SBHC Medicaid Site Readiness Review Checklist - New Mexico ...

SBHC Medicaid Site Readiness Review Checklist
Location:
Mailing Address:
Reviewer(s):
Affiliation:
Telephone:
Date of Visit:
Criteria
Environmental Requirements
• Waiting area/parking lot clean, accessible
• Office hours and after hour availability posted or available by message
• NO SMOKING signs posted
• Policy in place to provide services to all students, regardless of ability to pay
• Private rooms with soundproof walls and basic medical equipment
• Dedicated and private telephone line, fax line and private e-mail account
• School Health Advisory Committee (SHAC) meets at least twice yearly and
has representative membership from school and community
Handicap Access Requirements
• Parking: Minimum 1 per facility with shortest access to entrance (Width 96”
and parking non-obstructive to ramp)
• Main entrance ramp: Minimum 48” wide and elevator if more than 1 story
• Water fountain: Accessible OR staff available to assist
• Restroom: Accessible OR staff available & handrails installed OR available
Fire Safety Requirements
• Exit signs, extinguishers prominently displayed
• Sprinklers OR evacuation plan posted
Bio Hazard Requirements
• Disposable needle containers present and labeled appropriately
• Sterilization equipment available and adequate and tested routinely. If using
sterilization equipment, provide log of test strips
• Log of sterilization dates maintained
• Infection materials disposed of separately with appropriate labels
• Standard precautions observed and signs posted. Agents labeled as
hazardous material
• Policies and procedures to address OSHA standards &\ and disposal of
hazardous wastes (e.g., Who does cleaning? How often?)
Medication Requirements
• Prescription pads are not presigned AND are inaccessible to the public
• Expiration dates of medications are routinely checked and appropriately
replaced
• Log of expiration dates maintained
• Medication inventory control log maintained
• Sample medication management policy and procedure in place if applicable
• Medication is stored in a secure area not readily accessible to the public
• Medication refrigerator thermometer and temperature logs posted and
checked routinely
• Controlled substances are secured under double lock and signed out only
by those covered under law to do so
Staffing Requirements
• Direct patient care personnel are BLS trained and present during office
hours
• Selection system is in place for critical patients
• Written policy regarding the transportation of clients by SBHC personnel.
This policy must be congruent with local school district policies, as well as
provider agency policies, in terms of safety and liability issues
Access Requirements
• System in place for emergency and unscheduled appointments
• No show &/or cancellation system in place
• Appointment reminder process in place
Preventive Health Requirements
• Process for preventive care check-ups includes documentation of health
education and anticipatory guidance
• Preventive health guidelines up-to-date and posted in patient rooms
• Emergency kit available OR process in place to handle emergencies
Met
(Y/N)
Comments
SBHC Medicaid Site Readiness Review Checklist – Revised 05/07

SBHC Medicaid Site Readiness Review Checklist (page 2)
Criteria
Met
(Y/N)
Medical Records Requirements
• Medical records are inaccessible to the public and behind double locks
• Standardized format utilized and records are securely bound
• Name, DOB and gender documented on each page of medical record
• Allergies prominently displayed (labeled, highlighted, etc.)
• Problem list/medication list/immunization-preventive health list used
when applicable
• One chart per patient
• Measures to ensure confidentiality, privacy, security, and HIPAA
compliance for personal health information maintained
• Diagnostic report has independent section in chart. All labs or other
procedure results to be charted
• SBHCs are required to develop and maintain a quality assurance (QA) plan
that monitors and evaluates the appropriateness and effectiveness of
services provided, including a procedure by which clients, families, and/or
school concerns or complaints will be addressed through a patient, parent
and school staff survey
• SBHCs will have cooperative arrangements with community health care
organizations and primary care providers to provide health services to
clients during hours when the SBHC is closed
• SBHCs will collaborate on and provide health promotion, health education
and disease prevention
• Client data generated by the SBHC may only be used without identifiers
and only in the aggregate form
Licensure
• SBHCs will comply with the regulations of the New Mexico Board of
Pharmacy, if appropriate
• SBHCs will comply with Clinical Laboratory Improvement Amendments
(CLIA) for all laboratory testing
• SBHC providers are licensed and eligible for credentialing by MCOs/SE
• Mid-level practitioners are appropriately identified (e.g., CNP, PA, SW,
Psychologist)
3-Year Recredentialing Criteria (to be completed only at recredentialing visits every 3 years)
• SBHC providers have current malpractice insurance
• Within the last 3 years, one or more SBHC providers have had a
professional liability claim that resulted in settlement or judgment (if yes,
provide details on separate paper)
• Within the last 3 years, one or more SBHC providers have had sanctions,
suspensions, or terminations imposed by Medicaid or their state board (if
yes, provide details on separate paper)
• Within the last 3 years, one or more SBHC providers have had a formal
client complain filed with an MCO/SE or with the Medical Assistance
Division (if yes, provide details on separate paper)
Comments
Reviewer Signature: Date: Approved: yes no
SBHC Medicaid Site Readiness Review Checklist – Revised 05/07