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Practitioner Office Site and Medical Record-Keeping Standards

Policy Name: Practitioner Office Site and Medical Record-Keeping Standards Policy Number: 4409 
Policy Manual Section: Health Care Services Related Policies:4405, 5000
Issuing Department: Quality Management
Original Policy Date: 7/93
Revision Date(s): 1/01, 1/03, 7/27/2006, 02/2008, 05/2009, 1/27/2012, 03/27/2014
Review Date(s):
(No Revisions)
Replaces Policy Number: F088A.07, 4410

  1. Policy Purpose/Statement of Intent/Background
    • “HealthPlus” shall refer to HealthPlus of Michigan, Inc. and its affiliated entities, HealthPlus Partners, Inc., HealthPlus Options, Inc., and HealthPlus Insurance Company, unless otherwise stated.
    • The policy shall pertain to the Commercial, Medicaid, MIChild, County Health Plan, and Medicare product lines and their respective products e.g., HMO, POS, PPO, TPA, and Medicare Part D.
    • To assure that the organization complies with all applicable state and federal laws and regulations, including, but not limited to, those pertaining to the Medicaid, Medicare, and Medicare Part D programs.
    • To ensure the quality, safety, and accessibility of practitioner office sites through compliance with office site standards.1
    • To ensure the adequacy of medical/treatment record-keeping practices of HealthPlus practitioners.
  2. Definitions
    National Committee for Quality Assurance - accrediting agency for health plans.
    A professional who provides health care services. Practitioners are usually licensed as required by law.
  3. Policy Statement
    1. HealthPlus shall follow all applicable rules, regulations, including the HealthPlus Bylaws pertaining to this policy.
    2. HealthPlus staff shall establish procedures for the administration of this policy.
    3. Each HealthPlus practitioner will maintain their office (facility) in a safe and sanitary condition, free from hazards to patients, personnel, and visitors, and will assure that their office equipment, fixtures, and operations comply with local applicable fire, safety, and sanitation codes.

      HealthPlus maintains standards for practitioner offices and for medical record-keeping practices which are shared with practitioners during initial credentialing/contracting and on an ongoing basis through inclusion of the standards in the HealthPlus Provider Manual. In the event that HealthPlus has reason to believe that a practitioner’s office is not in compliance with the standards due to the receipt of a complaint from a member or an observation of HealthPlus staff during routine visits, an office visit will be conducted to determine compliance with the standards listed below. Each practitioner office site (facility) is expected to meet the following standards:

      • Practitioner Office (Facility) Standards
        • Physical Conditions/Physical Accessibility
          1. The facility is clearly identifiable from the road.
          2. Adequate parking is provided, including handicapped spaces.
          3. Handicapped access to facility, exam rooms, and restrooms is provided.
          4. Exits, corridors, and hallways are free of obstruction.
          5. Adequate seating area is available for each patient.
          6. Safe and sanitary environment is maintained in the facility.*
        • Exam Rooms
          1. Adequate and well-lit examination room space is provided.
          2. Soap dispensers and paper towels are provided for hand-washing and drying.
          3. Exam table covering is changed and/or table disinfected with an appropriate agent before each patient use.
          4. Only non-patient care items are stored under sinks.
          5. Medications, needles, and syringes are stored where they are not accessible to patients.
          6. Waste cans are covered and those containing medical waste have opaque/red plastic liners.
          7. A container for sharps is located in each room where injections are given.
        • Medication
          1. Medications are labeled and stored in central medication area or in the refrigerator, if needed.
          2. Medications are checked regularly for expiration; documentation present.
          3. Controlled substances (Class II-V) are kept under double lock with access limited to appropriate staff; sign-out log maintained.*
          4. A practitioner who dispenses medications (not giving out samples, but filling prescriptions from large bottles) maintains a Drug Control License and follows pharmacy regulations.*
          5. Prescription pads are secured and have restricted access.
          6. Medications returned by patients are discarded in an appropriate manner.*
        • Storage
          1. A thermometer is present in refrigerator and freezer with log maintained showing daily monitoring and temperature between 36° F to 46° F (refrigerator) or <0° F (freezer).
          2. Refrigerator and freezer are clean and food is not stored with medications/specimens.
          3. Combustible/flammable materials are stored away from heat sources.
          4. Hazardous/toxic materials are stored away from heat sources.
          5. Cylindrical gas tanks are stored in a secure manner.
          6. Syringes and needles are stored in a non-public area and are disposed of in hard-sided containers marked “Biohazard”.
        • Lab/X-ray
          1. X-ray license is posted and current.
          2. Pregnancy warning is posted (Radiation sign on door).
          3. Protective equipment (lead apron, etc.) is available.
          4. Current CLIA Certificate is present.
        • Infection Control
          1. If an autoclave is used, all sterilized items are properly wrapped and dated with the “run” date.  Autoclave items are considered sterile as long as packaging integrity is maintained, e.g., no tear in package or water damage to package.
          2. All sterilized items are stored in a clean area.
          3. Each autoclave is quality checked appropriate to the frequency of operation: weekly with a live spore test on equipment operated on a daily or weekly basis.  If patient items are processed less frequently than weekly (e.g., every 10 days, bi-weekly or monthly), a live spore test is performed with each run.  A heat indicator test strip is included in every load.  All results are logged, dated and signed.
          4. Cold sterilization is performed using the correct solution containing an FDA approved high-level disinfectant/sterilant. Disinfectant boats are labeled with the name of the solution and date solution is to be changed/expires.
          5. Daily indicator tests are performed on cold sterilization soaking solutions to assess solution concentrations to ensure solution is adequate to achieve disinfection. All results are logged, dated and signed.
          6. Evidence of annual OSHA training of employees is maintained.
          7. Exposure control plan is reviewed and updated annually.
          8. Medical Waste Plan is on file.
          9. Medical waste is discarded in appropriately marked containers/red bags.
          10. Procedures are in place to report communicable diseases to appropriate authorities.
        • Emergency Procedures
          1. At least one staff member certified in CPR is present during all patient care hours.
          2. Disaster plan is maintained.
          3. All exits are clearly marked.
          4. Fire extinguisher is present, service tag current
      • *Required standard

      • Medical Record-Keeping Standards
        1. Medical records reflect an organized system for consistent recording and documentation of patient information.
        2. Medical records are stored in a manner that allows for easy retrieval for patient care.
        3. Medical records are maintained in a confidential and secure manner that allows access by authorized personnel only.
        4. Staff confidentiality statement is maintained on site.
        5. Medical records are not released without proper authorization.
        6. A separate record is maintained for each member.  If a family record is used, information for individual family members is separated and clearly identified on each page.
    4. Appointment Availability Standards

      The office maintains appointment availability to meet the HealthPlus accessibility standards (Policy 5000 and Procedure 5000pr) appropriate for the type of office and type and severity of the patients’ symptoms.

    5. Monitoring and Review

      On an ongoing basis, compliance with the standards is monitored through reports of observations of HealthPlus staff (e.g., Provider Network Management staff, HEDIS® review staff, etc.) during routine site visits and through member complaints reported to Quality Management through the Quality Concerns process (Operational Policy/Procedure OP4405). When appropriate, an office site visit is conducted in response to a reported complaint or concern within 60 days of receipt of the concern or within 60 days of determining the complaint threshold has been met. When a complaint about physical accessibility or medical/treatment record keeping practices is received, the office is reviewed for compliance with the standards. When a complaint about the physical appearance or the adequacy of waiting area or exam room space is received, the office will be reviewed for compliance with the standards if the complaint threshold has been met (3 or more cases in a rolling quarter or 6 in a year). An expedited office site visit (as soon as possible) may also be conducted if it is believed the complaint or concern represents substandard treatment/practices which could present serious danger to a member’s health or unnecessarily place a member in a high risk situation. The review is conducted using the standards listed above.

    6. Scoring/Goals
      1. The review is conducted to assess compliance with all applicable standards above, using a compliance tool.  To meet the HealthPlus threshold for compliance, all required standards (indicated with an asterisk above) must be met, plus an overall compliance of 90% of all applicable standards. 
      2. Findings and results of the review are shared with the practitioner/office staff at the time of the review.
        1. If a practitioner scores less than 90% on the review, a follow-up review is performed every 6 months until the threshold is achieved. HealthPlus staff will provide clear direction to practitioner office regarding necessary actions that must be taken to achieve compliance with deficient standard. Instances of continued non-compliance are documented and reported to a Plan Medical Director and the Quality Improvement Committee as needed.
  4. Implementation

    HealthPlus staff is responsible for establishing, publishing, and maintaining procedures and work rules to implement this policy.

1 NCQA HP Standards and Guidelines, Credentialing and Recredentialing Standards

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