51. Has the physician practice implemented procedures to comply with the health information privacy rule under HIPAA? X 51.1. Do these procedures include the following: a. A notice of privacy practices and authorization form describing the uses and disclosures of protected health information (PHI) that the physician practice may make, as well as the patient's rights and providers' responsibilities with respect to PHI, which should be provided to patients with a goodfaith effort to obtain patients' signatures acknowledging receipt of the notice before providing care X b. A process for keeping records of documented disclosures of PHI and for accounting of and responding to requests for disclosures made X 51.2. Has the physician practice addressed the security of individually identified protected health information that is stored or transmitted electronically, as required under the HIPAA security rule? X 51.3. Is there a security plan that includes administrative, physical, and technical safeguards for PHI that is collected, maintained, used, or transmitted? X 51.4. Does the security plan include remote access to office information systems and the use of portable computers such as personal digital assistants? X 51.5. Does each provider and staff member who is authorized to access office information systems have a unique password? X 51.6. Are electronic data systems backed up periodically (e.g., nightly) to avoid loss of information? X Communication and Teamwork 52. Is there a process for tracking pending lab and other test results, consultation reports, and other pertinent documents to ensure their receipt by the practice? X 52.1. Is there a mechanism to ensure that lab and other test results, consultation reports, and other pertinent documents are acknowledged and documented by the physician before filing? X 52.2. Is there a mechanism for reporting urgent information to the physician immediately? X
80.1. Are protocols established to help first-contact employees (e.g. receptionists) identify individuals who might have active TB? X Communicable Disease Procedure CLIA 81. Is there a mechanism to ensure that the office's clinical lab performs only examinations or procedures that it is certified to perform? X Health Center is CLIA waived 81.1. Are state regulations for clinical laboratories examined to ensure compliance (some states have regulations more stringent than CLIA's)? X 81.2. Do policies and procedures exist to ensure that laboratories in the physician office comply with CLIA and/or applicable state regulations? X 82. Do laboratory policies and procedures address the integrity and handling of specimens to include patient identification, as well as specimen collection, preparation, labeling, and tracking? X Fire and Life Safety 83. Is the physician practice site in compliance with building and fire codes? X 84. Are fire drills conducted according to the practice's building occupancy classification in accordance with the National Fire Protection Association's (NFPA) Life Safety Code? X 85. Is there a fire and emergency evacuation plan posted at the physician practice site? X 86. Are fire extinguisher and emergency telephone numbers readily available at the site? X 86.1. Are fire extinguishers in good working order? X 87. Is the office staff trained in emergency procedures in case of fire or other disaster? X 88. Is smoking prohibited? X Safety and Environment 89. Are floor coverings intact, clean, and free of obstructions and tripping hazards to pedestrians? X 90. Are electrical cords placed where they do not create a tripping hazard? X 91. Are stepups and stepdowns clearly marked? X 92. Is ventilation and lighting adequate? X
118.3. Are the results of the assessment used to improve office services? X 118.4. Is there documentation and tracking of complaints to identify trends and make improvements? X Event Report 119. Is there a policy in place that includes criteria for termination of care/discharge from the practice? X 119.1. Is the patient notified in writing by registered or certified mail?* X 119.2. Does the termination letter inform the patient about how to obtain the services of another physician and clearly state the effective termination date? X 119.3. Are records made available to the new physician upon receipt of the patient's authorization? X 120. Does the practice have a formal, nonpunitive system for reporting events, near misses, hazards, and patient safety issues? X Event Report 120.1. Is there an approved event reporting form (paper or electronic) available to providers and staff of the practice to report events, near misses, hazards, and patient safety issues? X 120.2 Are reported events, patient safety issues, and near misses investigated through interviews, medical record reviews, inspections, and observations? X 120.3. Are reports and investigations analyzed to identify areas for quality and safety improvement? X 120.4. Is there a committee or other forum regularly held to communicate quality and safety issues and to discuss improvement action plans and results of actions taken? X Staff Process Improvement Committee 120.5. Is feedback provided to the practice managers, providers, and staff? 120.6. Does the committee review reports of events (e.g., events per 1,000 office visits) compared to previous reporting periods? X 121. Does the practice endorse open communication with patients, and has it adopted a practice of disclosing to patients when an unanticipated adverse event or error has occurred? X