RotaCare QA Report as of December 2013

As I shared in the newletter there were no glaring imperfections...You all have an excellent program and it is going well.

I do not need to address the report or come up with a plan on how to correct any of the simple areas that were noted.

A huge thank you to our team of Morena, Gail, Docs Steve and Mike, and Myan for all the work they do to keep us always moving forward and not just moving forward ...but doing it correctly!!!

Happy new year...blanche

Clinic: San Rafael
Date: 12-16-2013


Monthly QA Review
	Priority H-M-L	Findings	Relevant Code or Policy	Resolution or End Date	Owner	Observation or Best Policy
QA Process
Being reported quarterly?		Yes. 20-30 charts reviewed per quarter
Challenges
Opportunities for Improvement

Volunteer files include:
Volunteer Application		100%
Health Status attestation/Initial Health Exam		100%
Proof of current TB status		80%	Policy #1025 on Volunteer application, Health Status and TB screening			***2 were missing TB and 1 RN license; It was later discovered, 1 volunteer had left and RN had not come in a while--File will be updated upon her returm
Orientation checklist		100%
Confidentiality Statement		100%
		100%
Release for Job Injuries		100%
Abuse Reporting Form		100%
Receipt and Acknowledgement of Volunteer Handbook		100%
Physician Files should also include:
Physician Volunteer Application		100%
Physician Volunteer Release of Information		100%
Volunteer Peer Reviews		100%
Copy of insurance coverage limits		N/A
All licensed volunteers:
Proof of current licensure		90%				See above ***

Medical Records
Contains:
Registration Form		100%
Care Record Sheet		100%
Discharge Sheet		100%
Information to be included:
Name		100%
Current Address		100%
Age and Date of Birth		100%
Sex		100%
Date services began		100%
Last date of service		100%
Consent for Treatment Authorizations		100%

Medical Record Documentation
Documentation to be included:
The date		100%
The reason for encounter		100%
Appropriate history and physical exam		100%
Review of lab, xray, etc		100%				Very nice referral and follow up program. Very organized.
Assessment		100%				Discussed completing all vital signs, many were missing Respiration, one missed height, otherwise very thorough.
Pertinent discussions with the patient and other healthcare professionsals		100%
Informed consent or refusal given		100%
Signed and dated informed consent or refusal forms		100%
Plan of care treatment and meds - specifying frequency and dosage, referrals and consults, patient/family education/specific instructions for followup)		100%
Patient's progress (response to treatment, change in treatment, change in diagnosis, non-compliance)		100%

Safety
Staff aware of role in Fire?		Yes
Staff aware of role in medical emergency?		Yes
Staff aware of how hazardous wates/sharps are handled?		Yes
Staff aware of how to report unusual occurences?		Yes

Pharmacy
Meds are stored securely		Yes
Supplies/inventory reviewed for expirations		Yes

Patient Confidentiality
Patient personal information not in public view or publicly accessible		Yes
HIPPA form		Yes

Point of Care Testing
Current tests being done onsite (list)		Urine dip, UPT, glucose
Review of Quality Control log - QC being done?		Yes				100% complete
Staff with current competency to perform test?		Yes, upon hire


Action Plan Due Date: N/A
*Due Date is 15 Days from Date of Receipt of QA Review *
*Note: All findings coded as high need to be included in clinic response*