Name of RHC
Rural Health Clinic Policy & Procedure Manua=
l
Updated: Date of Update
&=
nbsp; On
Date of Update, the Annual Evaluation Committee of Name of RHC updat=
ed
the rural health clinic policy and procedure manual of the clinic.
&=
nbsp;
&=
nbsp;
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Name |
Title |
Signature |
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Name of RHC Physici= an |
Medical Director |
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Nurse Practitioner<= /span> |
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Office Manager |
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Nonmember |
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Mark R. Lynn= |
Healthcare Consulta= nt |
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Name of RHC
Rural Health Clinic
POLICY AND PROCEDURES MANUAL
Introduction
This policy manual is s= pecific to the operation of the rural health clinic in Your City, Your State and supplements the policies and procedure guidance provided in other policy and procedure manuals prepared by Name of RHC.= Your Medical Director makes a sustained and substantial effort to ke= ep the rural health clinic in full compliance with applicable State, Federal (OSHA, CLIA, etc.) and this policy manual is one of the tools that helps en= sure compliance. This policy manua= l only address items specific to rural health and does not address other issues wh= ich are more appropriately addressed in other forms of guidance. Such guidance includes the followi= ng list of resources:
=
&nb=
sp; 1.
=
&nb=
sp; 2.
=
&nb=
sp; 3.
= &nb= sp; = &nb= sp; =
If the guidance in the = Rural Health Clinic policy manual is found to conflict or differ from guidance in some other policy manual, the specific guidance should be brought to the attention of the Office Manager who will resolve the conflict through appropriate channels based upon the specific situation. This manual should be reviewed on = an annual basis by the Medical Director, Mid-Level Practitioner, Office Manager and the annual evaluation committee and such review should be documented.
Condition I:<=
span
style=3D'mso-tab-count:2'> &=
nbsp; Complian=
ce
with Federal, State and Local Laws
100 Compliance with Federal,
State and Local Laws
= <= /p>
The C=
linic
will make a sustained and substantial effort to be in full compliance with =
all
applicable State, Federal (OSHA, CLIA, etc.), and local.
110 Policy and Procedure Re=
view
The O= wner of the clinic is NAME OF RHC PHYSICIAN dong business as Name of RHC in Your Ci= ty, Your State and is responsible for the operation of the clinic. This clinic = is organized under the laws of Your State as a for-profit sole proprietorship.= The Medical Director, Mid level Practitioner, Office Manager, and &nb= sp; non-clinic personnel will review and approve the policy and procedures of the clinic annually.
Name of RHC is the Medic= al Director and is responsible for the overall direction of the facility. The = Office Manager is responsible for the business functions and the overall function = of the clinic operation, including scheduling and supervising billing and cler= ical personnel. The Mid-level practitioner position reports to the Medical Director for Medical/operation= al issues and to the Office Manager for business office matters. The Organization chart is presente= d as Appendix A in Section 11 of this manual.
The clinic is under the = Medical Direction of Name of RHC The responsibility of the Medical Director(s) is further delineated in the policy section headed "Physician Responsibility".
The c= linic has a Midlevel Practitioner on site at least fifty percent of its scheduled days of operation. The clinic maintains other ancillary support staff as required by patient volumes. The office Manager schedules and supervises clinical and ancillary personnel. The office hours of the clinic are= as follows:
Clinic Hours of Operation
&n= bsp; = ; Monday Tuesday Wednesday Thursday Friday Saturday Sunday
&n=
bsp; =
; 8
to 5 =
8 to 5
8 to 5 =
;
8 to 5
8 to 5
Physician Office Schedule
&n= bsp; = ; The schedule for Name of RHC, medical director for the facility, is as follows:
&n= bsp; = ; &n= bsp; = ; &n= bsp;
&n= bsp; = ; &n= bsp; Monday Tuesday Wednesday Thursday Friday Saturday Sunday
&n=
bsp; =
; &n=
bsp;
Mid-Level Office Schedule
&n= bsp; = ; The work schedule for the clinics Mid-Level practitioner, is more than 50% of t= he time the clinic is open and is as follows:
&n= bsp; = ; &n= bsp;
&n= bsp; = ; &n= bsp; Monday Tuesday Wednesday Thursday Friday Saturday Sunday
&n=
bsp; =
; =
The Physician, Midlevel Practitioner and other members as required, annually review the policies and procedures of the clinic. This review includes all patient care policies and is performed before approval = is made.
Healthcare Business Spec= ialists will perform an annual evaluation of the program, which will include both utilization review of services, policy and procedure update, medical record review of open and closed records and quality review of records. This annual evaluation will be per= formed with the annual evaluation &nbs= p; committee that will include the medical director of the clinic, Mid-Level practitione= r, office manager, a nonmember of the clinic staff, Executive Director of the corporation, and a representative from Healthcare Business Specialists. The Annual Evaluation Committee is comprised of the following people:
= &nb= sp;
= &nb= sp; Name of RHC &= nbsp; &nbs= p; &= nbsp; &nbs= p; Medical Director
&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Nurse Practitioner
&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Office Manager
&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; Nonmember
&nbs= p; &= nbsp; &nbs= p; Mark R. Lynn = &nb= sp; = &nb= sp; Healthcare Consultant
120 Anti-Discrimination Pat=
ient
Policy
The services provided by= the Name of RHC or any other operations it might in the future support, are available to all persons desiring those services regardless of race, color, national origin, religion, age, physical or mental handicap.<= /p>
125 Personnel Summary
&n=
bsp; =
; The
following table is a listing of the professionally licensed employees of
|
<= o:p> N= ame |
<= o:p> P= osition |
H=
ire D= ate |
E=
nd D= ate |
L=
icense N= umber |
R=
enewal D= ate |
|
Name of RHC |
MD |
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NP |
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LVN |
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=
130 Physician Documentation=
The documentation for Name of RHC is located behind the tab = &nb= sp; for Professional Licensure located in the Credentials File.
= &nb= sp; State License
&n= bsp; = ; &n= bsp; Diploma
&n= bsp; = ; &n= bsp; Curriculum Vitae
&n= bsp; = ; &n= bsp; Drug Enforcement Authority Prescriptive Permit
&n= bsp; = ; &n= bsp; State Prescriptive Permit
&n= bsp; = ; &n= bsp; Hospital Privileges
Certification of Liabili=
ty
Insurance according to Facility Policy is located &=
nbsp; behind
the tab for Liability insurance.
140 Midlevel Practitioner
Documentation
The documentation for the Midlevel Practitioner is located behind the tab for Professional Licensure = in the Credentials File.
&n= bsp; = ; &n= bsp;
&n= bsp; = ; &n= bsp; State License
Board of Examiners' Lett= er approving as a Midlevel Practitioner
&n= bsp; = ; &n= bsp; Diploma
&n= bsp; = ; &n= bsp; Curriculum Vitae
&n= bsp; = ; &n= bsp; Certification of Liability Insurance according to Facility Policy
150 Professional Nursing or
Licensed Personnel Documentation
=
&nb=
sp;
The documentation for any Licensure of RN’s, LPN’s, or Medical Assistants is located behi= nd the tab for Professional Licensure in the Credentials File.
&n= bsp; = ; &n= bsp;
&n= bsp; = ; &n= bsp; State License
&n= bsp; = ; &n= bsp; CPR Certificate
&n= bsp; = ; &n= bsp; Continuing Education Information &nbs= p;
&n=
bsp; 160 &=
nbsp; Ancillary
Professional Personnel Documentation (Lab/X-Ray)
=
&nb=
sp;
= The documentation for any Licensure of any laboratory professional or &= nbsp; &nbs= p; radiological professional is located behind the tab for Professional = &nb= sp; = Licensure in the Credentials File.
&n= bsp; = ; &n= bsp;
&n= bsp; = ; &n= bsp; State License
&n= bsp; = ; &n= bsp; CPR Certificate
&n=
bsp; =
; &n=
bsp; Continuing
Education Information &nbs=
p; &=
nbsp; &nbs=
p; &=
nbsp;
170 CLIA/X-Ray Certification
Documentation
=
= The documentation for the laboratory (CLIA) or X-Ray equipment is &= nbsp; &nbs= p; located behind the tab for Professional Licensure in the Credentials File.
&n= bsp; = ; &n= bsp; CLIA Certificate: =
&n= bsp; = ; &n= bsp; X-Ray: &= nbsp; NA
&n=
bsp; =
; &n=
bsp;
&n=
bsp; <=
span
style=3D'font-size:14.0pt'>
Condition II:=
&=
nbsp; Location
of Clinic
200 Map showing Location of=
the
RHC
&n= bsp; = ; The documentation for the location of the clinic is located = ; &n= bsp;
&n= bsp; = ; &n= bsp; In Appendix B.
=
&nb=
sp;
210 &=
nbsp; Letter
from the State Department of Health determining clinic is eligible for
certification.
The documentation for the approval of the rural health clinic status for Name of RHC was in the first rural health policy and procedure manual and cannot be located.
=
&nb=
sp;
220 &=
nbsp; Medically
Underserved Area and/or Health Professional Shortage Area designation
documentation.
= The documentation for the underserved status of the area can be obtained &= nbsp; &nbs= p; by calling or writing:
&n= bsp; = ; &n= bsp; = ; Mr. David Brand
&n= bsp; = ; &n= bsp; = ; Division of Shortage Designation
&n= bsp; = ; &n= bsp; = ; Bureau of Primary Health Care
&n=
bsp; =
; &n=
bsp; =
;
&n=
bsp; =
; &n=
bsp; =
;
&n= bsp; = ; &n= bsp; = ; Telephone: (301) 594-3813
230 The physical address and
phone/fax number of the clinic
= &nb= sp; = Name of RHC
&n=
bsp; =
; &n=
bsp; =
;
&n= bsp; = ; &n= bsp; = ; Your City, Your State 93610
&n= bsp; = ; &n= bsp; = ; Telephone Number: (559) 665-0275
&n=
bsp; =
; &n=
bsp; =
; Fax
Number: (559) 665-7126
Condition III=
: &=
nbsp; Physical
Plant and Environment
300 City, county or Fire
Marshall's Inspection Report
The documentation for th= e Fire Marshall's report is located behind the tab titled Preventive Maintenance a= nd is obtained every three years.
310 Maintenance Program
The Office Manager will = check periodically to insure that the staff is maintaining the building in accord= ance with the following guidelines:
&n= bsp; = ; Maintenance Items &n= bsp; = ; &n= bsp; Maintenance Schedule
&n= bsp; = ; Custodial Services (interior) = &nb= sp; = &nb= sp; Daily
&n= bsp; = ; Custodial Services (exterior) = &nb= sp; = &nb= sp; Mont= hly
&n= bsp; = ; Mechanical and air handling &nb= sp; = &nb= sp; = A= nnually
&n= bsp; = ; System adjustment &nb= sp; = &nb= sp; = &nb= sp; Annually
&n= bsp; = ; Inspect fire extinguisher &n= bsp; = ; &n= bsp; = ; Monthly
&n= bsp; = ; Inspect and test general medical &= nbsp; &nbs= p; &= nbsp; &nbs= p; Daily
&n= bsp; and laboratory equipment
&n= bsp; = ; Inspect existing sign age &n= bsp; = ; &n= bsp; = ; &n= bsp; Annual
&n= bsp; = ; Termite inspection &nb= sp; = &nb= sp; = &nb= sp; = Annual
&n= bsp; = ; Exterminator services = ; &n= bsp; = ; &n= bsp; = ; Annual
The preventive maintenan= ce plan is maintained in the clinics Log Book that has copies of the preventive maintenance plan for the clinic and includes control for laboratory services and temperature logs for refrigerators and freezers. Copies of the Maintenance Log and Control Logs are inclu= ded in the Preventive Maintenance Tab.
Any contracted maintenan= ce service contracts will be evidenced by a contract for these services behind= the preventive maintenance Tab and copies of relevant invoices will be maintain= ed for one year and then placed in the Outdated RHC Policy Manual File.
&n= bsp; = ; Specific Equipment will have a preventive maintenance program.
320 Storage and Care of Sup=
plies
and Equipment
Laboratory and other med= ical equipment are calibrated daily before the equipment is used. See Log Book.<= /p>
is contracted to provide external laboratory services and provides a daily cou= rier service to collect specimens. Test reports are provided on = hard copy through a telecommunications hookup within 24 hours. Positive values w= ill be called directly into the medical center in as short a time as possible. Information on the laboratory is as follows:
_________= ________________
_________= ________________
_________= ________________
Preventive maintenance inspection and testing pr= ogram is to insure:
A. That the equipment is operating properly. If it is a measuring instrument, its output should have satisfactory fidelity and accuracy. If it = is a therapeutic instrument it should deliver accurately and safely the therapeu= tic effect at the proper time. (V= alues of proper operation should be furnished by the supplier)
B. That equipment and all accessories, cables, and power cords are safe.
C. That the equipment is mechanically in good condition with no missing parts, loose 'switches or knobs, and no broken glass.&n= bsp; Casters should be free and lubricated (if required) so that mobile equipment will not tip or make unpleasant noises.
D. That a full set of accessories, spare recording paper, and other consumable supp= lies necessary for operation is available with the equipment.
E. = All operating manuals are reading accessible to person operating equipment.
F. = Maintenance manuals are provided for engineering.
G. That the optimum reliability and life of the equipment is obtained by carrying o= ut manufacturer's recommended maintenance procedures.
H. &= nbsp; Th= at the equipment and its accessories are clean, untarnished, and of good appearance, both for sanitary reasons and to improve confidence in the equipment and the part of the user, the patient, and observers.
&= nbsp;
ELECTRICAL INSTRUMENTAT=
ION
SAFETY INSPECTION & TEST PROCEDURES
&= nbsp; Prior to testing any patient care or non-patient care equipment for electrical safety, = ; it shall be visually inspected for any physical defects, such as damaged fords= or plugs, missing or broken knobs or switches, etc. Any defects found will be corrected immediately. It shall also be checked to see that all cables, accessories, and consumable supplies are readily available.
&=
nbsp; &nbs=
p; DEFINITION: Electro medical equipment shall be defin=
ed as
that &n=
bsp; =
; &n=
bsp;
330 Manufacturer's recall of
supplies
{ = ; On receipt of a drug recall, clinic personnel will immediately inspect all medication areas for the affected lot numbers.
&n= bsp; = ; { = ; Affected medication will be immediately removed from stock and = &nb= sp; &= nbsp; destroyed or returned as directed.
&n= bsp; = ; { = ; A drug recall file will be maintained indicating all actions taken.
{ = ; A device recall will be handled in the same manner as a drug recall.
340 Biomedical Waste Plan
This plan prescribes min= imum sanitary practices relating to the identification, segregation, handling, labeling and storage of biomedical waste.&= nbsp; Such practices are necessary to ensure that waste is properly manage= d in order to eliminate the exposure of employees, patients, and the public to disease-causing agents. This = plan also describes required training of personnel involved with biomedical wast= e, and indicates how spills or leaks of biomedical waste should be cleaned up = and disinfected.
&n= bsp; = ; I. &= nbsp; Normal Protocol
Biomedical waste shall be identified and segregated from other solid waste at the point of origin wit= hin this facility.
&n= bsp; = ; &n= bsp; Biomedical waste shall not be mixed with hazardous waste.
Biomedical waste that is= mixed with radioactive material shall be managed and disposed.
&n= bsp;
Any other solid waste, w= hich is neither hazardous nor radioactive in character, mixed with biomedical waste, shall be managed as biomedical waste.
&n= bsp; = ; &n= bsp; A. Identification
Biomedical waste is defi= ned as any solid or liquid waste that may present a threat of infection to humans. The term includes, bu= t is not limited to, non-liquid tissue and body parts from humans and other primates; laboratory and veterinary wastes which contain human disease -cau= sing agents; discarded sharps; and blood, blood products, and body fluids from humans and other primates. The following are also included:
(a)
(b)
(c)
Also included as biomedi= cal waste are sharps, which are devices that are capable of puncturing, lacerat= ing, or otherwise penetrating the skin. These devices include, but are not limited to needles, scalpels and needles attached to disposable syringes.&n= bsp; Also included are intact or broken glass and intact or broken hard plastic, when contaminated with blood or other body fluids. Suction canisters, or similar disp= osable medical items, filled with blood or body fluids that are gelled by a polymerizing agent prior to on-site transport may be handled and packaged as non-sharp biomedical waste.
&n= bsp; = ; &n= bsp; B. = Segregation
Biomedical waste, except= sharps, shall be packaged in red bags that meet the strength specifications. Also, red bags shall have a 6-inch biological hazard symbol imprinted on them, unless the bag is 19" x 14= " or smaller, when a 1-1/2" symbol shall suffice. All bags also shall be imprinted w= ith the phrase "Biohazard", "Biohazardous Waste", "Biomedical Waste", or "Infectious Waste".
Discarded sharps shall be segregated from all other waste and shall be placed directly into sharps containers that meet the specifications.&n= bsp; Sharps containers (and sharps-container holders or sleeves for wall mounting, if they are used) shall be marked with a biomedical hazard symbol that is at least 1-1/2" across and with the phrase.
A 275-pound bursting str= ength, double-walled corrugated cardboard box may be used as a sharps container for contaminated items made of glass or hard plastic. The box shall be lined with a larg= e, labeled red bag.
Biomedical waste may be = put down a drain into a sewer system if the waste is in a liquid or semi-so lid form= , if aerosol formation from the waste material is minimal, and if protective app= arel is worn by the person discharging the material into the sewer.
&n= bsp; = ; &n= bsp; C. Handling
Filled red bags are fill= ed sharps containers shall be sealed at the point of origin.
Persons handling sealed = red bags or sharps containers, or cleaning spills or leaks of biomedical waste, shall wear personal protective equipment, as required by OSHA.
Non-sharp biomedical was= te shall be red-bagged at the point of origin. Sharps shall be put into sharps containers at the point of origin.
Nothing shall ever be re= moved from a red bag or from a sharps = ; container.
All red bags shall be containerized in preparation for off-site transport. Home health agencies shall transpo= rt red bags from clients' homes to the home office in sanitizable containers that = are marked with a 6-inch symbol and the phrase. Sharps containers may be transport= ed without further containerization.
Sharps containers shall = not be overfilled and, when inserting sharps into the containers, the opening shal= l be observed to make sure nothing is sticking out.
Contaminated needles sha= ll never be cut, bent, or recapped, except when recapping is required by the procedu= re being performed. If recapping is done, it shall be done one-h= anded, or by using a recapping device.
&n= bsp; = ; &n= bsp; D. Labeling
Labels need to be placed= on transport containers (boxes or tubs), = ; and shall have printed on them this facility's name, address and a date. The date is not required on anythi= ng if biomedical waste is removed from the facility at least once every 15 days.<= /p>
Red bags, including thos= e used to line boxes or tubs, shall be labeled on the same day that they are put i= nto use. If small red bags are pl= aced into a labeled, large red bag (box liner) prior to off-site transport, then= the small bags need to be dated only, if the waste is picked up monthly. If the waste is picked up at least= once every 15 days, then no date or other labeling is required on these small red b= ags that go into a large, labeled, red box liner.
&n= bsp; = ; &n= bsp; = ;
Boxes and tubs shall be =
labeled
and dated (the date may not be required) prior to off-site transport. A
registered biomedical waste transporter may provide labels that are generat=
or-specific,
such as bar codes, for red bags, sharps containers, and outer containers.
&n= bsp; = ; &n= bsp; = ; Labeling shall be done! If labels are = not available, see your = ; &n= bsp; = ; &= nbsp; supervisor immediately.
&n= bsp; = ; &n= bsp; E. = Storage
Storage of biomedical wa= ste shall not be for a period greater than 60 days. The 60-day time period shall comme= nce when the first non-sharps item of biomedical waste is placed into a red bag= or sharps container, or when the sharps container is closed. Our Biomedical waste will be remov= ed from our facility by BFI, a registered transport company. We will keep all records provided = to us by our transporter for a minimum of three (3) years.
Biomedical waste must be= stored in designated areas that are located away from pedestrian traffic. Therefore, our biomedical waste sh= all be stored in the laboratory.
Our storage area(s) shal= l be made accessible only to authorized personnel by keeping the door(s) locked = at all times.
Our storage containers s= hall be marked with a biological hazard = ; symbol that is at least 6 inches across and also with the phrase "Biohazard", "Biohazard Waste", "Biomedical Waste", or "Infectious Waste".
&n=
bsp; =
; &n=
bsp; =
;
Our storage area(s) shal= l be free to vermin and insects, and shall be maintained in a sanitary condition= .
If we choose to store our biomedical waste in an outdoor area, the area will meet all the above crite= ria and in addition will be &= nbsp; designated by a biological hazard symbol that is at least 6 inches across, and will be secured against vandalism.
&n= bsp; = ; &n= bsp; F. = On-site Transfer
Sealed red bags and clos= ed sharps containers shall be transferred from the point of origin to the stor= age area by persons wearing gloves, and any other appropriate protective clothi= ng required by OSHA.
&n= bsp; = ; &n= bsp;
Every effort shall be ma= de to insure that sealed red bags and closed sharps containers are not broken open during on-site transfer between the point of origin and the storage area.
Red bags and sharps cont= ainers shall not be put down trash chutes, nor shall they be moved by use of autom= ated transfer methods.
There shall be neither r= ecycling efforts nor intentional removal of biomedical waste from red bags or sharps containers.
&n= bsp; = ; II. = Training
All new employees who de= al with biomedical waste shall be given initial &nb= sp; trai= ning in the concept and function of our waste-handling system before their duties commence. Employees wh= o deal with biomedical waste shall be updated after a rule change or waste-handling system change, and in addition shall attend an annual refresher trai= ning session with regard to biomedical waste.
All training phases (ini= tial, updates and annual refresher training) shall take into consideration the following aspects of biomedical waste management: identification, segregati= on, handling, labeling, storage, on-site transfer, training of employees and contingency plans for cleaning up and disinfecting spills and/or leaks of biomedical waste.
Training records signed = by employees shall be kept for all participants in all training sessions, and shall be maintained on-site for a minimum of three (3) years.
Specifically, in our fac= ility, training will be accomplished in the following manner: Prior to undertaking tasks invo= lving exposure to biomedical waste, and at least yearly thereafter, employees will read this biomedical waste plan and will be walked through our biomedical w= aste handling and disposal system, when they will be encouraged to ask any quest= ion involving our system. Trainee= s will sign a training record after each training session, which will be kept for = at least 3 years.
&n= bsp;
<= /span>III. Conti= ngency Plan for Spills
In case of a leak or spi= ll of biomedical waste, any solid material shall be picked up and put into appropriate containers by people wearing gloves and any other appropriate clothing. Sharps shall be pic= ked up using hemostats or other appropriate tools, and not hands.
&n= bsp;
&n= bsp; = ;
The contaminated surface= (s) then shall be cleaned with a solution of industrial strength detergent to remove visible soil, before being disinfected by one of the following methods: a) Steam for a minimum of 30 secon= ds; b) Rinsing for at least 3 minutes with a hypo chlorite (bleach) solution containing at least 100 parts per million available free chlorine; or iodine solution containing at least 25 parts per million available iodine; or c) U= se of chemical germicides that are tub= erculocidal and are registered by the Environmental Protection Agency as hospital disinfectants.
Specifically, in our fac= ility, we will use the following method to disinfect a leak or spill of biomedical waste:
&n= bsp; = ; &n= bsp; Clean with CitruGuard wearing special gloves.&nb= sp; All waste &n= bsp; = ; &n= bsp; = ; &= nbsp; materials will be placed in the red -bag hazardous material bag. = &nb= sp; = &nb= sp; = <= span style=3D'mso-tab-count:4'> &= nbsp; &nbs= p; &= nbsp; &nbs= p;
Liquid waste created by = any such disinfect ion operation shall be disposed of down a drain into a sewer syst= em.
Reusable containers for = holding red bags (waste baskets or cans, kick-buckets, etc.) shall be sanitized each time the red bag is changed out, by either method a), b) or c) above. Home health agencies shall use one= of these methods to sanitize their containers for transporting red bags, after= each use.