Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59A - Health Facility and Agency Licensing › Chapter 59A-33 - HEALTH CARE CLINIC LICENSURE › Section 59A-33.012 - Inspection Requirements and Process

Current through Reg. 50, No. 138; July 16, 2024
(1) An
				applicant for health care clinic licensure must demonstrate compliance with the
				requirements in chapter 400, part X, Florida Statutes (F.S.), chapter 408, part
				II, F.S., chapters 59A-35 and 59A-33, Florida Administrative Code (F.A.C.)
				during an inspection as required in sections
				408.806 and
				408.811, F.S. Inspections will
				be conducted for initial, renewal, change of ownership and complaint
				investigations.
(2) The medical or
				clinic director must attend the survey entrance conference and be available
				when the survey is conducted for the surveyor to determine compliance with
				minimum standards and requirements for licensure. Other key personnel required
				include the financial director, a representative of management or ownership and
				persons responsible for patient records and billing.
(3) To facilitate a licensure survey, the
				health care clinic shall have the following materials readily available for
				review at the time of the survey:
(a) The
				professional license or facsimile of the license for the medical or clinic
				director;
(b) Copy of medical or
				clinic director's written agreement with the health care clinic assuming the
				responsibilities for the statutory activities in sections
				400.9935(1)(a)-(i),
				F.S. If the medical or clinic director signs the Medical/Clinic Director
				Attestation, AHCA Form 3110-1028, incorporated by reference in rule
				59A-33.002, F.A.C.,
				acknowledging these responsibilities as specified in section
				400.9935, F.S., this requirement
				is met;
(c) Written policies,
				protocols, guidelines and procedures used or to be used by the facility staff
				in day-to-day operations. This includes protocols for physician assistants and
				advanced practice registered nurse plus a copy of the supervision form
				submitted to the Department of Health by the physician supervisor;
(d) Any policies, procedures, guidelines,
				checklists and/or means that are used in the systematic creation and
				maintenance of the health care clinic's medical record system;
(e) Any policies, procedures, guidelines,
				checklists that demonstrate compliance with the medical records retention,
				disposition, reproduction, and disclosure requirements of the medical or clinic
				director's practice act;
(f) Any
				policies, procedures, guidelines, checklists that demonstrate compliance with
				the office surgery requirements of the practice acts for services performed at
				the facility;
(g) Any policies,
				procedures, guidelines, checklists that demonstrate compliance with adverse
				incident reporting requirements and injury disclosure;
(h) Personnel files;
(i) Logs, charts or notes demonstrating
				day-to-day oversight of health care clinic activities by the medical or clinic
				director;
(j) Copies of
				professional licenses issued by the respective boards and the Department of
				Health under the several practice acts;
(k) Any patient referral contracts or
				agreements of the health care clinic that are in writing and a disclosure to
				the surveyor of any such agreements that are not in writing including the names
				of the parties to the agreement, the date and the essential terms of
				agreement;
(l) For health care
				clinics that are in operation at the time of the survey, the surveyor will
				select a sample of at least five (5) patient medical records from the previous
				6 months of operation with at least one Medicaid file, if certified as a
				Medicaid provider, plus the five (5) billing records that correspond with the
				five patient records;
(m)
				Description of means by which the health care clinic conducts a systematic
				review of billings that ensures billings are not fraudulent or unlawful. A
				sample must be reviewed by the medical director or clinic director at least
				once every 30 days and a record maintained by the health care clinic for at
				least three years identifying the records reviewed and when and what action was
				taken to correct fraudulent or unlawful billings. A log of systematic reviews
				shall be kept and maintained in a discrete file at the health care clinic for
				review on request of the Agency during the retention period;
(n) List of services provided or a general
				descriptor of scope, level and complexity of care for services
				provided;
(o) Current diagnostic
				and treatment equipment records showing equipment certification when such
				equipment must have regulatory certification. This requirement is met with
				presentation of a current maintenance agreement;
(p) An organizational flow chart with lines
				of authority and names of key individuals and positions;
(q) An all-inclusive and up to date listing
				of original signatures and initials of all persons entering information on
				billing and patient records, the printed name and medical designation, if any,
				such as PA, RN, MD, etc. The log shall be kept and concurrently maintained at
				the health care clinic. Information required by this rule shall be stored and
				maintained by the health care clinic for a period of 5 years.
(r) Log of all natural persons required and
				who have been screened under Level 2 criteria of Chapter 435 and Section
				400.991, F.S.; and,
(s) Documentation for the past two years or
				from the date of licensure, whichever is earlier, demonstrating in writing
				compliance, when, and what action was taken by the medical or clinic director
				to perform the functions, duties and clinic responsibilities under Sections
				400.9935(1)(a)-(i),
				F.S. Such documentation shall be made available to authorized agency personnel
				upon request.