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Survey Preparation & Regulatory Changes

Because every patient deserves exemplary care.

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Survey Preparation

Is everyone aware of the location of key documents?

Have you answered “Yes” to all the questions on your checklist?

Is the entire staff up to date on the survey process?

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Policies Reviewed Every Two Years

Corporate Compliance
Medical Records
Hiring, Training, Orienting
Infection Prevention
Pharmaceuticals
Equipment Management
Scope of Services Provided & Referred

Policy for Policy Review
HIPPA
Quality Improvement
Patient Services (incl. reference)
Emergency Preparedness

Reviewed by: MD/DO, NP/PA. and an outside person. Must be done for initial survey then every two years.

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Your Name on the 855a

Does your name match what is on the 855a?

DBA or
Legal name
Check it at Qcorp https://qcor.cms.gov/main.jsp

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Closing Your Clinic

What is your procedure when you need to close the clinic?

Sign on door
Posted on social media
Website
Message on your answering machine

** You must notify the State for any extended closures.

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Your Mission

Provide Outpatient Services.

The only limiting factor is not more than 50% mental health service.

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The Waiting Room

Safe

Clean

HIPAA Compliant

Can I hear the receptionist calling out labs etc.?

Secure

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Postings in the Clinic

What is posted?

OSHA/Labor Law
Privacy Statement
Hours on or near the door

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Exam Rooms

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Exam Room

How is the table cleaned?

What is the wet time?

Is all equipment on a list?

Has that scale been calibrated?

Is the sharps container locked?

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Risk

No medications or hazardous material in this lower exam table drawer.

ThinPrep: A preservative with the following warnings:

Inhaled: May cause depression of the Central �Nervous System resulting in weakness, nausea, �drowsiness, and possibly blindness.
Skin Contact: May cause irritation and or dermatitis.
Ingestion: May cause intoxication, CNS depression, nausea and dizziness. May damage liver, kidneys, and nervous system.

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Emergency Services

Does the list in the policy match the contents of the box?

Is everything within date?

Do all licensed and certified personnel

have at least BLS?

What is your emergency policy if a mental health provider is the only one seeing patients in the clinic and there is a medical emergency?

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Non-Physician Provider Staff

An NP, PA or Certified Nurse-Midwife is available to furnish patient care at least 50% of the operating hours.

How do you document that time?

All time spent in the clinic counts toward the 50%.

Time spent in a patient’s home, swing bed rounds, or a SNF/LTC counts toward the 50%.

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Infection Prevention

Is the clinic appropriately monitoring housekeeping?

Is there a housekeeping schedule? Is it posted?

How does the clinic prevent the spread of infection:

Hand hygiene for staff
Are single use devices only used once?
How are the clinic surfaces cleaned? Does the person know the wet/kill time?
Is the staff thoroughly trained on instrument sterilization?
How is medical waste disposed of?
Is there pest control?
Are clean and dirty areas clearly separated throughout the clinic?

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Sterilization in the Clinic

Does your instrument sterilization policy match the manufacturer’s instruction for use?

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Sterilization at the Hospital

How do you clean and transport the dirty instruments?

Do you know the hospital’s sterilization policy?

Do you know what to accept or reject?

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Secured

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Expired Supplies and Drugs

Telfa, gloves, peroxide, electrodes, needles, Iodoform gauze, etc.

Check anything with a date!

The red sharp container is not acceptable.

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Refrigerated Medications

Are there water bottles in the door of the medication refrigerator?

Is there food in your medication refrigerator?

Are there lab samples in your medication refrigerator? Where are they located?

How do you monitor the temperature of this fridge?

Are expired patient meds, labeled as expired? What is your process?

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Medication Policy

Is there a robust medication policy?
Are all drugs secured in the clinic?
Does your policy include the proper handling of single-dose and multi-dose vials?
Are drugs stored according to Manufacturer’s instructions?
Are all medications delivered in the clinic properly documented in the EMR?
Are we noting the lot number in the EMR for injected medications?
Is every person dealing with drugs trained on vials?
Is everyone trained on safe injection practices?
Is there proper recording for receipt and disposition of scheduled drugs?
Is there a policy for handling of drugs in a power outage?

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28-Day Reminder

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Sample Medications

Secured/Organized �In Original Containers

Do you have a

sample log?

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The Lab

Clinic must have the ability to do all four required tests.

Chemical examination of urine by stick or tablet
Blood glucose
Pregnancy test
Collection of patient specimens for transmittal to a certified laboratory for culturing.

All reagents, strips, controls, etc., must be within date.
CLIA Certificate is current and posted.
Renewals are done electronically as of March 2026.

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Blood Glucose

Be certain the device is for multi-patient use.
Read the manufacturer’s instructions for the Glucometer to be certain it’s not for home use.

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Chart Review

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Patient Records

Medications

Is the EMR capturing the medication, lot number, route of administration, dose, and date?

Abnormal Labs

Are findings and test reports appropriately authenticated by a provider?

Sign off

How long do your providers have to sign off. on charts?

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Patient Satisfaction Surveys

Available

in Spanish

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Personnel File Review

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Personnel File Review

Application
I-9
W-4
OIG Exclusion
Signed Job Description
Standards of Conduct
Performance evaluations, according �to your clinic schedule
Annual Training
Competency
Background checks, as appropriate
TB screening on hire
Hep B for those who work with patients

https://exclusions.oig.hhs.gov/

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Record Review

Types:

1. Physician oversight review to be certain that non-physician providers are providing care according to clinic policies.

How many, how often?

2. Quality review of 10 charts per quarter for completeness.

Can be done by anyone.

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Biennial Program Evaluation

Biennial review of the practice.

With CCN. This must be done every two years.
There is no waiver for this.
Look at the date of the last one and make sure it’s not more than two years old.
This is a failed survey if not completed.
Have you included some closed records?

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Emergency �Preparedness

All hazard Risk Assessment.
Written Plan for each risk.
Communication Policy, including not utilizing volunteers.
Training: Is there a signature log?
Testing: Is there an analysis?

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Emergency Preparedness: Communication

The communication plan must include all of the following:

Names and contact information for the following:

- Staff

- Entities providing services under arrangement.

- Patients' physicians

- Other RHCs or FQHCs

- Volunteers

Contact information for the following:

- Federal, State, tribal, regional, and local emergency preparedness staff.

- Other sources of assistance.

Primary and alternate means for communicating with the following:

- RHC/FQHC's staff

- Federal, State, tribal, regional, and local emergency management agencies.

A means of providing information about the general condition and location of patients under the facility's care as permitted.

A means of providing information about the RHC/FQHC's needs, and its ability to provide assistance, the authority having jurisdiction or the Incident Command Center, or designee.

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Emergency Preparedness: Training

The communication plan must include all of the following:

Names and contact information for the following:

- Staff

- Entities providing services under arrangement.

- Patients' physicians

- Other RHCs or FQHCs

- Volunteers

Contact information for the following:

- Federal, State, tribal, regional, and local emergency preparedness staff.

- Other sources of assistance.

Primary and alternate means for communicating with the following:

- RHC/FQHC's staff

- Federal, State, tribal, regional, and local emergency management agencies.

A means of providing information about the general condition and location of patients under the facility's care as permitted.

A means of providing information about the RHC/FQHC's needs, and its ability to provide assistance, the authority having jurisdiction or the Incident Command Center, or designee.

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Emergency Preparedness: Training

Initial training in emergency preparedness policies & procedures to all new/existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.

Provide Emergency Preparedness training at least every two years.

Maintain documentation of the training including signature log.

Demonstrate staff knowledge of emergency procedures.

If the emergency preparedness policies and procedures are significantly updated, the RHC must conduct training on the updated policies & procedures.

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Emergency Preparedness: Testing

The RHC must conduct exercises to test the emergency plan at least annually.

The RHC must do the following:

Participate in a full-scale exercise that is community-based every two years; or
When a community-based exercise is not accessible, an individual, facility-based functional exercise every two years; or
If the RHC experiences an actual natural or man-made emergency that requires activation of the emergency plan, the RHC is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
Conduct an additional exercise every two years, opposite the year the full-scale exercise, that may include the following:

- A second, full-scale exercise that is community-based or an individual, facility-based functional exercise; or

- A mock disaster drill; or

- A tabletop exercise or workshop, led by a facilitator, and includes a group discussion,

Analyze the RHC response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the RHC’s emergency plan, as needed.

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Emergency Preparedness: Provider-Based RHC

Demonstrate each clinic is capable of actively using the unified/integrated emergency preparedness program and is compliant with the program.

Each clinic has a documented community-based risk assessment.

Each clinic had a documented individual facility-based risk assessment.

Each clinic staff member has been trained on the EP policies every two years.

Demonstrate the clinic actively participated in the development of the unified and integrated Emergency Preparedness Program.

If you’re included in the hospital’s Emergency Preparedness Plan, you must still do the following:

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Analysis for Event, Tabletop, or Exercise

The purpose of this report is to analyze event results.
Identify strengths to be maintained and built upon.
Identify potential areas for further improvement.
Support the development of corrective actions that will guide future emergency preparedness initiatives to advance overall emergency preparedness within your clinic.

Report reviewed with staff
Assignments given
Attendance log at AAR meeting

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Survey Day

RHC surveys are unannounced. So be prepared!

Managers, share your knowledge with staff.

Most surveys take between 6 to 8 hours per clinic, depending on the number of rooms and providers/staff.

Remember, having easy access to policies, personnel records, and medical records as they are requested will allow the surveyor to proceed without delay.

Once complete, the surveyor will conduct an exit interview to discuss the survey findings.

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Summary of Deficiencies

Vials, single-dose dated.
Drugs not secured.
NP/PA not signing off on policies.
No analysis of an emergency event or exercise.
Not having all contact information in your Exemplary Provider binder.
No documentation of chart review.
No outside person signing off on policies.
Not abiding by the wet time of your disinfectant.
Signage not matching the name you told CMS you were called.
Expired supplies in the clinic i.e., iodoform, gloves, Blood glucose supplies, vacutainers, etc.

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Kate Hill, RN

VP Rural Health

The Compliance Team

khill@thecomplianceteam.org

��

uestions

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Company Contact

Name/Address The Compliance Team, Inc.� 905 Sheble Lane

P.O. Box 160 � Spring House, PA 19477

Phone 215-654-9110 � Fax 215-654-1041� Website www.thecomplianceteam.org