The RHC Policy & Procedure Manual

Only $79

The RHC Policy and Procedure Manual (PPM) developed by Healthcare Horizon, a division of Horizon Services, Inc. is a comprehensive collection of actual policies, NOT just an outline or guide. The purchaser is granted rights to download, change, adapt and save this manual as needed for the SINGLE RHC LOCATION for which they are purchasing the manual.

The staff of the RHC MUST customize this manual to meet the specific policies and procedures of their particular clinic. In general, when the RHC is owned and operated by a Hospital, that entity’s personnel manual will be inserted into this manual rather than re-construct the Section P of the manual being purchased. Other sections that may require using the Hospital’s existing manual include the Blood Borne Pathogen Policy (Section S of this manual).

The purchaser of this manual can be assured they will have more than adequate policies to pass a state inspection or re-certification survey.

HOWEVER, it is important to note that with the new ability to have an entity other than the state perform the initial certification survey (AAAASF and The Compliance Team) the clinic may need to have additional policies in place in order to comply with those entity’s ACCREDITATION STANDARDS, which may exceed the regulatory requirements of the state surveyor. The purchaser is encouraged to contact the entity they are contracted with for their initial survey to determine what additional policies may be needed.

This manual is contained on TWO CDs. The following is a detailed list of the exact table of contents from both CDs.

A GREAT COMPLIMENT to this manual is the RHC Toolbox which contains over 650 memorandums, regulations, forms, etc. specific to the RHC program, and is available thru this web site.

At the end of this table of contents is an excerpt of an actual policy taken from the manual.

RHC POLICY & PROCEDURE TABLE OF CONTENTS

A) Patient Policies

  • A1 Patient Eligibility
  • A1.1 Medicare Eligibility
  • A1.2 Procedure for Confirming Insurance/MediCAID Coverage
  • A1.3 Pre-Authorization Procedure
  • A1.4 Use of Advanced Beneficiary Notice (ABN)
  • A1.5 Family Member Exclusion
  • A2 Patient Registration
  • A2.1 Patient Check-In
  • A2.1.1 Electronic Signature-Patient
  • A2.1.2 Patient Photo
  • A2.1.3 MSP Documentation
  • A2.2 New Patient Packet Contents
  • A2.3 Patient Tardiness/No Shows
  • A2.4 Medication List Requirement
  • A2.5 Frequency of Patient Forms Completion/Signature
  • A2.6 Medicare Advantage Policy
  • A3 Patient Scheduling
  • A3.1 Telephone Triage
  • A3.2 Work-In Patients
  • A3.3 Acute Care Priorities
  • A3.4 New Patient Scheduling Thresholds
  • A3.5 Double-Booking of Appointments
  • A3.6 Procedure Scheduling
  • A3.7 Scheduling Other Clinic Rooms
  • A3.8 Scheduling for Consulting Providers
  • A3.9 Missed appointments/No Show
  • A4 Patient Flow
  • A4.1 Security Policy
  • A4.2 Waiting Room Protocols
  • A4.2.1 Required legal postings
  • A4.2.2 Toys in Waiting Room
  • A4.2.3 Furnishing Maintenance/Repair
  • A4.3 Exam Room Protocols
  • A4.3.1 Cleaning Room Protocol
  • A4.3.2 Furnishings Maintenance/Repair
  • A4.3.3 Exam Room Contents
  • A4.3.4 Sharps Disposal Units
  • A4.3.5 Closed Door Policy
  • A4.4 Clinic Hours
  • A4.4.1 Business Ofc. Hours
  • A4.4.2 Patient Care Hours
  • A4.4.3 Lunch Break
  • A4.4.4 Holiday Closing
  • A4.4.5 Weather-Related Closing
  • A4.5 Restricted Areas
  • A4.6 Exam of Patients
  • A4.7 Superbill Procedures (Paper System)
  • A4.7.1 Physician/Mid-Level Sig.
  • A4.7.2 Pt. Signs superbill
  • A4.7.3 Copy to Pt.
  • A4.8 Cash Patient Charge Slip Procedure
  • A5 Patient Rights & Responsibilities
  • A5.1 Patient Comment Policy
  • A5.4 Service-Therapy/Comfort Animal Policy
  • A5.5 Civil Rights Policy-Non-Discrimination
  • A6 Referrals
  • A6.1 Types of Services Referred
  • A6.2 Referral Process/Forms
  • A6.3 Tracking
  • A6.4 Follow-up
  • A6.5 Continuity of Care
  • A7 Provider Right to Terminate Care
  • A7.1 Procedure
  • A7.2 Notification of Patient
  • A8 Concealed Carry-Open Carry Policy
  • A8.1 Signage
  • A8.2 State Law
  • A9 Abusive Patient Policy

B) Medical Records

  • B1 Contents
  • B2 Security Access
  • B3 Release of Information
  • B3.1 Worker’s Comp. Release
  • B3.2 Legal Requirements
  • B3.2.1 Supoena Ducas Tecum
  • B3.2.2 Timing for Provision of Records Request
  • B3.3 Document Copy Charges
  • B4 Confidentiality
  • B5 Separation of Medical/Financial
  • B6 Documentation Requirements
  • B6.1 Timliness of documentation by provider
  • B7 Quality Assurance
  • B8 Treatment of Minors
  • B8.1 Diagnosis Emancipating Minor
  • B8.1 Diagnosis List
  • B8.2 State Rregulation Requirements for Minors
  • B8.3 Procedure for Forms Completion by Minor-Emancipated Patient
  • B9 Illiterate / Incapacitated Signature Policy
  • B10 Behavioral Health Records(SEPARATE MANUAL)
  • B11 Electronic Records Policies

C) Business Office

  • C1 Petty Cash
  • C2 Purchasing
  • C3 Telephone System
  • C4 Employee Accountability/Sign Out
  • C5 Time Clock
  • C6 Office Supplies
  • C7 Internet/Voice Mail
  • C8 Fax Machine
  • C9 Medi-Fax Unit
  • C10 Collection of Co-Pay & Deductibles
  • C11 Cash Patient Discount Policy/Deposit Requirement
  • C12 Cash Drawer Reconciliation
  • C13 Bank Deposit Procedure

D) Medical Supplies

  • D1 Ordering Responsibility
  • D1.1 Drug Ordering
  • D1.2 Supply Ordering
  • D2 Location
  • D3 Distribution to Exam Rooms
  • D5 Drugs/Samples Room Security & Inventory
  • D6 Shelf Life of Sterilized Supplies
  • D7 Controlled Medication Inventory Control
  • D8 Vaccines for Children (VFC) & Stock Refrigerated Medications

E) Procedures

  • E1 Laboratory Procedures
  • E1.1 Infection Control—Laboratory
  • E1.2 Staff Proficiency Testing
  • E1.3 Log Requirements
  • E1.4 Waived Tests Provided in Facility
  • E2 Injections
  • E3 X-Ray Services
  • E4 EKG Services
  • E5 Minor Surgical Procedures
  • E5.1 List of Procedures

F) Biomedical Policies

  • F1 Equipment List
  • F1.1 Location of Equipment
  • F1.2 Quality Control
  • F1.3 Repair/Maintenance Agreements
  • F2 AED Protocols
  • F3 Autoclave Protocols
  • F4 Equipment Sanitation
  • F5 Oxygen Storage
  • F6 Equipment Condition
  • F7 Equipment Repairs
  • F8 Equipment Recalls
  • F9 Equipment Inventory
  • F10 Equipment Testing
  • F11 New Equipment
  • F12 Disposal of Equipment
  • F13 Oxygen Recalls

G) Clinic Facility

  • G1 Janitorial Services
  • G1.1 Exterior Facility Services
  • G1.1.1 Mowing
  • G1.1.2 Trash Collection
  • G1.1.3 Landscaping
  • G1.1.4 Parking Lot Upkeep/Treatment
  • G1.1.5 Pest Control
  • G1.2 Interior Janitorial Services
  • G1.2.1 Responsibilities
  • G2 Emergency Plans
  • G2.1 Fire
  • G2.2 Tornado
  • G2.3 Bomb
  • G2.4 Security Call
  • G2.4.1 Active Shooter
  • G2.5 Earthquake Preparedness
  • G2.6 Flood
  • G2.7 Ice Storm
  • G2.8 Landslide
  • G2.9 Windstorm
  • G2.10 Hurricane
  • G2.11 Blizzard
  • G2.12 Eye Wash Station/Log Requirement
  • G3 Emergency Preparedness Plan (EPP)
  • G3.1 Purpose
  • G3.2 Exercise Types
  • G3.3 Emergency Plan Checklist
  • G3.4 Emergency Plan Specific Policies
  • G3.4.1 Evacuation
  • G3.4.2 Shelter
  • G3.4.3 Patient Health Records
  • G3.4.4 Use of Volunteers
  • G3.4.5 Medication Handling
  • G3.5 All Hazards Risk Assessment
  • G3.6 Communication Plan
  • G3.7 Training Program
  • G3.8 Testing Program
  • G3.9 Participation in a Healthcare System’s EPP
  • G4 Facility Keys
  • G4.1 Responsibility
  • G4.2 Access
  • G4.3 Duplication
  • G4.4 Non-employee access
  • G5 Alarm System
  • G5.1 Access Codes
  • G5.2 Alarm Trigger Procedure
  • G6 Electrical/Water System/Gas
  • G6.1 Location of Shut-off
  • G6.2 Emergency Procedure
  • G7 Smoke-Free Facility
  • G7.1 Signage at Entry
  • G8 Drug-Free Workplace
  • G9 Property Management
  • G9.1 Annual Equipment Inventor
  • G9.2 Equipment Maintenance Records
  • G9.3 Equipment Screening
  • G9.4 Supplies Inventory/Control
  • G9.5 Resource Materials
  • G10 Annual Fire Marshal Inspection
  • G11 Infection Control
  • G11.1 Hand Hygiene
  • G11.2 Barrier Precautions
  • G11.3 Hepatitis B
  • G11.4 Sharps and Needles
  • G11.5 Bio-Medical Waste
  • G11.6 Tuberculosis
  • G11.7 Non-Hazardous Waste

H) Billing Procedures

  • H1 Insurance Companies
  • H2 Medicare
  • H3 Medicaid
  • H4 Private Pay
  • H5 Procedure Billing
  • H6 Diagnostic Test Billing
  • H7 Medicare Bad-Debt
  • H8 Flu & Pneumonia Immunization Log
  • H9 Account Collection Policy
  • H10 No-Show Policy
  • H11 Chargemaster
  • H12 Account Adjustments Procedures
  • H13 Encounter Definition
  • H14 Injection Billing for Medicare Patient
  • H15 Use of Advanced Beneficiary Notice

I) Computer System and Internet Policies

  • I1 Computer System Maintenance
  • I2 Internet Access Policy

J) Patient Benefits Coordination

  • J1 Medicaid
  • J2 Medicare
  • J3 Commercial Insurance

K) Nursing Home Visits

  • K1 Billing Procedures
  • K2 Medical Records
  • K3 Medical Provider Requirements
  • K3.1 Employed or Contracted

L) Public Health

  • L1 Immunizations
  • L1.1 Ordering of Immunization Serums, Vaccines, etc.
  • L1.2 Receiving of Immunization Serums, Vaccines, etc.
  • L1.3 Storage of Immunization Serums, Vaccines, etc.
  • L1.4 Immunization Records Computerized System Procedures
  • L1.5 Immunization Protocols
  • L1.6 Immunization Standing Orders
  • L1.7 Immunization Declination by Patient or Parent/Guardian
  • L2 Sexually Transmitted Disease Reporting
  • L2.1 HIV Testing, Referral & Follow-up
  • L3 Training/Education Services
  • L3.1 Diabetes Prevention
  • L3.2 Nutrition
  • L3.3 Immunization Education
  • L4 Legal Reporting Requirements
  • L4.1 Child Abuse/Neglect
  • L4.2 Elderly Abuse/Neglect
  • L4.3 Caretaker Abuse/Neglect
  • L4.4 Domestic Abuse

M) Administration

  • M1 Confidentiality
  • M2 Organizational Chart/Disclosure of Ownership
  • M3 Job Descriptions
  • M3.1 Medical Director
  • M3.2 Mid-Level Practitioner
  • M3.3 Clinic Supervisor
  • M3.4 Billing Clerk
  • M3.5 Receptionist
  • M3.6 Patient Care Assistant
  • M3.7 LPN/RN/Medical Assistant\
  • M3.8 Physician
  • M3.9 Clinic Manager
  • M4 Quality Improvement
  • M4.1 Patient Rights & Responsibilities
  • M4.2 Problem Documentation Procedure
  • M4.3 Patient Incident Reporting
  • M4.4 Annual Evaluation
  • M4.5 Chart Audit
  • M4.6 Quality Assessment & Performance Improvement Plan
  • M5 ContractArrangements
  • M5.1 Hospital Transfer Agreement
  • M5.2 Business Associate Agreements
  • M6 Service Delivery Area Definition
  • M7 Non-Discrimination Policy
  • M8 Forms Approval Procedure
  • M9 Policy & Procedure Revision Procedure
  • M10 Annual Evaluation Policy
  • M11 Association Memberships
  • M12 Professional Continuing Education
  • M13 Travel Authorization
  • M14 Staff Meeting Agenda
  • M15 Workman’s Comp. Incident Reporting
  • M16 End-Of-Month Reports
  • M16.1 Encounter Reports
  • M16.2 Procedure Reports
  • M16.3 Bad-Debt Report
  • M16.4 Location Close
  • M17 Collaborative Practice Agreements/Protocols
  • M18 Medical Supervision
  • M19 OIG Voluntary Compliance Plan
  • M20 HPSA Designation
  • M21 Rural Designation
  • M22 Mid-Level Practitioner Compliance
  • M23 Corporate Compliance Plan
  • M23.1 Training Employees on Fraud Waster Abuse,
  • Corporate Compliance & Standards of Conduct Annually
  • M23.1.1 Employee Agreement to
  • Plan and Standards
  • M24 Employee Code of Conduct
  • M24.1 Non-Retaliation Statement
  • M24.2 Attendance & Punctuality
  • M24.3 Personal Appearance
  • M24.4 Sexual & Other Unlawful Harassment
  • M24.5 Workplace Etiquette
  • M25 Sliding Scale Fee Schedule
  • M26 Clinic Philosophy

N) Property Management

  • N1 Equipment Inventory
  • N2 Equipment Maintenance Records
  • N3 Equipment Screening
  • N4 Supplies Inventory/Control
  • N5 Resource Materials
  • N5.1 Release of Documents Policy
  • N5.1.1 Non-Return of Loaned
  • Items Policy
  • N5.2 Provision of Free Literature
  • N5.2.1 Location
  • N5.2.2 Quantity Limits
  • N5.2.3 Re-ordering Responsibility
  • N6 Cellular Phone Use
  • N7 Elimination of Surplus Supplies & Equipment
  • N8 Routine Maintenance (General)
  • N9 Wheelchair Use & Maintenance
  • N9.1 No-Lift Policy/Provision of Gait Belts

O) Clinical

  • O1 Blood-Borne Pathogen Policy & Exposure Control Plan
  • O2 HEP Policy
  • O3 CLIA Lab Certification–Waived Tests
  • O4 Emergency Response
  • O4.1 Emergency Kit Contents & Inspection
  • O4.2 Re-Ordering Emergency Kit Contents
  • O5 Scope of Services Provided
  • O6 Dispensing of Drug Samples to Patients
  • O7 Prescribing of Contraceptives to Minors
  • O8 Pain (Chronic) Management Policy
  • O8.1 Contract
  • O8.2 Treatment Plan
  • O8.3 Periodic Drug Screen
  • O8.4 Pediatric Pain Management Policy

P) Personnel Policies

  • P1 Introduction
  • P2 Effective Date
  • P3 Employment Relationship
  • P4 Initial Evaluation Period
  • P5 Contract & Temporary Employees
  • P6 Employment Documentation
  • P7 Equal Employment Opportunity
  • P8 Personnel File Confidentiality
  • P9 Attendance & Punctuality
  • P10 Time Sheet
  • P10.1 Form
  • P11 Sick Leave
  • P12 Vacation
  • P13 Insurance
  • P14 Holidays
  • P15 Pay Day
  • P16 Separation & Termination
  • P17 Performance Evaluations
  • P17.1 Performance Review Form
  • P18 Acknowledgement of Receipt & Understanding of Clinic Policies and Procedures
  • P19 Code of Conduct: see Policy M24

Q) Legal Requirements

  • Q1 Child-Elderly Abuse/Neglect Reporting
  • Q1.1 Procedure
  • Q2 Domestic Violence Reporting Requirements
  • Q2.1 Procedure
  • Q3 Malpractice Insurance
  • Q4 A.D.A. Compliance
  • Q5 OSHA Standards Compliance
  • Q6 Signature Verification

R) Cost Report

  • R1 Preparation Responsibility
  • R2 Reports required for completion of Cost Report
  • R2.1 Monthly Encounters by Payor Type
  • R2.2 Time Documentation
  • R2.2.1 Time Studies
  • R2.2.2 Time-Clock
  • R2.2.3 Medical Provider RHC time allocation
  • R2.3 Flu/Pneumonia Injection Cost Study
  • R2.4 Lab Test Cost Study
  • R2.5 Productivity Report by Provider

S) Blood Borne Pathogen Policy & Exposure Control Plan

T) Personnel Forms

U) Appendix

  • U1) New Patient Packet
  • U2) Approved Employee List for Laboratory Equipment Utilization
  • U3) Fire Drill Log
  • U4) Fire Drill Report Form
  • U5) Sample Employee Time Sheet
  • U6) HPSA Designation List from State Health Department (insert)
  • U7) List of Reportable Diseases (from State Health Department) (insert)
  • U8) Organizational Chart/Ownership Disclosure (insert)
  • U9) Medical Provider Licenses (insert)
  • U10) Annual Evaluation Report(s) (insert)
  • U11) Maintenance Agreement(s) (insert)
  • U12) Mid-Level Provider Collaborative Agreement(s) (insert)
  • U13) Medical Chart Forms (insert)
  • U14) Superbill (insert)
  • U15) Chargemaster (insert)
  • U16) Inspection Reports (State, Fire, Biomedical, etc.) (insert)
  • U17) Parental Refusal to Vaccinate Child Form
  • U18) Emergency Preparedness Plan Checklist
  • U19) Emergency Preparedness Communication Plan
  • U20) Emergency Preparedness Plan Training Log (insert)
  • U21) Emergency Preparedness Plan Exercise Documentation (insert)
  • U22) Emergency Preparedness Plan Community Participation