REQUISITOS PARA REALIZAR DIVERSOS TRAMITES EN EL RPM
IX. DENUNCIA POR INTERNAMIENTO
The practitioner and site information below must be documented at the top of each page of this form. All questions must be answered. Physician/Practitioner Name(s) ___________________________________________________ Last First ___________________________________________________ Last First ___________________________________________________ Last First ___________________________________________________ Last First Office Manager _____________________________________________ Last First Office Address _____________________________ _________________________________________ _________________________________________ Specialty_____________________________________________________ _____________________________________________________________ Phone Number______________________________________ Date _________________________________ Reviewer Name ____________________________________________ Last First Point Val u e YE S N O N/A Point Sco re A. Physical Accessibility 10 0.00%
1 Is there accessibility for people with disabilities (e.g., first floor access, ramps or elevator access, etc.)? If not, does the staff have an alternative plan of action? Is there access throughout the office, including in the bathroom(s)?
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2 Is accessible parking clearly marked (e.g., a sign or painted symbol on the pavement)? Note: This measure only applies to off-street parking and is N/A if parking is street-side only.
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3 Are the doorways and stairways that provide access free from obstructions at all times? Do they allow easy access by a wheelchair or stretcher?
2
4 For FL only: If applicable, are the stairwells protected by fire doors? Note: This
applies to facilities only.
2
5 Are the exits clearly marked and is there emergency lighting for instances of power failure?
2
6 Are the buildings and office suites clearly identifiable (i.e., marked with an office sign)?
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B. Physical Appearance 10
1 Is the office clean and well-kept (e.g., a neat appearance, no trash on the floor, furniture in good condition, no significant spills on floors or furnishings, etc.)?
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2 Is the treatment area clean and well-kept (e.g., no significant spills on the floors, counters or furnishings, no trash on floor, etc.)?
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4 Is there easy access to a clean, supplied bathroom (e.g., with soap, toilet paper, hand towels and hand washing instructions)?
1 Point Val u e YE S N O N/A Point Sco re
5 For FL only: If applicable, is the facility inspected annually by the local or state
fire control agency?
1
6 Is the waiting room well-lit? 1
7 Are fire extinguishers clearly present, fully charged and recently inspected (even if the office has sprinkler system)?
1
C. Adequacy of Waiting Area and Examining Room Space 10 0.00%
1 Is there adequate seating in the waiting area (i.e., 1 provider = 6 seats, 2 providers = 8 seats, 3 providers = 11 seats, 4 providers = 14 seats, 5 providers = 17 seats)?
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2 Does the staff provide extra seating when the waiting room is full? 1 3 Is there a minimum of two exam rooms per scheduled provider (or two
consultation rooms for Behavioral Health [BH] providers)?
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4 Is there privacy in the exam and consultation rooms (e.g., doors or curtain closures, rooms that cannot be visualized from waiting room, etc.)?
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5 Are the exam and consultation rooms reasonably sound proof (i.e., conversations cannot be heard from waiting room or other exam rooms)?
2
6 For FL only: Are all areas well-lit and well-ventilated? 1
7 Are otoscopes, ophthalmoscopes, blood pressure cuffs and scales readily accessible? N/A for BH providers.
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8 For Obstetrics and Gynecology (OB/GYN) only or any physician/practitioner
providing OB care: Does the office have the following readily accessible? If
not OB/GYN, check N/A.
8a Are fetalscopes (e.g., DeLee and/or Dopler) and measuring tapes for fundal height measurement readily accessible?
1 8b Are supplies for dipstick urine analysis (e.g., glucose or protein) readily
accessible?
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D. Adequacy of Medical Records 20 0.00%
1 Are there individual patient records? 2
2 Are records stored in a manner which ensures confidentiality (i.e., are they kept in an area not accessible to patients)?
2
3 Are all items secured in the chart? 2
4 Are medical records readily available (i.e., within 15 minutes of request)? 2
5 Medical recordkeeping practices:
5a Is there a place to document the patient’s allergies? 2 5b Is there a place to document the patient’s current medication list? 2 5c Is there a place to document the patient’s current chronic problems list? 2 5d Is there an immunization record on pediatric charts? N/A for BH providers. 2 5e Is there a growth chart on pediatric charts? N/A for BH providers. 2 5f Is there a place to document the presence or absence and discussion of a
patient self-determination or advance directive? If N/A, check N/A.
2 Point Val u e YE S N O N/A Point Sco re
E. Appointment Availability: Is the physician/practitioner available: 13 0.00%
1 Routinely within a wait time of 45 minutes or less? For LA only: Routinely within a wait time of 45 minutes or less (including waiting room and examination room time)? If the wait will be 90 minutes or more, is the patient given the option of scheduling another appointment? ForGA only: Routinely within 60 minutes or less from scheduled appointment time. Is a status notification given within 30 minutes of the scheduled appointment time and the option to continue to wait additional 30 minutes or reschedule? For unscheduled appointments: routinely available within 90 minutes or less? Is a status notification given at 45 minutes of unscheduled appointment and the option to continue to wait 45 additional minutes or reschedule? Ask the office manager.
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2 At least four days or 20 hours per week? ForNY only: At least 16 hours per week at this office location, or has a waiver been granted?
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3 For GA only; all other plans N/A: ArePrimary Care Provider (PCP) adult sick
visits available within 24 hours and/or PCP pediatric sick visits available within 24 hours? For LA only: Are sick visits available within 72 hours?
1
4 For GA, LA and WA only; all other plans N/A: Are specialist visits available
within 30 calendar days of request?
1
5 For GA only; all other plans N/A: Aremental health providers available within
14 calendar days of request?
1
6 For GA only; all other plans N/A: Areinitial visits for pregnant women
available within 14 calendar days of request?
1 7 Is there 24-hour call coverage for emergencies (by the physician or a covering
provider)? BH providers only: Is a crisis hotline available? Yes/No
1 8 Is urgent care available within 24 hours? For WA only: Is urgent care available
within 48 hours?
1 9 Is routine or problem care available within two weeks (FL, NM, NY, OH, TN,
TX), 10 days (MD, VA, WA), 28 days (NJ) orsix weeks (LA)? For GA only: Is routine care available within 14 calendar days? Is problem care available within 24 hours?
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10 Is the first visit after pregnancy determination (excludes home pregnancy test) available within two weeks? For LA only: Is the first visit after pregnancy determination available within the following time frames from the postmark date the coordinated care network sends the member’s welcome packet: within 14 days for the first trimester; within seven days for the second trimester; within three days for the third trimester; within three days of identification of high risk by the maternity care provider or immediately for an emergency? Are lab and X-ray services (usual and customary) available within three weeks for regular appointments and 48 hours for urgent care or as clinically indicated? Please circle appropriate health plan: [FL, GA, LA, MD, NJ, NM, NV, NY, OH, TN, TX, VA, WA]
Point Val u e YE S N O N/A Point Sco re
11 Are the phone lines adequate to handle the call volume of the total patient population?
1 12 Are physicals and wellness exams for adults available within 30 days (FL, MD,
NM, NY, OH, TN, VA, WA), 14 days (GA) or 10 weeks (TX)? Is a baseline
physical for new members available within 180 days of enrollment (NJ)? Please circle appropriate health plan (N/A for BH providers): [FL, GA, LA, MD,
NJ, NM, NV, NY, OH, TN, TX, VA, WA]
13 Are physicals or wellness exams for children available within 30 days (FL, MD,
NM, NY, OH, TN, VA), 14 calendar days (GA) or two months (NJ and TX) from
the date of the contract or request? Please circle appropriate health plan (N/A for BH providers) : [FL, GA, LA, MD, NJ, NM, NV, NY, OH, TN, TX, VA, WA]
1
14 NJ only: Are baseline physicals for new child members or adult members of
the Department of Developmental Disabilities available within 90 days of enrollment or according to Early and Periodic Screening, Diagnosis, and Treatmentguidelines? (N/A for BH providers and for all plans except NJ).
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F. Documentation Evaluation: Does the office have the following: 17 0.00%
1 A no-show follow-up procedure or policy? If not written, can the staff verbally explain the process?
2 2 A chaperone policy? If the provider does not have written policy, the office
must provide a statement on letterhead indicating a chaperone will be in the exam room. This element is a must-have to pass the site visit and
participate.
2
3 Is the Patient Bill of Rights posted? 1
4 Is the medical license or occupational license displayed? 1
5 FL and TX only: Is there a posted notice of the member complaint process? 1
6 FL only: Is the health management organization hotline number posted? 1
7 FL only: If the provider does not carry malpractice insurance, is the required
patient notification statement posted in a prominent place in the reception area?
1
8 Is there a written policy for hand-washing, gloved procedures, disposal of sharps items, etc.? May not be applicable for BH providers in private practice setting.
2
9 Is there a written OccupationalSafety and Health Administration (OSHA) Exposure Control Plan that includes universal precautions and blood-borne pathogen exposure procedures for staff? May not be applicable for BH providers.
2
10 FL and TX only: Is there a posted copy of the Clinical Laboratory Improvement
Amendments (CLIA) certificate or Certificate of Waiver, if applicable? (Attach
a copy to site evaluation tool.) For TX only: PCPs providing Texas Health Steps
services must have a CLIA certificate, CLIA waiver or laboratory services on site within the same building.
1 Point Val u e YE S N O N/A Point Sco re
11 FL and TX only: Is there a posted copy of the current radiology services
certification or licensure, if applicable? Attach a copy to site evaluation tool. 1 12 If the provider employs nurse practitioners, physician assistants or other
mid-level providers who will assess the health care needs of members, do they have written policies that describe the duties and supervision of such providers?
2
G. Health Insurance Portability and Accountability Act requirements and
regulations 8 0.00%
1 Are there written processes and procedures addressing the permitted uses and required disclosures of patient Protected Health Information (PHI)/ Individually Identifiable Health Information (IIHI)?
2 Does the provider have authorization forms available to designate personal representative(s) to which PHI/IIHI may be released and/or disclosed?
2 3 Are there physical safeguards in place to protect the privacy of patient
PHI/IIHI?
2 4 Is there a designated compliance and privacy person?
Name:_________________________________________
2
H. Office evaluation 12 0.00%
1 Is there an approved process for biohazardous disposal (i.e., solid, liquid or gas) to ensure the protection of members, staff and the environment?
2 2 Are pharmaceutical supplies and medications stored in a locked area that is
not readily accessible to patients?
2 3 Are there plans or procedures for narcotic inventory, control and disposal? 1 4 Are vaccines and other biologicals refrigerated, as appropriate? 1
5 FL only (facilities only): Is an alternate power source available in operative,
treatment and recovery areas to ensure the life and safety of members?
1
6 FL only (facilities only): Are food and snacks handled and maintained within a
clean environment to support patients with special nutritional needs?
1
7 FL only: Is there documentation of periodic instruction of personnel in the
proper use of safety, emergency and fire extinguishing equipment?
1 8 Is emergency equipment available (e.g., an oral airway, ambu bag, etc.)? If
not, note how the staff accommodates emergency situations. Is the physician or physician extender trained in CPR?
1
9 Observe two to three office staff interactions: Are they professional and helpful?
2 To complete the form, answer every question then total the number of points and record here.
100 Total 0
A copy of this complete profile was received by:
_________________________________________________ Office Manager / Physician / Practitioner (please circle one)
Office Manager / Physician / Practitioner Signature REMINDERS:
Do not deduct points for questions answered N/A.
Include those points for N/A answers in the total score.
If the provider has a CLIA certificate/certificate of waiver and/or radiology licensure, you must attach a copy of the documents to this site visit form.