Facility Attestation

Facilities providing primary care and obstetrics and gynecology services must attest to the following areas of competencies by signing below. Please describe your processes for each category. Neighborhood retains the right to conduct a quality on onsite assessment prior to the facility joining the network (initial credentialing) or in response to a complaint received from a member pertaining to environment of care.

Ability to handle medical emergencies in the Facility

Facility has the ability to manage unexpected medical emergencies and maintains in good working order equipment needed to manage emergencies, including:

Severe Allergic Reaction*

Severe Allergic Reaction *

Yes
No

Severe Allergic Reaction - Please describe your process or indicate whether a policy is attached*

Cardio-pulmonary Arrest*

Cardio-pulmonary Arrest *

Yes
No

Cardio-pulmonary Arrest - Please describe your process or indicate whether a policy is attached*

Staff is trained and facility ensures that training is current*

Staff is trained and facility ensures that training is current *

Yes
No

Staff is trained and facility ensures that training is current - Please describe your process or indicate whether a policy is attached*

Facility has a process for transferring patients to an emergency room*

Facility has a process for transferring patients to an emergency room *

Yes
No

Facility has a process for transferring patients to an emergency room - Please describe your process or indicate whether a policy is attached*

Ability to handle medical emergencies in the Facility - Please upload any applicable documents

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

Physical accessibility and maintenance

Office is handicapped accessible (including restrooms)*

Office is handicapped accessible (including restrooms) *

Yes
No

Office is handicapped accessible (including restrooms) - Please describe your process or indicate whether a policy is attached*

If injectable medication is administered – there is a process for regular disposal of needle/syringes*

If injectable medication is administered – there is a process for regular disposal of needle/syringes *

Yes
No

If injectable medication is administered – there is a process for regular disposal of needle/syringes - Please describe your process or indicate whether a policy is attached*

Containers are out of reach of children*

Containers are out of reach of children *

Yes
No

Containers are out of reach of children - Please describe your process or indicate whether a policy is attached*

If narcotics are administered, narcotics are stored in double locked storage*

If narcotics are administered, narcotics are stored in double locked storage *

Yes
No

If narcotics are administered, narcotics are stored in double locked storage - Please describe your process or indicate whether a policy is attached*

Process for checking narcotics validation is in place*

Process for checking narcotics validation is in place *

Yes
No

Process for checking narcotics validation is in place - Please describe your process or indicate whether a policy is attached*

There is a process in place for discarding narcotics*

There is a process in place for discarding narcotics *

Yes
No

There is a process in place for discarding narcotics - Please describe your process or indicate whether a policy is attached*

Physical accessibility and maintenance - Please upload any applicable documents

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

Medical Records Keeping and Confidentiality

Facility has policies and procedures re adequacy of medical record keeping (paper/electronic/both) which includes:

The patient record is secured and accessible to authorized personnel only*

The patient record is secured and accessible to authorized personnel only *

Yes
No

The patient record is secured and accessible to authorized personnel only - Please describe your process or indicate whether a policy is attached*

Record is legible*

Record is legible *

Yes
No

Record is legible - Please describe your process or indicate whether a policy is attached*

There is a written medical record policy that addresses security and confidentiality of the record*

There is a written medical record policy that addresses security and confidentiality of the record *

Yes
No

There is a written medical record policy that addresses security and confidentiality of the record - Please describe your process or indicate whether a policy is attached*

There is a process for retention of active and inactive files*

There is a process for retention of active and inactive files *

Yes
No

There is a process for retention of active and inactive files - Please describe your process or indicate whether a policy is attached*

There is a process regarding release of information requests*

There is a process regarding release of information requests *

Yes
No

There is a process regarding release of information requests - Please describe your process or indicate whether a policy is attached*

Records are available to covering practitioners*

Records are available to covering practitioners *

Yes
No

Records are available to covering practitioners - Please describe your process or indicate whether a policy is attached*

Consent or refusal of treatment is documented in the record*

Consent or refusal of treatment is documented in the record *

Yes
No

Consent or refusal of treatment is documented in the record - Please describe your process or indicate whether a policy is attached*

All employees sign a confidentiality agreement and receive instruction regarding HIPAA*

All employees sign a confidentiality agreement and receive instruction regarding HIPAA *

Yes
No

All employees sign a confidentiality agreement and receive instruction regarding HIPAA - Please describe your process or indicate whether a policy is attached*

Medical Records Keeping and Confidentiality - Please upload any applicable documents

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

Internal Policies and Procedures

Facility has documented processes for handling:

Patient grievances*

Patient grievances *

Yes
No

Patient grievances - Please describe your process or indicate whether a policy is attached*

Employee training*

Employee training *

Yes
No

Employee training - Please describe your process or indicate whether a policy is attached*

Hospitalization for patients needing inpatient care*

Hospitalization for patients needing inpatient care *

Yes
No

Hospitalization for patients needing inpatient care - Please describe your process or indicate whether a policy is attached*

Practitioner coverage is available 24 hours per day 7 days per week*

Practitioner coverage is available 24 hours per day 7 days per week *

Yes
No

Practitioner coverage is available 24 hours per day 7 days per week - Please describe your process or indicate whether a policy is attached*

Internal Policies and Procedures - Please upload any applicable documents

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

By signing below, I attest that this Facility has the capability to handle the key areas specified above

Name*

Signature*

Title*

Date

Practice Information

Practice Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

Site Liaison/Contact Person*

Service*

Service *

Primary Care
Obstetrics & Gynecology
Both

Medical Director*

Please upload any applicable documents

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB.

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.

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