaluation Summary Report template (Attachment A) shall be used for reporting for the year in review.

I hope this is what you're looking for.
Please let me know if you have any questions.

Rhonda L. Grandi, cHAP, CRHCP
Director of Outpatient Clinics
Eastern Plumas Health Care
500 First Avenue
Portola, CA 96122

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Contributor: gvasquez@sierra-view.com

Thank you! I really appreciate the tips.

Lupe


Guadalupe Vasquez
Health Clinic Manager
559-791-4700
GVasquez@sierra-view.com

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