Anywhere Rural Health Clinic, Anywhere, State
__________Rural Health Clinic
Annual Evaluation Report
Fiscal Year 200_
Table of Contents
Introduction
2
Service Area Defined
3
Annual Evaluation Committee
4
Annual Evaluation Process
5
Conclusion
9
Appendix A -
Annual Evaluation Review of Medical Charts
10
Appendix B1-
Annual Evaluation of the Job Performance of the
Practice Coordinator
18
Annual Evaluation of the Job Performance of the
Nurse Practitioner
19
Appendix B2-
Appendix C -
Annual Evaluation of Office Policy & Procedure
Appendix D -
Annual Evaluation Committee Meeting
20
21
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1
Introduction
This annual evaluation report is prepared to evaluate the services and the effectiveness of the
rural health clinic program offered by _________Rural Health Clinic, ________. This annual
evaluation report and process is required to be in compliance with Federal Medicare regulations
for Rural Health Clinics. In particularly the CFR cites the following regulations which this annual
evaluation process fulfills:
*
The clinic carries out, or arranges for, an annual evaluation of its total program.
*
The evaluation includes review of:
*
*
-
the utilization of clinic services, including at least the number of patients
served and the volume of services.
-
a representative sample of both active and closed clinical records; and
-
the clinic’s health care policies.
The purpose of the evaluation is to determine whether:
-
the utilization of services was appropriate;
-
the established policies were followed; and
-
any changes are needed.
The clinic staff considers the findings of the evaluation and takes corrective action
if necessary.
Additionally, the interpretive guidelines stipulate that the group of professional personnel, which
can be the governing body acting as the group, is responsible for an annual review of patient care
policies.
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2
Service Area Defined
As an integral portion of the annual evaluation of ______ Rural Health Clinic, Anywhere, State.
the following information is presented to assist the evaluation team to determine the effectiveness
of the overall program. The service area which the practice primarily serves is defined as
Anywhere, State. The following illustrates the service area for _______ Rural Health Clinic.
POPULATION STATISTICS
Demographically, the area served has the following populations:
City or Town
_______, _______
Population
6,000*
_______ County
40,433**
Source:
*
______ Chamber of Commerce
**
Estimate July 1, 1996, Table 2.04, 1997 Statistical Abstract of __State___, 10th Edition
FY 99
FY 98
(7/1/98 – 6/30/99)
(7/1/97 – 6/30/98)
City / Town
Zip Code
# Visits % of Total # Visits
% of Total
Marksville
71351
6509
46%
6464
47%
Mansura
71350
1542
11%
1250
9%
Hessmer
71341
1175
8%
1297
9%
Centerpoint
71323
1033
7%
1046
8%
Plaucheville
71362
757
5%
856
6%
Moreauville
71355
740
5%
738
5%
Simmesport
71369
469
3%
465
3%
Cottonport
71327
452
3%
440
3%
Effie
71331
295
2%
259
2%
Alexandria
71301
152
1%
179
1%
Deville
71328
151
1%
109
1%
Dupont
71329
88
1%
39
0%
Pineville
71360
83
1%
99
1%
Bunkie
71322
81
1%
106
1%
Evans
71339
60
0.42%
60
0%
Vick
71372
56
0.40%
52
0%
Bordelonville
71320
52
0.37%
66
0%
Echo
71330
30
0.21%
35
0%
Calcasieu
71333
26
0.18%
28
0%
Miscellaneous Zip Codes
397
3%
247
2%
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3
Annual Evaluation Committee
The interpretive guidelines for rural health clinics further clarify what is required in an annual
evaluation [Section VIII- PROGRAM EVALUATION (42 CFR 481.11)]. An evaluation of a clinic’s
total operation including the overall organization, administration, and policies and procedures
covering personnel, fiscal and patient care areas is to be done at least annually. This evaluation
may be done by the clinic, the group of professional personnel required under section 481.9(b)
(2), or through arrangement with other appropriate professionals.
The interpretive guidelines stipulate that the group of professional personnel, which can be the
governing body acting as the group, is responsible for an annual review of patient care policies.
In consideration of the above regulation an annual evaluation committee was formed to evaluate
the total rural health clinic program. This report reflects the minutes of the annual evaluation
committee which met on October 8, 200_ at 12:00 noon at the site of ______ Rural Health
Clinic. The following are members of the annual evaluation committee for the clinic:
Name:
Title:
____________, M.D.
Medical Director
___________, FNP
Nurse Practitioner
___________
Practice Coordinator
______________
Patient Advocate
_______________
Regional Director
_________________
Regional Vice President
Signature:
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4
Annual Evaluation Procedures
Services Provided:
The primary services of the rural health clinic are Physician and Nurse Practitioner services
provided by Drs. _______ and ________ and _______, FNP under the medical direction provided
by _________, M.D. Typical services include the following:
Office visits of a diagnostic nature
Utilization of Medical Services
Patients Serviced in Fiscal Year 1999 (7/1/98 - 6/30/99):
For the period the following number of visits were recorded:
Description
Visits
Physician
9,369
Nurse Practitioner
4,435
Totals
Provider
13,804
Rural Health
Program
Rural Health
Commercial/PVT
Non Rural
Health
Total
__________NP
4,359
76
4,435
__________M.D.
1,579
70
1,649
________M.D.
5,250
114
5,364
___________ M.D. (NH)
2,356
Total
Percentage
2,356
13,544
260
13,804
98%
2%
100%
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5
______ RURAL HEALTH CLINIC
FY 2_ MOST FREQUENT DIAGNOSIS
FY 2_
ICD-9
CODE
401.1
462
473.9
250.00
490
465.9
V70.5
463
599.0
724.5
382.0
487.1
782.1
558.9
V70.0
519.8
714.0
244.9
719.41
784.0
428.0
729.5
496
787.0
493.90
414.9
536.8
786.5
787.91
786.2
461.9
715.96
723.1
780.4
DESCRIPTION
Benign Essential Hypertension
Acute Pharyngitis
Sinusitis, Chronic NOS
Diabetes Mellitus, without mention of complication, Type
II
Bronchitis, not specified as acute or chronic
Acute URI, unspecified site
Subpopulation Health Examination
Acute Tonsillitis
UTI, site no specified
Backache, unspecified
Otitis Media, acute suppurlative NOS
Influenza with other respiratory manifestations
Rash & other non specific skin eruption
Gastroenteritis, Non infect NEC
Routine Medical Examination
Other diseases of respiratory system, not elsewhere
classified
Arthritis, Rheumatoid
Hypothyroidism NOS
Pain in Joint – shoulder region
Headache
Congestive Heart Failure
Pain in Limb
Chronic Airway Obstruction, not elsewhere classified
Nausea Alone
Asthma NOS w/o status asthmatic
Ischemic Heart Disease
Disorder, Stomach Function NEC
Pain chest NOS
Diarrhea NOS
Cough
Acute Sinusitis, unspecified
Osteoarthrosis NOS, Lower Leg
Cervicalgia
Dizziness & Giddiness
FY 2_
FREQ.
RANK
FREQ.
RANK
1939
872
644
620
1
2
3
4
1179
878
437
285
1
2
5
10
601
582
558
459
401
358
316
294
265
243
233
225
5
6
7
8
9
10
11
12
13
14
15
16
826
592
419
383
261
342
430
3
4
7
8
11
9
6
205
190
185
163
155
143
135
123
123
122
118
116
113
110
107
105
104
104
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
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6
_________ RURAL HEALTH CLINIC
SERVICE CATEGORIES
FY 2_
UTILIZATION OF MEDICAL SERVICE
Office Visit – New
Office Visit – Established
Nursing Home
Preventive Medicine
Immunizations
Injections
Lab
Pulmonary
Surgery
Consultations
X-ray
Allergy
Cardiography
FY 2_
FY2_
FREQUENCY
FREQUENCY
1,088
10,378
2,080
22
360
1,094
2,726
10
110
1
120
37
126
731
10,428
1,495
0
7
1,022
1,852
16
136
0
171
210
71
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Review of Active Charts:
A sample of forty two (42) active
provides a list of findings.
charts were reviewed and the report called Appendix A
Personnel Evaluations:
Evaluations of the Practice Coordinator and Nurse Practitioner have been prepared and are
attached as Appendix B to this report. All employees are performing as expected and no clinical
or administrative actions are requested from the annual evaluation committee.
Policies and Procedures:
A comprehensive review of the policies and procedures of ________ Rural Health Clinic was
performed and the results are noted on Appendix C of this report.
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Conclusion
According to the _______, the expected visits (demand) for family practice within __________
county is sixty four thousand sixty two (64,062). _______ Rural Health Clinic incurred thirteen
thousand one hundred thirty eight (13,138) visits within ________ County or twenty point five
percent (20.5%) of the market share. It can be concluded that the ______ Rural Health Clinic is
productive and benefiting the community of _______ and _______ County with the provision of
primary care services.
Name:
Title:
Signature:
_____________, M.D.
Medical Director
____________________
_________, FNP
Nurse Practitioner
______________________
_____________
Practice Coordinator
_____________________
_______________
Patient Advocate
_____________________
_______________
Regional Director
_____________________
__________________
Regional Vice President
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9
Appendix A - Annual Evaluation of Medical Charts
While on-site, 42 active medical charts were reviewed for adequate documentation of services
performed. Fourteen charts per provider with random chart selection from alphabet A, C, P, T,
every tenth (10th) chart, rejecting workmans compensation and pre-employment physicals.
Findings:
The following standards were found to be deficient with less than seventy percent (<70%)
compliance:
#3 – There is an updated problem list or flow sheet for health maintenance;
#4 – There is documentation of smoking habits and history of alcohol use or substance
abuse (N/A for patient < 14 or < 3 visits); and
#17 – For patients </= 10 years of age, there is a completed immunization record or a
notation that immunizations are up to date.
1.
An action plan has been developed for each deficiency which has been identified. The
plan describes the expected outcome and timeline for completion. Charts reviewed were
found to be in good order and the results of laboratory work, radiology and consultation
were recorded accordingly.
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10
INSERT MED.REC. REVIEW
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11
MEDICAL RECORD REVIEW
ACTION PLAN
Clinic:
Rural Health Clinic
Date of Review: May 4, 200_
Listed below are the medical record standards where compliance was noted to be less than
70%. Please review these standards and address each issue indicated with a specific plan on
how these items will be improved. Please indicate in the appropriate column the date
implementation is anticipated.
STANDARD
ACTION PLAN
EXPECTED OUTCOME
COMPLETION DATE
#3
A problem list has been
placed on each chart.
Increase compliance to 100%
Ongoing – charts will be
reviewed in January 2000
to assess compliance.
Discussed and reviewed with
each provider. Problem list
will be revised to address
deficiencies.
Increase compliance to 100%
#4
#17
Ongoing – charts will be
reviewed in January 2000
to assess compliance.
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Appendix B1 - Annual Evaluation of the Performance of the Practice
Coordinator
The Annual Evaluation Committee reviewed the performance of administrative duties of
_____________ on an annual basis. ___________ has demonstrated and performed the
following satisfactorily.
Leadership abilities
Quality of relationship with staff and public
Ability to encourage public confidence in the Medical Clinic operation
Knowledge and management of the operational budget
Maintain an effective and efficient clinic operation on a daily basis
Constructive recommendations to the Annual Evaluation Committee
Creativity in promoting good public relations and constructing and/or carrying out
programs of community education.
Additional Comments:
Name:
Title:
_______________, M.D.
Medical Director
________________
Practice Coordinator
_______________
Regional Director
Signature:
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Appendix B2 - Annual Evaluation of Performance of Nurse Practitioner
The Annual Evaluation Committee reviewed the performance of clinical duties by the Nurse
Practitioner. It was determined that ________, FNP had performed the following satisfactorily:
___________, FNP has performed adequately in the following areas:
Clinical competency,
Adherence to protocols and orders,
Interaction with patient and clinic personnel.
Additional Comments:
Name:
Title:
____________, M.D.
Medical Director
___________, FNP
Nurse Practitioner
____________
Practice Coordinator
Signature:
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Appendix C - Annual Evaluation of Office Policy and Procedures
The Annual Evaluation Committee of ________ Rural Health Clinic met on October 8, 200_, to
conduct the Annual Evaluation of ______ Rural Health Clinic. As an integral part of this
evaluation the policy and procedure manual was reviewed and the staff questioned regarding the
need for changes in policy and procedure. Specifically, the Practice Coordinator, Nurse
Practitioner, and Medical Director were asked if there were any policies and procedures that need
revising or should be added to the policy procedure manual.
As a part of this process the Medical Director and Nurse Practitioner had a chance to review the
patient care policies and make changes where appropriate. Additionally, the Practice Coordinator
and the Annual Evaluation Committee evaluated the financial, organizational, general, and office
policies and made changes where appropriate.
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Appendix D - Annual Evaluation Committee Meeting
_______ Rural Health Clinic Policy & Procedure Manual
On
October 8, 2000_ the Annual Evaluation Committee of _____ Rural Health Clinic in
___________ met as required by Medicare regulations.
The policy and procedure manual is continuously reviewed and updated.
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Billing Evaluation Outline
Topic
Description
Yes
RHC Medicare
Office Visits
Are Rural Health Clinic office visits billed on the
UB-04 form the Medicare Intermediary using
revenue code 52X?
X
RHC Medicare
Hospital Visits
Are Hospital inpatient and emergency room visits
billed to the Medicare Part B carrier using the
HCFA-1500 form?
X
Nursing Home
Visits
All Medicare nursing home visits are billed on the
UB-04 form to the Medicare Intermediary using
revenue code 524 or 526.
X
Home Health
Oversight
Medicare Home Health oversight is not billable
on either the UB-04 form or the HCFA-1500.
This time is allowable on the Medicare RHC cost
report.
Flu Shots
Medicare flu shots are not charged to the
patients and maintained on a Medicare approved
log. All flu shots are logged and supply costs for
flu shots are maintained.
Pneumoccocal
Vaccinations
Medicare flu shots are not charged to the
patients and maintained on a Medicare approved
log. All flu shots are logged and supply costs for
flu shots are maintained.
Allergy Shots
Special Instructions as outlined in Medicare are
followed for allergy shots.
Billing
All claims are filed with electronic billing.
Charges
Charges to patients are set based upon CPT
codes and charges are the same for all patients.
Co-Payments
Co-payments of 20% from Medicare are
collected from patients at the time of service.
Other co-pays are collected at the time of
service.
Bad Debts
Medicare co-insurance payments that can not be
collected are placed on the Medicare cost report
as Bad Debt for reimbursement.
No
Comments
N/A
X
X
X
X
X
X
X
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Topic
Description
Yes
Patient
Charges
Charges are evaluated and updated on an
annual basis.
X
Coding of
Claims
The CPT coding is as accurate as possible. The
physicians should review the E and M codes
every fall for the new codes and interpretations.
X
Radiology
Claims
The Rural Health Clinic bills the professional
component of X-Ray services if performed in the
RHC. The clinic uses the TC modifier when
billing X-ray services to the Medicare carrier on
the HCFA-1500 form.
Laboratory
Claims Waived
Tests Only
The six (6) required laboratory tests are billed as
nonRHC services.
No
Comments
X
X
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Definitions:
Name
Definition
Medicare Part A Fiscal Intermediary
The Medicare Part A Fiscal Intermediary is the government
contractor who typically process Hospital claims. ______ is
the intermediary for ______ Rural Health Clinic. This
intermediary only accepts the UB-04.
Medicare Part B Fiscal Carrier
The Medicare Part B Carrier is the government contractor who
typically processes the physician bills in the state. This
contractor usually only accepts the HCFA-1500 Form.
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19
Annual Evaluation Outline
This outline is a tool used in the annual evaluation process of the rural health clinic. It is
designed to help determine the appropriateness of current operational policies and the
reflection of these policies in practice. The evaluation will also validate the effectiveness of
established policies and practices, and indicate the need for revisions and/or development of
new policies and procedures.
Organization
Purpose:
To ensure maximum efficiency and inform persons of the organization structure of authority
and accountability.
Topic
Description
Yes
Organization
Is there an organization
chart or written description of
the organization?
X
Does the organization
operate in accordance with a
formal organizational plan?
X
Does the organization
operate in accordance with
all legal requirements?
X
Do all professional
personnel hold a current
license?
X
No
Comments
Goals & Plans
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20
Administration
Purpose:
To assure the provision, management, and support of the operation in providing services.
Topic
Governing
Body
Description
Is there a Governing
Body?
Yes
No
Comments
Goals & Plans
X
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