And now, I would like to introduce our speaker to kick us off with Part 1 today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director, Facility, Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We are so thankful that you're here with us this morning, Laura, to kick us off with Part 1. Okay. Thank you, Lindsay, and welcome, everyone. As Lindsay mentioned, this is Part 1 of 2 for the Rural Health Clinics. Those entities came about several years ago in order to help meet the needs of patients in that rural health area that didn't necessarily need hospitalization, but yet needed continuing care. In fact, just this year, CMS did add a few new requirements to some of the staffing for a rural health clinic. Those, by the way, are optional people, but they wanted to make sure that they met the qualifications to provide safe and effective care for your patients, your people. I have on slide number 2 an email address for CMS, and this particular email address goes right to those people who have oversight and govern and are responsible for rural health clinics, and it's nice that CMS did provide that for us, excuse me, because, excuse me, CMS did provide that for us so that you can get information directly to and from them, and it's not so confusing that it would be, okay, so it's a hospital, who does that involve? The information I'm providing today is just informational only. It is not to establish or provide any specific legal advice or establish an attorney-client relationship. So you'll have to work with your own counsel, your legal representative, whoever that happens to be. Perhaps your professional carrier has an attorney that you can work with. Perhaps there is an issue that comes up. If you want to reach out to me, I would urge you to go through GHA, ask the question, and they're great about getting it to me, and I'll respond back. I can tell you what does the code say, what does that regulation say, and the interpretive guidelines, what do they expect or want to see out of a clinic. I do like to do a brief introduction on the rural health clinics, and this is the most recent map as of May of this year that shows where are all of these things located throughout the United States. There is a very large cluster within the middle United States. You know, you'll see it from all the way from Minnesota all the way down through Louisiana and Georgia. They're all over the place, but it seems like there's a major cluster right in that area, and why they did this, again, to increase primary care and access to that in those rural areas and yet provide support, funding, so that they can give care. There are certain requirements. Of course, it has to be in a rural area, also in an underserved area, underserved by the way of healthcare providers. The clinic has to use what they call that team approach. Those of you who worked in hospitals many years ago, and I think there's kind of a resurgence of it, a team concept on the nursing floors where you had one person, then you had the associated staff to help them. Well, that's what they've done here, and they want that team approach between physicians and non-physicians in providing that direct care. It has to be staffed at least half of the time with one of your advanced practice providers, a PA, a nurse practitioner, a certified nurse midwife, and the clinic itself has to provide those outpatient primary care services and basic lab services. Now, there's a caveat with that basic lab service, and I'll get to that as we go through this program, but again, the main advantage, it really helps with that funding, the reimbursement rates for those who do have Medicare and Medicaid. There is some resources out there for you. I've got a couple here I want to show you right away. This happens to be the Rural Health Information Hub. This is great for clinics such as yours because it has resources. It talks about this guide and funding opportunities along with it, and there's also your state rural health organizations that are out there that can also provide. This happens to be the National Association. That's their link for you to show this is what you have. These are who you can contact in your particular state, and it goes alphabetical. We're talking Appendix G today. It's for rural health clinics, and these are the topics that I'm covering over this next 90 minutes or so. And there's a few in addition because my slide wouldn't be able to collapse at all, so you can read it. So that's why I did have to put it on two of them, but really, the overall reason we're here is so that when the surveyors come out, so you don't get one of these, and that is the statement of deficiencies where you have to do that plan of correction. This is when they're of a certain level or of a certain degree that they really need to have those things taken care of. They want them corrected. And, of course, no provider wants to get noticed that they have been involuntarily terminated from that Medicare and Medicaid agreement because that can happen, and usually it's because the fix hasn't happened or that it was of such a nature that there was no fix that could have happened, and yet it's unsafe to be able to provide care. How does it all work? The federal regulations and what we're covering over these next two days, they all start in what's called the Federal Register. That's where the laws go into effect. And then CMS, they have the responsibility to publish that regulation out to their surveyors, and that's what's called in a transmittal. They also have to develop the interpretive guidelines, survey procedures. Interpretive guidelines, it's just that. It interprets what is this regulation saying? What do we expect to see when we're coming out? What's embodied in that regulation? And, of course, then they update the manual. Three types of surveys. Certification when you're getting started. Validation when they're coming back around. By the way, we know all of those surveys are all unannounced. And then a complaint. And a complaint is what hopefully we'll never have to get. They do a really deep dive with those complaints, and they look at other records that happen to perhaps follow that same pace of care or segment of care. So let's say you happen to have a diabetic patient who was in and there was no teaching, patient went home, had some really bad quality, perhaps didn't survive. They would come in and look at all diabetic patients within your clinic to see what information, what care was provided. I do want to give you just some suggestions on things to have handy in your library. In other words, download them so you can get to them quick. The most recent manual, and, again, Rural Health, yours is Appendix G. That's the link for it. You may have to copy paste it to your surf engine. But also take into consideration Appendix Q. That's immediate jeopardy. That will tell you what are they going to do? What are the surveyors going to do when they get a complaint? They're usually out in a few days, and you have to do a follow-up, and then there are repeated visits more frequently because of that issue. And Appendix V. That is emergency preparedness. Everyone, every facility, every care provider over which CMS has the responsibility must abide by certain requirements. And we will cover that in Part 2. And these are in response to all of the natural and sometimes man-made issues that come up in healthcare situations. It's not always your clinic. It may be within your community. But yet you have to respond to that and still take care of patients. And you as a clinic may be asked and tasked upon to help out a local hospital if they are impacted and can't take care of patients. But, again, we're going to cover Appendix C next time. I just want to give you a couple of screen shots here. This is what the appendix looks like for the entire operations manual. And it covers everybody over which CMS has purview. Again, your Appendix C, Q is immediate jeopardy, and Z is emergency preparedness. You will see, again, many of these. You've probably heard of them before. For your particular manual, Appendix G, your last update was just June of this year. So they did make some updates. Also, the transmittals I mentioned, CMS puts those out when there's something new coming around. You go to the first page of your manual, and you will see that blue lettering. Click on the blue lettering, and it takes you right to that transmittal page. That transmittal will tell you what was the date that it came out, what were the changes. It's nice because when there is something new, especially a new manual, it will tell you right away what's changed, what's new, what is revised, what's been deleted. It's a very quick way, rather than going through your very large manual, to find it. CMS also puts out called memos. Again, these are to their surveyors. And that tells them, hey, this is new. Go look at it. I've got the link here on this slide, number 19, for you to just kind of get an idea. You can copy-paste it. But pay attention to what it references. Not everything is for hospitals or clinics or even end-stage renal disease. And, in fact, they just posted several this morning that expired. And they had to do with end-stage renal transplant facilities. So, yeah, I want to be careful on what they did. And this is an example of what that memo would look like. This is one we're going to talk about. And it's going to be next week when we're talking about staffing. And, in particular, if you're going to have certain staff on board, what are the requirements that CMS says have to be in place for those individuals? So I do want to talk a few of those memos as they affect rural health clinics. Not just necessarily staffing, but there's three in particular. Excuse me. The hospital improvement rule, infection prevention and control, and infection breaches in particular. And, again, emergency preparedness. So I want to start with the hospital improvement. Actually, it was a very long name to it. Regulatory provisions to promote program efficiency, transparency, and burden reduction. Short-term hospital improvement rule. But there are certain things in here that do impact you. And that's why it's a very broad and encompassing rule. This thing was almost 600 pages long. So that's why I did find something that attached to you. First one was the review of your provision of services. The policy and procedures that you have to have. Looking at your program evaluation. And then emergency preparedness. Specifically testing and training. I do like that they made some changes, made it a little more user-friendly. And this came out, a lot of the changes happened in the events because of COVID where people were so tied up taking care of patients that they didn't have that opportunity. They simply didn't have time to take care of their patients. And then do everything that CMS said they had to do. And so in response, thank you, CMS, they did recognize if that emergency plan had been activated for COVID, they got a pass on certain testing. And then there was some training. But there was certain testing that you were allowed to not have to do. So I want to start with infection control breaches. Those of you who have not had an opportunity to listen to these programs before, any time you see an asterisk on my slide, that means I have a reference in the appendix for you. So for breaches, this talks about those breaches, the words are slips, when we have to refer them to our public health authorities. And these are not only ones that we self-report, but those that a state agency or an accrediting organization might find during one of their surveys. So there is a list of those that they have to be referred. Usually it's to your state authority, your healthcare associated infection prevention coordinator, whoever you want to call that person. And then, folks, your patient care policies talk about storage, handling, administration of medication, and safe injection practices. And the reason they were doing that is because there were four breaches they found in particular either hadn't been referred or now must be referred. Using the same needle on more than one individual. You would think that in this day and age, we wouldn't do that. But there are those situations where that does occur. And, of course, we know that can lead to a host of infections. Everything from hepatitis C to HIV infection. Using the same syringe or injection device on more than one person. Reusing a needle or syringe. What they're talking about in this one is you've got your sterile vial and perhaps you have a syringe and you've got multiple patients that you're going to have to be using this vial on in the same day. You can still do that. You can. What you can't do is use the same needle or syringe, of course, both of them, for repeated use. This one was the result of an issue down in Nevada where a physician was reusing a syringe because he didn't want to pay whatever it cost for that syringe. He would change the needle, but not the syringe. Not recognizing the backflash of blood and fluid that could get into the syringe from that prior patient. And as Murphy's Law would have it, the first patient who used that sterile needle and syringe happened to be hepatitis C positive. And so they injected him. They took the needle and syringe, changed the needle, used the same syringe, got a clean needle. And then went back into the same vial to withdraw medication. Well, in doing so, there was contamination into the vial. And so that contamination, the reuse of the vial, just kept getting passed on down the line. Several patients got extremely ill. And this physician was brought up on criminal charges because of the issue that was involved. He also used the same Lansing or finger stick device on more than one patient. Again, one patient, one product. Emergency preparedness. I did mention they added some changes to it, but they also had a lot of definitions and expanded that testing of exercise, what would be allowed. And they also, again, added then the emerging infectious disease. Thank you, COVID. That was added to it. But it really made sense because we're seeing so many of them that are rampant and very challenging to control. And that's why they added that to where we need to do a risk assessment. Again, revised guidance on training and testing. Again, we're going to cover this in part two. Now, Lindsey mentioned we have a few questions throughout. These are all optional if you want to answer them. But it sometimes gets you thinking about, are we doing this? And I cover it after we go through the questions. So I'll have that put up there for Lindsey. Okay. Perfect. This question should now be on your screen for everyone. It says, recently we have had difficulty finding qualified interpreters for our LEP patients. And to substitute, we use only clinical staff who are fluent in the language, use clinical staff only in an emergency, then use an electronic or phone communication system, use handwritten material to the extent that we can, or use the language line service. And just a quick note for those of you who may have joined us after we initially got started this morning. If you have questions for Laura throughout the presentation, we do utilize the time of these polling questions to address those questions for her as well. So you should see that Q&A option there at the bottom of your Zoom window where you can type in your questions. Or if you don't see that option, you can, of course, utilize the chat as well. And Laura, I did see a comment in the chat a little bit earlier about one of the links. I know that typically we have to copy and paste into the browsers for those. And if it still doesn't work for anyone, we're happy to provide an additional separate link in an email tomorrow as well. Yes. Yes. Thank you, Lindsay. Absolutely. I think this one was specifically for Appendix G. Okay. We can send that out. Mm-hmm. Okay. Let me go ahead and end the poll and share those results. Okay. All right. That's fine. And by the way, those are all perfectly acceptable options. You can use any of those. All right. For your facility, for hospitals, it's called conditions of participation. For a rural health clinic, it's called conditions for certification. And same with if you happen to be familiar with ambulatory surgery centers, it's the same thing. There are certain laws that we have to follow. Doesn't matter if a state law, of course, but there's federal laws. The Social Security Act, the conditions for certification, the basic requirements with your Medicare agreement, basis for terminating that agreement. What if you don't allow the survey team to come in and visit? If that's the case, you don't let them in, they could immediately terminate you from the agreement. So here's how the process works. So it looks like going through this, nothing else, just a general reminder, if you participate in Medicare or Medicaid, you have to be certified. And that means you meet the conditions for certification. That is determined on a couple different levels. One is first the offsite review of the location. This is what the surveyors do. They will go back, they will look at where you're located, and they look at how the Census Department identifies your area. Is it urban? Is it metropolitan? Is it rural? Or is it, there's also mountainous region. Then there's the onsite survey, that's the one we're all familiar with, where they come in and they talk to people, they look at your records or documents, and they just observe care being provided. They make the determination if the application meets all of the federal requirements, again, location and staffing. So again, that's usually done before they ever get there. What they're looking at once they're onsite is how are you delivering care? What's your organizational functions? Who do people report to? Who is sort of the chief in charge for that particular day? How then do you provide care? Who is providing that care? This is a way for CMS to assess how you're complying with all of the standards, whether it's health, safety, or quality. All surveys are unannounced. And if you, again, refuse to allow immediate access upon reasonable request, you could be excluded. Usually what they're trying to do is, they know that you're busy, but they will still come in and observe. They do want to see how you provide care. But they're really not supposed to come at those really late hours, unless that's been previously agreed upon between you two. They will make a preliminary assessment. They want to make sure, again, location and staffing requirements are met. You're in a real area. It's underserved. They're going to look at the shortage of your primary care providers and health services, or both. And then they're also going to look and analyze information about what you. This is an area of potential focus. What do you put out to the public about who you are and the services that you provide? Types of survey, it's either standard or full, however you want to rephrase it. This happens on the initial application. They also do it on recertification. This is required if you do not have deemed status. In other words, another accrediting organization like Joint Commission has come in, done their thing, then they would come in and do a recertification. They also do what's called a sample validation. Here they're looking at and kind of following those accrediting organizations. This is usually done no later than 60 days after that organization has been in. A couple years ago they were having some issues with one or two of them, that they weren't meeting the standards CMS had put out. They were letting things not be cited that really should have been noted as a deficiency. And so that's why they started really beef up some of those representative validation surveys. Well, and then we have our complaint. I mentioned before, it's very narrowly focused. They want to make sure, are you in current compliance with what those requirements are? And it will only evaluate current compliance or non-compliance at the time of the survey. That's what they're looking at. If they have an investigation, again, this is usually a complaint, and the violation is one or more of the conditions, and there's no indication that you've done any corrective action, then you're cited as current non-compliance. However, if you do have, they call it a past violation or non-compliance, but you did take steps to put things into place to correct it, and you're still compliant. In other words, they did a double negative here. No current non-compliance, then you won't be cited. So let's say you're having an issue with, maybe you've got a water management program. On your first survey, you were having some problems, and maybe there was an issue reported of black mold or standing water that was really starting to not look healthy, and now you put things into place. You're working on it, because that could take time. You've got to get a contractor out there to take a peek at it, see what can be done, how do they fix it, make sure it meets with the standards, and you're still in the process of fixing it and doing great. Sure enough, here comes CMS again, but you're working on it. CMS should not be citing you on it, because you're doing what needed to be done. It just takes time sometimes. The good news is with our surveyors, they now have to go through training too. They have to have experience to do a surveyor. They have what's called principles of documentation. That's a training course they must go through. There's also the basic surveyor training that is required, and usually whoever comes out, they should be at least an RN with hospital or rural health clinic experience, because what they need to do is, is this facility really in compliance with the conditions, because it involves patient care. Then they look at what you are. They want to know who this rural health clinic is, so they want to know what are the basic characteristics. What do you put out in your website, for example, or maybe you have something down at the library about your clinic. They see the physical layout for this. For existing rural health clinics, not just coming in, but for those who have already been certified, if you do, if you have what's called a mid-level staffing waiver issued and still in effect, they want to see what that looks like. This is when you have tried to get those advanced practice providers in, also known as mid-levels, and you can't, I mean, you've done everything possible, other than kidnapping to go get one, then you have that waiver. Also that you have applied. Have you applied for visiting nurse services and found eligible to offer those? So that's what they're looking at for existing. They will also look at any past surveys that you've had done, what the results of those, because again, they want to make sure he's still compliant with anything that might've been noted that wasn't quite out of compliance, but was close. And was there anything done to fix it? Have documentation ready for them. They want a list of the patients you have for that day. They want to know the name, why the person's coming in, and who provided the care. Now this could be after the fact, but they still want to see that. They want to follow that patient from the minute they hit their door until they leave your clinic. What was the progression of care? They want a list of visits from the past six months. If it is a complaint survey, again, they want lists that include the month of that complaint. So if the complaint happened nine months ago, they may also want it from that nine months back. And they want cases from the past year where you had to send somebody off for emergency services, like by ambulance, however that happened to be, they had to go to the next level of care. They want that list of those patients. Then they want information about who works there, who is your medical director, who's on your medical staff. That includes allied health professionals and advanced practice providers, and anyone else who provides care, whether it's your lab tech, technician, LPN, whoever it is. So they want to see that organizational chart. And essentially what they're looking for is that chain of command. Who do they go to if there's an issue that comes out? They want your policy and procedures. Personnel records, usually they ask for a sampling of the personnel records. Yes, QAPI. You do have to participate in QAPI. What about your contracted services? Where's that list? Are they current? They want access to a copy machine and a conference room so they can meet, do their record reviews and interview. Now, not all the interviews may take place in that conference room because they may talk to your staff as they're on the floor working, and then a copy of the floor plan. Because during the survey, what they're trying to do with that floor plan is follow the flow of care. They can allow or refuse somebody from your clinic to go along with that surveyor. It's up to them, not you, it's up to them. They can't touch patients. They're not allowed to do any exams or provide any clinical services to patients. That could be a glass of water. And they also need to be aware of what issues or adverse events that you've had, especially if there was an immediate jeopardy. For example, you gave a medication to a patient that had a known allergy and they had a very bad anaphylaxis response, that they want to see those. They're also gonna observe care. So they will usually select one or two patients because they're trying to get a better picture of your routine practices. Who comes in and sees them? How long are they waiting? What kind of care is being provided? Who's with them? Let's say you're doing a sensitive area exam. Do they offer the same gender, patient gender, somebody to be in there with them? That's what they're trying to do. And various types of service, whether it's newborn or geriatric care. They are also gonna look around to see how the physical plant environment looks. What's the general condition of your building? Is it clean? Are there any smells? I did one where there was one room that was waste stepped into and I happened to see a lot of the ceiling tiles and some of the drywall was off the wall. And I was asking, what's this all about? And he said, oh, we found black mold. And it's like, oh, okay, why are we still in here? They also wanna observe interactions with your patients between you and your patients and then staff activities. How are they doing with infection prevention and control? Medical record protection, are they keeping it confidential? On the infection control, are they washing their hands between patients? Are they using gloves when they're supposed to? Are they properly drawing up medications for those injectable medications? Who's supervising them? Do you have a technician who's not being supervised according to what the state law requires? Or an LPN or even an advanced practice provider? Who's doing their supervision? On the document review, I just got some key aspects I wanted to point out. First, of course, they're going to look at your medical records. For personnel, they're looking at who do you have on staff, education, training requirements, licensure, credentialing, whatever your state does require. And your policy and procedures, they want to make sure that they're current and that leadership has signed off on them and currently. If you have any contracts, written agreements, same thing. Who signed off on them? Are they current? When were they last reviewed? Has it been 10 years since that particular contract was reviewed? Maybe it's time for a revisit on that contract. And they want to make copies of documents. They're allowed to do that with certain limitations like peer review. But as far as medical records, your policy and procedures, your contracts, they have a right to make copies. If that happens, ask to get a copy yourself because then you're going to see what they're looking at when they make a particular reference. Let me just talk briefly about clinical record review. So with a full survey, they're looking to see those patients who have been seen by your physician or non-physician within the prior 90 days. Remember, they're going to ask for six months of records. So they're going to go back 90 days to look at these. Usually 20 records at a minimum. If your case volume is over 50, if it's less than that, they want to see at least 10 records. Include your Medicare beneficiaries, your private pay patients. And again, any transfers that you had to make an emergency transfer to a hospital, include those in there because they'll want to see them. On a complaint survey, they will look at the conditions. What was related to that complaint? What was the issue at hand? Medication practices, patient given a medication with a known allergy. They will not stop at just that record. They want to see other records of the similar situation. Deemed status, they will determine which ones, your state agency, your regional office, they determine for the accrediting organization which records to look at and which CFCs that they're to evaluate. Again, it's based on the nature of the allocation. And these could be much older records that they asked for rather than six months. Could go back a year or so. They are looking in the clinical record for various basic information. What's the social data on the patient? What's their age, their gender? Some of their biometric data. Their symptoms that you happen to have. Pertinent medical history was noted. What's their assessment? What'd you find out on that physical P&E that you have to do? And their health needs. And then a brief summary of the visit, disposition, and any instructions you gave to that patient. That's what they're looking at. For reports, again, they want to see any diagnostic laboratory results, consultative findings, physical exams. And the lab results. They want to make sure that the clinician is aware of them. We usually saw that by initial was on that. So that, yes, somebody at least was looking at that and taking action if needed to be. On the practitioner, they're looking for what orders they made, any reports, how the treatments were, and how are they responding to medication? Anything else they need to know that this physician, that provider, is actually monitoring this patient's care. For example, let's say you had a patient with cluster headaches or migraines and they gave them verapamil for the treatment of that. Well, that report should be, this is what we gave it for. And yes, the patient reported 90% improvement in their headaches. That's what they want to see. That the physician, that practitioner is aware of how it's working. And of course their signatures, whether it's the physician or any other professionals, RNs, LPNs. They want them legible. That means it's complete. It is dated. It's timed and authenticated promptly. They're not waiting two weeks to sign off on that entry. You may have auto-verification once that physician or provider has reviewed it, but you have to be able to show your EHR does do that. That yes, indeed, they went in, they reviewed it, and then once they closed it out, it was auto-authenticated. Interviews now. So now they're going to go out and talk to people. This is how they not only collect, but they verify and validate information, say in your policy and procedure. Usually very informal. They can do it while they're walking around and brief and right to the point. How do you verify that medication with the patient? What are you looking for when you're doing it? So they'll ask them and then they'll observe them. And the staff know and understand what they have to do for compliance. Again, medication administration, do they do the five rights? So once they're all done, they do go back. They go through each of the conditions for compliance. With a complaint, they look at the evidence related to each of those conditions that were under investigation. Compliance is cited as a deficiency. Now we had said before, I said before, that if they're on site and you had a prior deficiency and you were working to fix it, you're in the process, you wouldn't be cited. Well, on the other hand, if they find a deficiency during the survey, it's noncompliance. Again, unless you've identified it before the survey and you've taken action to correct it. But if they find it during the survey and you correct it, you will still be cited. So it depends on when was it identified and when did you start to take action to correct it. So again, if it occurs prior to the survey and you've taken care of it, then you won't be cited. If it's identified, no other evidence of noncompliance, it's considered passed and you won't be. That's again, when they go back and they look at your past surveys, make sure, yes, indeed, you did fix it. On the citation level, this depends, and there's two of them. Condition and their standard. It depends on the manner and degree that you satisfy the standards within each condition. So the condition is the top layer. Then you have your standards that come back down underneath that. Lack of compliance depends on the nature of your noncompliance. Seriousness of the deficiency or the actual harm and how widespread is it. And I've got here on this slide, number 53, how that does look. You've probably seen it before with joint commission where you have, it's very common and high severity, uncommon, low severity. That's how they color code this. And then finally, our exit conference. They will give you preliminary findings. They usually do that. It also helps with some exchange of information. It's not always guaranteed because if you have an attorney, your attorney is in that exit conference, or if you aren't communicating between each other well or it's hostile, then you won't get your exit conference. They'll just finish and leave. You can record it, but the surveyor has to consent, especially to video. You can do audio or video. You have to give a copy to that surveyor or the team if that's what you're going to do. And again, they have to consent, especially to video in order for it to be recorded. So now they're all done. Now they're going to send you any findings of noncompliance, why they indicate noncompliance with a regulatory requirement. They won't say, oh, you're doing a great job. Looks good, way to go. They only give a specific factual finding. They won't tell you if it's standard level or the higher condition level. What they would say, the requirement related to G0111 was not met. That's how they're going to do it. They won't rank them because they look at everything equally. In other words, they won't say, start here with medical records and then go down to disposal of trash. They won't do that. They will discuss each deficiency finding. They have, they will get these findings back to you within 10 working days, 10 working days. So it's a little bit longer. If there are deficiencies and you don't have deemed status, in other words, you're not with an accrediting organization, you have to put your plan of correction to the survey agency 10 calendar days after you get that report. It's a very short window of time. Deemed status, you submit that plan of correction again, 10 calendar days of the report, only if it's a condition level. And you can volunteer plan of correction even if it's the standard level. Again, if it's deemed status, that's what you have to do. It's a little bit different than if you don't have deemed status. The timeframe for implementing that plan of correction, in other words, putting that plan of correction into place, not that you put one together, but now you're gonna do what's in there. You have three options on there, by the way. Accept as stated and do your plan of correction. Record objections and still submit a plan of correction. Record objections, don't do a plan of correction, but give evidence on why, why that citation was wrong. Have those written arguments. Now you can use counsel, you can use someone to help you with that. That is not prohibited. That counsel simply can't be in the room during the exit interview. So again, you have options for each deficiency. It's like, no, you're looking at an old policy and procedure, we revised that. Here's the new policy and procedure and it was done two years ago. You didn't look at the right one. Otherwise your plan of correction has to look at each deficiency, how those actions are gonna correct it or improve what led to the citation, how you're going to implement that action, and when do you expect that completion date? That's for each and every deficiencies. You must monitor and track those procedures. So you wanna make sure that it's effective and you're in compliance. Include in there who is responsible to implement that plan of correction. It might be your COO, CEO, whoever that happens to be. And a signature and date signed is on that form. I have that again in the appendix for you for what that looks like, which brings me to question number two. Lindsey. Okay, if I could come off of mute there. All right, let's get that one up here on your screen. Okay, this question should now be up that says, our processes for follow-up to any survey include a designated individual to lead the response, plan of correction, or a team of clinical and non-clinical administrative personnel to prepare a plan of correction. We have no process, identified team or person, or possibly prefer not to answer here. And then Laura, there is one question pending right now in the Q&A, and it may be a little bit more than you're planning to address today. And if so, we can maybe take this offline, but I'll read it and then we can go from there. So it says, this person is new to rural health clinics. Could you please address conducting and billing a preventative service in this G0438, G0439, in conjunction with another E&M service? Yeah, that's one that we'd have to take offline. I usually don't address billing issues, Lindsey. Right. Because, yeah, sorry. No worries. Yep, I see this question came in from you, Sharon. So if you wanna reach out to us at education at gha.org, and we'll see if we can get additional information for you and set you on the right path there. I know Laura's message today and for this series is to provide the regulatory information. Correct me if I'm wrong, Laura, but not as much as the billing operations. Correct, the integrity manual. Yes, you're correct. Perfect. Okay, let's go ahead and end this poll and share those responses there. Oh, good. Okay, so you have a team or someone who designated. That's great. They always have such a fun job. All right, here's the procedures. And right now, we're gonna go ahead and start going through the actual manual. The numbers you see in the upper right-hand corner, that's the tag numbers. Tag numbers, that's just simply how they identify what they look at and where they could possibly issue a citation or deficiency. That's the easy way for them to do it. So we have services provided by physicians who are at the clinic. You can do it by contract. That contract has to include the services that you're going to do, that you have Medicare certification and a cost reporting. Surveyor will talk to your leadership and the physician. They could be the same people, but they wanna talk to leadership. They wanna also find out if there is an agreement in place for these services to be provided. I mentioned visiting nurse service. Why they put it so far up close, I can't answer it, but they did. So a visiting nurse service, you can have that through your clinic. This you have to do, if you're gonna do it, you have to meet each and every one of these requirements. You're located in an area where there is a shortage of home health agencies. They are provided to homebound individuals. Otherwise, homebound are those who can't leave because of their condition. That could be also, if it is a behavioral health issue, they cannot get out. That they are provided by an RN or an LPN. Now these can be employed, they can be separately paid by the rural health clinic. And you have a written care plan for each and every one. That that care plan for that individual patient has been established and reviewed by a physician every 60 days or by an advanced practice provider. And it's reviewed at least every 60 days by that supervising physician and it's also signed off by those. So if you have an advanced practice provider the physician still has to review and sign off on it. Even though your state may not say they have to have that supervision, CMS says, yes, they do have to review and sign off. These are services that are usually performed by an RN or an LPN to make sure the patient is maintaining some level of safety and we have the desired results for that care plan. They're doing their blood sugars. They're maintaining those safe blood sugars. Perhaps there's a little bit of home care involved that a patient or their family member can monitor and do and the RN or LPN can also come in and do. There's personal care services that would fall under home health like helping them get a bath in and out of bed, making sure their medications are listed out maybe in one of those pill dispensers, that's fine. What it does not include is housekeeping, running errands for that individual, doing their grocery shopping, that's not included. Homebound, again, that's a person permanently or temporarily confined due to their medical health issues, and that includes if they leave infrequently. Say you have a morbidly obese individual who cannot get out of the house because of their condition. Perhaps you have a patient who maybe they're undergoing chemotherapy and they're immunosuppressed and they can't leave. It's just a temporary time. It's really safer for them to be homebound. That would be included in there. For your agency shortage, that secretary, they determine that, that it's in a county or area where there is no other home health agency or services available to that patient. Permanent residents, they're not within the area serviced by one that would participate. Home health agencies have to sign up and be eligible to take Medicare and Medicaid payments. And either there's nothing in their area or reasonable travel distance isn't possible. You know, having a patient have to go 60, 100 miles, that's all that far. Having them go 10, 20, not so unreasonable. But they also take into account the climate and terrain. I know in Georgia, you have some mountainous regions and you also have some climate that can be a little unforgiving. And other states have the same issue. I'm in Colorado. We have those mountainous regions and there's a couple of rural health clinics that we have where you need a four-wheel drive. You must have a four-wheel drive and you must have chains to get to certain areas. And so that's what they also take into consideration. Overall, you can do visiting nurse service if you meet those requirements. And again, it's provided by an RN or an LPN. It's in the patient's home and it's documented in their records. And it goes according to that written plan of treatment. So we still have to have that. Again, doesn't have to be your staff. Can be another RN or LPN that you work with that can make those services available. Surveyor is going to look at personnel folders. They wanna make sure they're currently licensed. You can go through your board of medicine, your board of nursing. Those are considered original source rules, source sources for you to confirm, yes, indeed, they are licensed or is there any restriction on those license. For visiting nurse, they're going to look at sample records. They wanna see that written treatment plan established and signed off by the provider. That it was reviewed at least every 60 days by a physician and what services were also provided according to that plan. They also will observe at least one of those visits to make sure care was actually provided according to the written treatment plan. So they did to go along with you when you do those services. I asked on one of those questions about interpreters because one of the requirements is that we comply with all laws, whether it's state, federal or local law in your area. I'm also gonna talk personnel and location with this particular segment. So you have to comply with all of these laws and regulations. The surveyor will refer certain non-compliance to those agencies that have jurisdiction over that particular issue. For example, OSHA, maybe your health records, your personnel records show that there hasn't been TB testing or universal precautions training for the staff and perhaps a staff member is injured. That goes to OSHA. EPA, your hazardous material waste issues. Are you doing anything that you might have human waste that you have to properly dispose of it? If you're under a final enforcement by say, let's say it's by OCR, Office of Civil Rights, you will only be cited if that final enforcement is in effect and you haven't done anything to correct it at the time of survey. So again, that's the only time you are cited if you're under final enforcement. So I do wanna talk about interpreters non-discrimination. This is one of those federal laws, the Affordable Care Act and section 1557. It's a condition for your certification that you comply with all laws. And that particular section 1557 is just that. It talks about non-discrimination. It is enforced by the Office of Civil Rights. If CMS finds it, they will turf it to OCR. And then OCR comes and pays you a visit. Some of them actually overlap. What's in section 1557 overlap with these conditions. And by the way, some of the provisions that they check on aren't in the manual. So just, I'm bringing this to your attention so you're aware of it. Surveyor can send it again over to OCR if they see something that is violation. Essentially what this does, section 1557, it prohibits discrimination based upon the protected classes. And the protected classes are those who by constitutional law that's your main thing, race, color, national origin. But they also added in their sex, age and disability where there's discrimination in health programs and activities. And Medicare and Medicaid is two such items. Enhanced language assistance. This is for those patients who cannot hear. So in other words, we have to do sign language. And by the way, what they're spelling out is ASL, American Sign Language. Or limited English proficiencies. If we have those, we have to provide interpreters and those interpreters must be qualified. So what you have to do, you have to put up the sign wherever patients entered. That could be the main desk or if you have say an urgent care door, if that's how you're gonna do it. Somewhere where patients first walk in, they see it. And what it's saying is that if you need interpretive services, they're available at no charge to you. And here's how you do that, okay? You have to make sure your staff know what your policy and procedure is and what they have to do. You put up a sign in 15 languages. And again, it's a tagline that just says, hey, if you need help, this is what we can do at no charge. Four states and the District of Columbia have 17 languages. So if you're one of these four states, Colorado, Maryland, Rhode Island, Virginia or the District of Columbia, you could have 17 languages. Have someone in charge to handle those grievances. The taglines are the Office of Civil Rights. They have a document that lists the top 15 in each state. I have the link there, copy paste it. Go to where when you get in there, go to where it says Appendix A. You don't have to use this list by the way. If you have one from other sources and it's reasonable, you can rely on it, say it's from your state. You're directly from your state, great, you're okay. That's fine, just show where you got that list. So that's what it will show when it pops up. What are the top 15 languages and what is the sum of the gross? And for those who have 17, they usually clump 15, 16, 17 together with which ones they are and how many collectively that you would see. So again, you have to comply with all federal and state laws. That's why it's on your interpreter. Yes, you can use a language line. Yes, you can use staff who are qualified. Meaning, can they adequately and correctly translate from English to the other language and back again. And it's nice if your staff, your healthcare staff can do that because they understand the medical ease where perhaps your registration clerk might not understand so much or your security guard. They may not get so much. So if you have clinical staff, wonderful, fine to use them. They don't have to be certified. They only have to be qualified. The ways you have to be licensed according to what your state and local law says you have to be, that varies by state. If you currently have a state licensed citation, again, you're not cited unless the state's taken final action and you haven't been compliant at the time of the survey, you haven't fixed it. If it's revoked, well, of course you're not in compliance and you're cited at that high condition level. If again, you're not in compliance and the surveyor finds it, they can send it over to the state because the state may not know. Now your bodies, your personnel. Same thing, they have to be licensed whether it's certified or registered according to what your state law says, and it must be current. And it's where the rural health clinic is located. Clinic has to make sure anyone who has to have licensed registration, whatever you call it, that it's in their personnel folders. And what are the requirements for your advanced practice providers? It's a requirement of your state that the provider signs off on all records, a percentage of whatever that happens to be. The surveyor will verify exactly that, that they've gone through, they looked at personnel folders to make sure it's present and it's up to date. They'll verify you have and you follow your procedures to determine your staff is properly licensed and certified. And that you also have policies to verify your contracted personnel are the same way. Maybe you use local tenants. Maybe you're using agency nurses. That's fine, same thing. You still have to make sure they've got a current and most likely an unfettered license. Location and definition, that's your clinic. Rural area and a shortage area. The rural area, essentially you're not urbanized. That's what it is. And you're in a rural area that's designated as a shortage area. You're not a rehab facility or something that does primarily care and treatment of mental behavioral health diseases. And then all the other requirements. The shortage is your personnel. That's your personnel health services or your primary care manpower. And this is according to your last census. It includes extended cities that the Census Bureau has determined is rural. And there's a lot of that where people, these little clusters are starting to become a little bit more urbanized than actually rural. What is excluded? Central cities of 50,000 or more where you have at least 25,000 cities together, contiguous areas, and they combine the population of 50,000 into one community. Closely settled territories that surround cities designated as urban. That is excluded from that designation. Shortage area, what is the ratio of your primary care providers to your resident population? They also look at your infant mortality rate, those 65 and over, and those where the family income is below poverty level. Now that's the designation of the shortage area. Manpower, what are they used to determine that? Well, the area served is the rational area of your primary medical services, the ratio of PCPs practicing to what's going on with your resident population. So if you've got three providers and your resident population, say, is 10,000, well, that could be okay. That may not be considered a shortage. But primary medical care manpower in a contiguous area, that could be one that's overutilized. They're distant from where the patient is or it's simply inaccessible. So even though you might have three providers in your area, your patient population is too far away. Maybe they're 50 miles away or they're living up in the mountains in the terrain and they can't get to you. Only the regional office determines this. You're in a rural area and a shortage area. So the regional office makes that. What if you have what's called a mobile unit? Well, first off, permanent. Everything that you have to provide services is in one permanent structure. It's in your building. The mobile is equipment, supplies, objects. They're in a mobile structure, but they're at a fixed location. If it's only a mobile unit, that's all you have. Let's say you happen to have a trailer. You still have to comply with all of the conditions, including location. So that's the only thing you have. They must have fixed times on specified dates so they adhere to the schedule. That's your mobile unit. If you have a new unit, they meet the same, the rural shortage area. In existing, the new location has to meet the same. So if you're getting a mobile unit in addition to your current one, you still have to meet the location. And they have to operate at locations that meet those requirements. That places and times that you have documented by your clinic, available to the public ahead of that scheduled operation. And they have to be posted on the mobile units and publicized. If you have a website, great. If, again, you have another place you can post at the fire department, the library, somewhere that folks would have information. These are my dates and times and where I'm going to be. For more than one location, if you happen to have this, each unit has to be individually approved. You can't have more than one permanent location. Again, physical address where services are provided, but you can have a mobile. If you have several facilities operating out of that permanent unit at different locations, that's fine. And you just have to enroll in each site separately. The surveyor will check your webpage. How are you holding yourself out? Are you having multiple locations? Staff, where are your other locations other than a mobile unit? Do you know where that is? So you have several facilities out of a permanent site at different locations, and you're trying to provide services at each facility. You have to enroll each unit separately. You have to occupy... If you occupy several suites within the same building, that's great. You're still one unit. So if you happen to have a community center where you have several suites in there, that's fine. It's still one unit. And you can occupy different suites in the same building, but still all have to meet the conditions. Can't commingle your services. Certain exceptions where you were not disqualified. If you were previously approved, and now your area doesn't meet that definition of rural or shortage, you're not disqualified. You're okay. Private non-profit facility that meets all the requirements except location will be certified if by July 77, they were operating and not enough physicians to meet the needs. Again, that's a private nonprofit. And you have to apply for that exception to the secretary. Grandfathering is another issue that might come up where somebody else moves in. You can remain a rural health clinic if again, the population or availability of your providers even increase. There's no special procedure. They will still get information about your data, your location. But if you relocate, then it doesn't apply and you have to meet all of the requirements again. So again, you're in a rural health area and now you've got this population boom. It's great. You need more providers. They come in, great. You're okay. But if you decide to build a new site and move, then yes, you have to go through the application. I know that's a lot to start with. I wanna now move on to the physical plan. This is your building. How does it look? Is it built, arranged and set up so you have access? In other words, can a patient get into your building? Think ADA. Does it also ensure safety of patients and have enough space so you can give direct services? For safety of patients, think about how would they, how would you prevent unauthorized access to your building? Are some of your back doors locked securely? Are there alarms? So if it's a fire door and you open it, does an alarm go off? What about steps? How many steps? Is it a trip hazard? Is there loose carpeting or tile that could cause a trip hazard? Is there water or something that could maintain a slip? They wanna look at not only the layout, but the fixtures so there is no hazard or increased risk of hazard and injury to that patient. They also look at your ceiling tiles, by the way. Are they there? Are they falling down? Is there evidence of water or some other kind of contaminant present within that tile? Are they set up? Is your plant designed and structured according to what your state and local codes say you have to have building, fire and safety? So for example, let's say for provision of services, do you have enough adequate lighting in hallways so patients don't step onto something or trip? Have things that have been dropped, been picked up, water that's on the floor? If you're in an area that collects water, maybe you get a snow and it melts. Are you addressing it as soon as practicable? Fire and safety, accidents clearly marked. Does their alarm go off if a door that's supposed to remain closed is closed and secured? I worked at one where during the changing of seasons, you know, one day it'd be terribly hot and the air conditioning was just blowing really hard. And then overnight, temperature started to drop and it shut off. Well, then the next morning it starts to get hot again, the air conditioning kicks in and sure enough, some of their outside security doors actually popped open. And this happened throughout the day and the evening when no one was there to monitor it. And there were times when they had evidence that an unauthorized person was in their clinic. So that's what they look at. Are we making sure this building, people, supplies, medications, everything is properly stored? Do you have enough space to do your job? Have enough equipment in there to provide those direct services? How about the supplies? Are they properly stored and secured? What do you have for direct services? Not management, but direct services. You comply with all of those laws and regulations but acceptable standards of practice for primary care. CMS won't establish the standard of care. They leave that to those experts. How much space do you need to provide these services? Maintenance is next. You must have, must have a preventing maintenance program. That's on all of your clinical equipment, whether it's a computer, the monitor, whatever it happens to be. Make sure all essential clinical equipment, all essential equipment, let me clarify that, is safely operating. Mechanical, electrical, anything with patient care. Also, the essential equipment that they list out. It's not just clinical equipment. It's heating, air conditioning, plumbing, elevators, if you have that. Biomedical equipment, whether it's for therapeutic or diagnostic. Whether it's a reusable scope, EKG machine, whatever it happens to be. That could also be, by the way, your glucose monitors, glucometers. Are they properly working? And have they been maintained? And is there a record of it? All equipment must be inspected and tested for performance and safety. I underline that, that is not in it because that's an area they kind of really watch. And in fact, they may bring in with them during the survey someone who's specially trained in biomedical. They will also do it for fire and safety. They will bring in someone who's very familiar, has training in fire safety and other code requirements. They wanna make sure this is also done before you first use it or after any major repairs. It must be inspected, tested, and maintained to make sure it's safe for use, it's available, and it's reliable. Think about your defibrillators. How are you testing those defibrillators? Are you using an AED? Great. Is the AED functioning safely and is it also reliable in what it does? Same with your EKG machines. As far as who's going to do this maintenance, that's up to you and the piece of equipment. Clinical staff could do it. Maybe you want to contract it out or a combo of both. Have a contract. You could have a contract for your Biomed. That sometimes is safer for you. Again, these are folks who knows how to run these things. What's the ins and outs and when does it need to be replaced? If that's the case, make sure they are following manufacturer's recommendations for schedules and activities, and document those preventing maintenance activities. Put that into your performance improvement plan. If you're getting these funky readings off your EKG machine, okay, maybe that's a time we need to look at it. When is it happening? What is the issue involved? Who can fix it? How long will it take to fix it? The surveyors want documentation on that equipment. When was it inspected? How was it tested? Who's maintaining it? If anything is missing, they want to see your policy and procedure on that maintenance because what they're seeing, one of the problems that they frequently cited, that it's a content or failure to follow your own policy and procedures, especially how often is maintenance done and who's responsible. They want a copy of the manufacturer's recommendations for that equipment. Hopefully, it's not that old that you still have it, and then they want to talk to staff. Any problems with that piece of equipment? Does it break down? Does it just not read right? If that's the case, then they want to see that documentation on it. Brings me to question number three, Lindsay. Okay, let's get that one up here on the screen. Okay, so this one should now be where you all can see it. It says, our clinic maintains a supply of sample medications for patients. Such medications are well secured at the nurse's station with limited access, secured in the pharmacy only, fairly secured near the nurse's station but not in a locked closet, not secured, open closet in a hallway, or possibly prefer not to answer here. And again, if you have any questions for Laura, go ahead and be typing those into the Q&A option there, or if you don't see that as an option at the bottom of your Zoom window, you can, of course, type in your questions there in the chat as well. And they put medications, drugs and biologicals, in this segment, not so much on administration of medications, but how are we storing them? How are we keeping an eye on those things? Because we don't want them getting legs, whether intentionally or inadvertently, that they are properly secured. Okay, so we have a few who don't want to answer. I like it that the majority of you are seeing well secured. That's excellent. That's good to hear. So we have to make sure they're properly stored. Now, drugs can be everything, and biologicals, everything from your IV medications to an ointment. That's all part of this. It's part of your preventive maintenance program of all things. You'd think that'd be in your medication, but no, they decided to put it here. They want to make sure they are stored and maintained according to what the manufacturer says. What's the temperature? Does it have to be in a dry place or in a moist place? What is the expiration date? And how are you monitoring that? We can't keep in areas where they're not secured, where they're readily accessible to unauthorized persons or even personnel. Your policies, your procedures, they have to identify who can have access to drugs and biologicals. Secured, they can be in private offices or where someone, let's say patients and visitors are not allowed unless somebody's with them at all times. Perhaps your physician wants to talk to a patient and say, put them in my office, I'll be there in a minute. Well, that's fine, but somebody has to stay with that patient until the physician shows up. They can't be in there alone if you have meds or biologicals in that office. They are not secured when they're in unlocked cabinets where patients, visitors, others can have ready access, and there's no staff around to monitor it. That closet at the end of the hallway that's always open, even though staff is walking up and down the hall, staff have to keep pretty much a constant eye on that closet. Shut the door and lock it. That's fine. You can do that, but they have to be secured. The conditions of your premises, we touched on it briefly where they want to make sure it's clean and orderly, that this is part of your preventing maintenance program. They're clean in the waiting room, the exam room, restrooms, office spaces, even the staff lunchroom. You think, why would that be? Because if you have a lot of food hanging around in your staff lunch room, do you get little critters that decide to show up and come visit you? They also will probably look at some of your storage rooms. Again, they're looking for critters, vermin, that could have gotten access. I had a clinic where they had this very large room. It looked like an old garage, essentially, is what it looked like. I happened to see the door and asked what that was. He said, well, we don't go in there. It's a storeroom, but we don't go in there. When I asked why, he said, because of the rats. It's like, okay, I think we need to address this one. And granted, no patients went out there, but there was always that possibility, if a door opened or whatever happened. They did end up, CMS was out, and they did get a citation. We tried to get it fixed in time, but unfortunately it didn't happen. You have certain duties that you monitor your housekeeping maintenance activities, because you want to make sure everything's working, that it is a clean environment. You're coming back in the next day and the trash hasn't been emptied. The counters haven't been cleaned off appropriately by those who have that responsibility. Are the floors clean? How about monitoring? Are your repairs being done when you send out for them? Are you going to do a renovation or build a new part to your clinic? That's what they want to do. Are we monitoring and making sure that it's done safely and according to the health code? You may have an older building. Do you have to have asbestos in that older building where you have to take precautions for elimination, mitigation? Policies and procedures have to talk about those measures to keep it clean and orderly, and again, during any construction or renovation. Waste disposal, that includes medical waste. If you got a wound in your blood, your bloody items, are you putting those in biohazard bags? What about your used needles and syringes? Food sanitation or pest control, which I've already touched upon. How do you prevent spread of infections? Hand hygiene is one of the best ways to do it. That means washing your hands and using gloves. Safe injection practices, single-use devices, point-of-care use devices done safely. High-level disinfection and sterilization, if you have that. If you are doing, say, a wound care or stitching up a wound and you're using those forceps and the needle holders, whatever it happens to be, using that high-level disinfection. Routine cleaning, just of your services, your fixtures, your carpet, toys, if you happen to have your toys. If you have those for the kids in the waiting room, who's cleaning them? How often? When were they last done? That's what they're looking at. Now, the final section, that's on organizational structure. Who's there and who reports to who? You must have medical direction by a physician. You also have to disclose the name and address of those who are responsible for that medical direction. That goes to your state agency, and you also have to notify them when there's been any change. So, your medical director has retired. Who's coming in to take over? You have to notify the state. The names, the name, the address, and phone number. You want evidence they are licensed in the same state as you are, and it doesn't require a resurvey or recertification. So, as long as you can show and verify it, then it doesn't usually require that resurvey. The policies, the line of authority, and responsibilities have to be in writing. On your staff, you have a healthcare staff. I am going to discuss it further in detail. They did include it here, but you have a physician, MD or DO, but you could also have an oral surgeon or a podiatrist, somebody who acts within the limits of the services they provide. You have your advanced practice providers, PA, nurse practitioner. Now, here's where one of the new things came out. These are optional individuals. You don't have to have them. A certified nurse midwife, clinical social worker, psychologist, a marital counselor, and then all your other staff, your ancillary staff from RN, lab tech, other technician, LPN, whoever that happens to be. They give us definition of what these are. This is according to CMS. Not necessarily what your state says, but what the CMS says. Physician, that's who's legally authorized to practice medicine or surgery. That also includes supervision, collaboration with others, and oversight requirements. In other words, they have oversight requirements for the advanced practice providers. Same with the oral surgeon, as long as they are within the scope and the services that they are providing. The medical director must be a physician. They hold a current license where you're located. They're responsible for the quality and appropriateness of care that is provided. There has to be documentation of who this is, name, address, phone number, and what are their duties. I'm going to cover those specific duties tomorrow. If your director leaves and you have someone acting and you have that is, you have to have someone who is there acting as the medical director. You don't give a waiver. You have to have someone there. Now, CMS will give you reasonable time to find a replacement. You have to give them documentation that you have done good faith efforts before they actually showed up, and what arrangements you have made for any temporary physician services, and somebody to perform those duties. It's not available to give this time frame. It's not available if you're going for initial certification. You have to have a director when you have that initial certification. If you're already certified, you will still be cited. It's the discretion, how long you have to implement that plan of correction to get a new director in. Now, the interpretive guidelines do note the regulation allow you to carry out duties using telemedicine. That's okay. You should be able to get a physician within a reasonable time. The state agency will recommend to the regional office to give you an extension in order to provide that, and you have to notify the state agency of what you've done to recruit that replacement and when you can expect some kind of an outcome. Now, there is good news here. You can use locum tenens as a medical director. That's fine, but they must contract to stick around for at least six months, at least six months. You have to have other healthcare staff also available, so that's kind of a non-question. PA, nurse practitioner, nurses, whoever it is. The surveyor, they want documentation of who that director is. They want to confirm they're still there and they're appropriate licensed, and they want evidence. If you don't have one, what are your efforts to fulfill that replacement? Again, you can use locums to do that. There are certain disclosures you have to make to the state. First off, who are the owners and who's responsible for directing the operations of your clinic? As far as how organized, the person who is responsible for day-to-day operations. What are the lines of authority between those directors and the owners, because they could be different, and the lines of authority between the operations director and other staff? That's why they want to see that organizational chart. Who reports to whom? Usually, your director is going to report to your owners and the staff will report to your director. Identify in writing who you have, where they fall in the chain, and what their functions and responsibilities are. They want a written record of the name and address of those who is responsible for the day-to-day operations. It could be the medical director, if that's who it is. I listed in here the Form 855A. That's when you're doing your basic enrollment, and other personnel, that's Form 29, how you collect that data. Then finally, of course, we have to have our policy and procedures and administrative processes. Your personnel, your fiscal, how are you getting money? How is that going to operate? What's your budget? Who does purchasing? Who's responsible for it? What's their level of authority, if it's a certain amount? Building and equipment maintenance, and other pertinent topics, maybe staffing, alternative staffing. The surveyor, again, wants to see that organizational chart and supporting documentation. They want to make sure folks are operating within their scope of practice, that they know who to report to, and what are the change of command, if there have to be supervision. Brings me to my final situation for the next six minutes. We have a hospital. It was a critical access hospital, huge decrease in the population because a major employer left the area, so economic downturn. The administration, the physician owners said, we're going to convert to a rural health clinic. The application started in March. They converted all of their policy and procedures. They put up their clinic hours, established those. What staffing did we need at that rural health clinic level? The notice, they put it out on their doors and on their website. There was no other information made public, like communication by, say, the physician to their patients. They didn't talk about it for some reason. Well, now we've got an increase in flu cases, that time of year. Now they started operations in February. Over a two-week period, six patients came into the, quote, clinic after hours, only to find out, oh, nobody's here. They're closed. There's no health services available. They did, too, you know, there's information on the bottom. As of this date, we are no longer a hospital. We're a clinic. Here's our hours. I have an emergency. Call this number. So they did that. Next hospital was over 30 miles away. Do you think MedLib's going to have any citations and any other advice you might want to offer to our clinic in this situation? And, Lindsay, I guess I'll have you put them into the chat box for that. Okay, great. Now, while those folks are trying to go through that, I do just want to do a brief, I want to show you how to find these appendix. They're in the last part. There's roughly about, okay, 18 pages. I put in here the memos that I did mention, some of the survey training, surveyors training. You can take this training. It's free. You can have access to it. So if you're new to your role, you might want to look at some of this training that you can tap into. There's alphabetical ways you can do it. Not all of it applies, but it's still there. There are resources. CMS has a site just for you. And they also have what's called a Medicare Learning Network. I love this because it has a lot of good information right to the point, and it doesn't overwhelm you with that information. For short, this is what's required as being a rural health clinic, ABCD, what you have to have in place. Quickly on deficiencies, I didn't go into it this time. You can access deficiency reports to find out where has your clinic been in the past. That's what it would look like. You'll go to the bottom of that page where it says downloads, and then you will get an Excel format. It's nice because you can copy-paste. A couple years ago, this was not available. They didn't have it. So it's nice now that they've seen more influx of these clinics that are certified, and they can get a good base. Otherwise, basic information for you. I talked about medication storage that includes your vaccines, what some of the recommendations are, use a medical refrigerator, not a dorm refrigerator, educate staff on how they store it and how they handle it. Also, there is a most recent update of March of this year. I have a feeling this one may get tapped for an early update. We're now seeing an increase in the impacts and the bird flu, where there is now that crossing over from the avian to humans. We had a case here in Colorado, as a matter of fact. So I have a feeling they're going to start updating that once that vaccine is available. Then finally, that emergency preparedness. I'm going into further detail on that tomorrow with the next section. So get more resources in the appendix. I didn't want to clog up our program today with those. So I'll turn it back to Lindsay and see if we have any comments for my poor little clinic. Perfect. And if anybody does have any final comments there, you can go ahead and type that into the chat in regards to the sound discussion question. And while you may be doing that, Laura, looks like there is a couple of questions here in the Q&A as well. Great. And this first one asks, so my apologies if this was addressed earlier, this person had to jump off, but asking, is there a requirement that a rural health clinic be a certain distance from a hospital or is there a minimum distance? That's a good question. It's not like a critical access hospital. That's a very good question. What they're looking for more is where are you located? Because you may have a rural hospital that's 30 miles away. You would be okay. So that's what they look at is where are you located and what's around you, not so much distance as if it were a critical access hospital. So when this was a critical access hospital, they were fine because they were 30 miles away. So they did not say, I have a feeling if you have a critical access hospital that maybe is 20 miles away, they may have a little issue with it being rural. It depends on what does the census say. And don't forget, it's also part of your staffing shortage. It's not just where you're located. You have to meet that shortage issue also. You may not have a physician or one physician and for them to be on call 24-7, no, that's not reasonable. They would look to others. So you may be again, 25 miles, one MD, that's it. And you're still qualified. Perfect. Okay. And then speaking of that medical director, couldn't that person be an OBGYN MD? Yes. As long as it's a physician and they understand they're responsible for all care, whether it's geriatric or OB care. Absolutely. They can be that medical director. They have to understand what are their responsibilities, who they supervise and can they do it? Okay. Perfect. I don't see any other comments here in the chat if you wanted to do this final discussion and then we'll see if we have any more. Yeah. See, the problem was the physician owners didn't talk to their patients and they really should have, you know, say, hey, we're converting. The hospital is no longer there. And so if you have an emergency that comes up afterwards, don't bother going to the clinic, go here. So these were some patients who hadn't been there in the year in the timeframe that it closed. You'd think they would heard about it, but we can't assume it. So yeah, they did get a citation and that's where they realized, oh no, I didn't tell my patients. I figured, you know, they should have seen it when they walked in. We can't make that assumption. Always, always tell your, have them tell their patients. They got it fixed right away. Never happened. You know, after that one little episode, it was like two or three months. It didn't happen after the fact. And so they did put a plan of correction into place right away and it was resolved immediately. So it wasn't a big issue for them. Thank you, everyone. Thank you, Lindsay, for all your help again. And hopefully we'll see most of those folks here from you tomorrow. Absolutely. I did just post some information there for you all in the chat. Just as a reminder, you will get an email tomorrow morning. Just note that it will come from educationnoreplyatzoom.us. And that email will include a link to the recording of today's session. And again, a link to the slides that Laura presented. But you do see here in the chat a link to those slides now as well. And then as Laura mentioned, we do look forward to having you all back with us for part two tomorrow. And you should have received your email already with a link to join that session. It is a different link than the one you used for today. So just make note of that. And if you have not received that link and you're a member of the Georgia Hospital Association, please reach out to us and we're happy to provide that information for you. If you're joining us as a member of a partner state hospital association, I encourage you to reach out to your contact within your association for that follow-up information as well. Thank you all so much for joining us today. Thank you, Laura, as always, for your time and information that you shared with us. And we look forward to part two tomorrow. I hope you all have a wonderful afternoon. Thank you so much.

Rural Health Clinics

regulatory frameworks

risk management

patient safety

CMS staffing requirements

compliance measures

interpreter services

Medicare reimbursements

preventive maintenance

emergency preparedness

corrective plan

survey processes