Dec 7, 2021

Discussion on the Most Common Clinic Deficiencies – Part 4

In Part Four of our discussion, we will address one of the most common deficiencies in a clinic environment as cited by our surveyors in 2020/21 and how it is often confused with the standard addressed in Part Three of this series. To close out this series, we will look at a deficiency that can easily be avoided by a simple policy update.

There are two types of chart review for RHCs:

  1. Chart Review for quality improvement to include in your biennial evaluation.
    • Maintain a log of reviewed charts for inclusion in your evaluation.
    • Remember to include a closed record.
  2. Physician oversight when there is no state requirement (you choose the number of charts to review and put it in your policy)
    • Complete this requirement even when the NP has autonomy.
    • Maintain a review log to prove the number of completed chart reviews matches the number required in your policy.

The ADM 9.0.2 standard was addressed in our last newsletter and surveyors are documenting confusion by clinic staff between the two different chart review requirements (ADM 9.0.2 and ADM 6.0.4), so we will restate the two standards to help clarify the difference:

The Standard: ADM 9.0.2

There is evidence the clinic periodically audits its Patient Health Records for completeness and the results are documented at QI meetings. The number and frequency of records is identified in clinic policy. The leadership reviews and documents the chart review findings and takes corrective actions.

The Deficiency:  Not auditing Patient Health Records and properly documenting, specifically for the following:

  • Completeness
  • Documentation of audit results (including number of records reviewed) in QI meeting minutes
  • Documentation of leaderships review, findings and any corrective action taken
  • Ensuring the number of patient health records and how often they are to be audited is clearly identified in the clinic policy

Please note: This can be done by anyone trained in the elements of a complete chart.

QI meeting minutes must include documentation of periodic audits of Patient Health Records based on the number of records identified in the clinic’s policy.  The minutes should include the names of leadership who reviewed the audit findings and any corrective action taken when issues are identified.  The results of the corrective action should be documented in future QI meeting minutes to complete the QI process.

The clinic must ensure that the number of records to be audited and how often the audit will be conducted is delineated in the clinic’s policy.

Clinics are confusing compliance with the above standard with the following standard:

The Standard: ADM 6.0.4

The physician assistant and/or nurse practitioner participate with the physician in a periodic review of the patient health records. (§491.8(c)(1)(ii))

The Deficiency: Clinics are not conducting a periodic review of patient health records where the physician assistant and/or nurse practitioner participate with the physician in the review process. The chart audit for completeness (ADM 9.0.2) and submitted for documentation at QI meetings does not fulfill the requirement for ADM 6.0.4 for chart review with physician and PA and/or NP.

Most often the surveyor finds that periodic review of patient health records, for medical oversight, with a physician and PA and/or NP has not been completed.

If you require more clarification, call The Compliance Team, and ask for an RHC advisor.

To close out this series, we have one additional standard that is frequently cited as deficient.

The requirement timeframe was changed for Standard QI 1.0 regarding Program Evaluation from annual to biennial, which also requires a policy change that is often overlooked by clinic staff. By simply updating your policy to reflect the change from annual to biennial, your clinic can avoid a deficiency.

The Standard: QI 1.0

The clinic maintains continuous quality improvement processes and carries out, or arranges for, a biennial evaluation of its total program. (§491.11(a))

The Deficiency:  Not updating the clinic’s policy from annual to biennial evaluation which puts the clinic out of compliance with their own policy.

Useful resources:

Quality Improvement (

Basics of Quality Improvement (


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