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POLICY & PROCEDURES XxxxxxxxxxxxTABLE OF CONTENTS Chapter 1: Provider Page 1. Organization Chart…………………………………………………………………………………2 2. Laboratory Director Position Description………………………………………………..2 Chapter 2: Administration 1. Medical Record Retention Policy……………………………………………………………. 4 1. HIPPA Compliance Policy………………………………………………………………………. 4 2. Fraud, Abuse and Waste Prevention Policy…………………………………………….. 4 3. Supply Management Policy……………………………………………………………………. 5 4. Electrical Equipment Check Policy…………………………………………………………. 5 Chapter 3: Patient Care 1. NCS/EMG Procedures and Policy…………………………………………………………….6 2. Normative Values Policy…………………………………………………………………………6 3. Medical Emergency Policy………………………………………………………………………6 4. Universal Precautions Policy…………………………………………………………………..7 5. Outcome Assessment Policy……………………………………………………………………7 Chapter 4: Facility 1. American Disabilities Act Compliance Policy…………………………………………...8 2. Facility Policy………………………………………………………………………………………...8 3. Emergency Plan Policy…………………………………………………………………………...8 4. Power Outage Policy………………………………………………………………………………8 Appendices: A…………………………………………………………………………………………………………………10 B…………………………………………………………………………………………………………………13 C…………………………………………………………………………………………………………………17 D…………………………………………………………………………………………………………………22 E…………………………………………………………………………………………………………………24 F…………………………………………………………………………………………………………………26 G…………………………………………………………………………………………………………………31 H………………………………………………………………………………………………………………....32 I………………………………………………………………………………………………………………….34 J…………………………………………………………………………………………………………………. 42 K…………………………………………………………………………………………………………………4311/27/2017 1 XxxxxxxxxxxxCHAPTER 1 PROVIDER 1. Organization Chart Xxxxxxxxxxxxis a sole proprietorship owned by the Laboratory Director. Xxxxxxxxxxxxprovides NCS/EMG services as an independent contractor with like professional private practice businesses or with hospitals. 2. Laboratory Director Position Description a. The Laboratory Director is the owner of Xxxxxxxxxxxxb. Shall be current with: i. Licensure 1. Washington State professional physical therapy license 2. Secretary of State Professional Limited Liability Corporation designation 3. Washington State business license 4. Seattle business license 5. Anacortes business license 6. Oak Harbor business license 7. Sequim business license ii. American Board of Physical Therapy Specialties Electrophysiologic Clinical Specialist (ECS) designation iii. Healthcare Provider Basic Life Support certification iv. Insurance 1. Malpractice insurance including riders for: a. Teaching b. Data breach 2. General business insurance v. Taxes 1. Washington State Business & Occupation tax 2. Federal income tax 3. Seattle Business & Occupation tax c. Shall maintain current membership in profession organizations i. American Physical Therapy Association ii. Academy of Clinical Electrophysiology and Wound Management Section iii. EDX SIG iv. American Congress of Electroneuromyography v. Physical Therapy Association of Washington d. Shall comply with all federal and state, business and healthcare insurance laws, rules and regulations e. Shall complete annual education modules on: i. HIPAA Privacy and Security ii. Fraud, Abuse and Waste Prevention f. Shall educate and inform regarding NCS/EMG issues to:11/27/2017 2 Xxxxxxxxxxxxi. Physical therapists and other licensed healthcare providers ii. Physical therapy students iii. Patient/clients iv. Policy makers v. Legislators vi. Regulators vii. Insurers g. Is responsible for developing and implementing the following policies and procedures11/27/2017 3 XxxxxxxxxxxxCHAPTER 2 ADMINISTRATION 1. Medical Record Retention Policy a. The Laboratory Director is responsible for developing and implementing the Medical Record Retention policy b. Washington statutes don’t address a specific time frame for medical record retention c. Xxxxxxxxxxxx follows the State of Washington Medical Quality Assurance Commission Guideline on Retention of Medical Records (Appendix A) d. Xxxxxxxxxxxx annually stores the electronic medical records for the three clinics on DVD storage discs e. These discs are held for ten (10) years in a locked filing cabinet in the main office, which are physically destroyed after ten years f. Rue & Primavera and Island Hospital facilities i. Each have secured file rooms storing paper medical records ii. These records are held for 10 years, then are destroyed g. Olympic Medical Center has only electronic cloud storage for medical records 2. HIPPA Compliance Policy a. The Laboratory Director is responsible for developing and implementing the HIPAA compliance policy including: i. Business Associates Agreement (Appendix B) ii. Patient Brochure (Appendix C) iii. Employee Contract (Appendix D) b. This policy follows these guidelines: i. Health Information Technology and-security-electronic-health-information ii. Medicare Education/Medicare-Learning-Network MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf iii. APTA c. The Business Associates Agreement is signed by both parties for each clinic d. In addition, the clearinghouse Availity and professional credentialing CAHQ as well as the merchant credit card company TSYS require quarterly attestations and/or computer sweeps e. The Laboratory Director shall engage in annual education modules on HIPAA Privacy and Security 3. Fraud, Abuse and Waste Prevention Policy11/27/2017 4 Xxxxxxxxxxxxa. The Laboratory Director is responsible for developing and implementing the Fraud, Abuse and Waste policy b. The Laboratory Director at Xxxxxxxxxxxx is the compliance officer and contact person c. This policy follows: i. APTA Center for Integrity in Practice ng_Risk/Understanding_Risk/Primer/PreventingFraudPrimer_Pre sentation.pdf ii. ABIM Choosing Wisely Campaign for EDX content/uploads/2015/02/AANEM-Choosing-Wisely-List.pdf iii. Medicare’s Comparative Billing Report for Electrodiagnostic Testing CBR201602 d. The Laboratory Director shall engage in annual education modules on Fraud, Abuse and Waste prevention 4. Supply Management Policy a. The Laboratory Director is responsible for developing and implementing the Supply Management policy b. The Laboratory Director at Xxxxxxxxxxxxis responsible for managing supplies including electrodes and electronic equipment 5. Electrical Equipment Check Policy a. The Laboratory Director is responsible for developing and implementing the Electrical Equipment Check policy b. The Laboratory Director at Xxxxxxxxxxxx is responsible for: i. Assuring the electronic equipment is checked annually for current leakage ii. Check during every session for broken or frayed wires and/or accessories iii. Weekly calibration checks of the EMG machine 11/27/2017 5 XxxxxxxxxxxxCHAPTER 3 PATIENT CARE 1. NCS/EMG Procedures and Policy (Appendix E) The Laboratory Director at Xxxxxxxxxxxxis responsible for developing and describing the general procedures for the performance of NCS/EMG studies 2. Normative Values Policy (Appendix F) a. Xxxxxxxxxxxx follows the published nerve conduction study guidelines found in: i. T Dillingham, S Chen, M Andary, et al. Establishing high-quality reference values for nerve conduction studies: a report from the normative data task force of the american association of neuromuscular & electrodiagnostic medicine. Muscle Nerve;54:366– 370, 2016 ii. S Chen, M Andary, R Buschbacher, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve;54:371–377, 2016 b. For nerves not listed in the above article, Xxxxxxxxxxxx follows the book: Kimura, Jun. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. Fourth Ed. 2013. Oxford Press, New York, New York 3. Medical Emergency Policy a. The Laboratory Director at Xxxxxxxxxxxx is responsible for reviewing and following each clinic’s medical emergency management procedures. b. Specifics describing the emergency action and evacuation policies are found in the manager or director’s office at each Xxxxxxxxxxxx contract site: i. Rue and Primavera Occupational and Physical Therapy, PLLC 1. Oak Harbor, WA 2. I would activate the emergency 911 system and initiate CPR ii. Island Hospital Medical Arts Pavilion Physical Therapy and Rehabilitation 1. Anacortes, WA 2. Activate the appropriate Code system (depending on the emergency type) and initiate CPR until the emergency team arrived iii. Olympic Medical Sleep Center 1. Sequim, WA 2. Activate the appropriate Code system (depending on the emergency type) and initiate CPR until the emergency team arrived11/27/2017 6 Xxxxxxxxxxxxiv. The Laboratory Director at Xxxxxxxxxxxx shall maintain a current Healthcare Provider Basic Life Support certification 4. Universal Precautions Policy (Appendix G) a. The Laboratory Director is responsible for developing and implementing the Universal Precautions policy b. Xxxxxxxxxxxx follows the FDA and CDC guidelines for cleaning and disinfecting in the healthcare setting i. FDA nandguidance/guidancedocuments/ucm253010.pdf ii. CDC n-guidelines.pdf c. The Laboratory Director at Xxxxxxxxxxxx is responsible for following universal precautions 5. Outcome Assessment Policy a. The Laboratory Director is responsible for developing and implementing the Outcome Assessment policy b. The Laboratory Director at Xxxxxxxxxxxx is responsible for monitoring outcomes c. This includes: i. Patient satisfaction surveys (Appendix H) ii. Referral source satisfaction surveys (Appendix I) iii. Peer reviews (Appendix J) d. These outcomes direct best practice and changes are made accordingly11/27/2017 7 XxxxxxxxxxxxCHAPTER 4 FACILITY 1. American Disabilities Act Compliance Policy a. The Laboratory Director is responsible for developing and implementing the American Disabilities Act Compliance policy b. The Laboratory Director at Xxxxxxxxxxxx is responsible for assuring access to all clients/patients c. All three clinics: Rue & Primavera, Island Hospital and Olympic Medical Center are compliant with the ADA and are fully accessible d. Both Island Hospital and Olympic Medical Center are accredited public hospitals and are ADA compliant e. Rue & Primavera is a private outpatient clinic that has a wide door that is entry-level and has a wheelchair accessible restroom 2. Facility Policy a. The Laboratory Director is responsible for developing and implementing the Facility policy b. All three clinics: Rue & Primavera, Island Hospital and Olympic Medical Center each have: i. Separate restrooms for staff and patients ii. Dedicated room for NCS/EMG testing iii. Patient waiting rooms iv. Break rooms for staff c. Rue & Primavera and Island Hospital facilities each have paper medical records in secured file rooms d. Olympic Medical Center only has electronic cloud storage for medical records e. None of the three clinics have dedicated areas for secure personal belongings storage 3. Emergency Plan Policy a. The Laboratory Director at Xxxxxxxxxxxx is responsible for: i. Reviewing and following each clinic’s emergency preparedness plan ii. Developing and following Xxxxxxxxxxxx emergency preparedness document (Appendix K) b. In the event of a natural disaster, Xxxxxxxxxxxx shall maintain patient report back up files on a secure cloud server 4. Power Outage Policy a. The Laboratory Director is responsible for developing and implementing the Power Outage policy11/27/2017 8 Xxxxxxxxxxxxb. All three clinics: Rue & Primavera, Island Hospital and Olympic Medical Center each have uninterrupted electrical supply and surge protection in place c. Xxxxxxxxxxxx EMG machine has auto-back up storage to prevent data loss for when the power is disconnected d. In the event a contract facility does not have uninterrupted electrical supply and surge protection in place: i. To ensure patient safety, the EDX procedure should be suspended during a power outage or electrical storm in the immediate vicinity of the facility ii. All electrodes should be removed from the patient or the electrode wires should be unplugged from the pre-amp and should not be reapplied until the power outage is over and power is restored or the electrical storm has passed iii. The EDX equipment should be turned off and unplugged. This is necessary to prevent circuit overload situations as power is restored iv. If possible, all EDX data should be saved before unplugging the EDX equipment v. After the power is reinstated or the electrical storm has passed the EDX equipment can be turned back on and the study continued11/27/2017 9 XxxxxxxxxxxxState of Washington APPENDIX A Medical Quality Assurance Commission Guideline Title: Retention of Medical Records GUI2017-02 References: Chapter 70.02 RCW Contact: Michael Farrell, JD, Policy Development Manager Phone: (509) 329-2186 E-mail: michael.farrell@doh. Effective Date: June 30, 2017 Supersedes: MD2013-08 Approved By: Warren Howe, MD, Chair (signature on file) Purpose The Medical Quality Assurance Commission (Commission) issues these guidelines to assist physicians and physician assistants (collectively “practitioners”) in the proper maintenance, retention and disposition of medical records. Guidelines A. Retention of Records 1. There is no general law in Washington requiring a practitioner to retain a patient’s medical record for a specific period of time.1 The Commission concurs with the Washington State Medical Association recommendation that practitioners should retain medical records and x-rays for at least: a. ten years from the date of a patient’s last visit, prescription refill, telephone contact, test or other patient contact; b. 21 years from the date of a minor patient’s birth; c. six years from the date of a patient’s death; or d. indefinitely, if the practitioner has reason to believe: i. the patient is incompetent; ii. there are any problems with a patient’s care, or iii. the patient may be involved in litigation. 2. A practitioner should consider whether it is feasible to retain patients’ medical records indefinitely. 1 RCW 70.02.160 requires a health care provider to maintain a record of existing health care information for at least one year following receipt of an authorization to disclose that health care information and during the pendency of a patient’s request either to examine or copy the record or to correct or amend the record.Retention of Medical Records Page 1 of 3 11/27/2017 10 Xxxxxxxxxxxx3. A practitioner should verify the retention time required by their medical malpractice insurer. 4. A practitioner should inform patients how long the practitioner will retain medical records. B. Storage of Records 1. Medical records, whether in electronic or paper format, should be stored to allow for lawful access and in a place that maintains confidentiality. 2. A practitioner may contract with a third party to act as custodian of the medical records. The responsible person, corporation, or legal entity acting as custodian of the records must comply with federal and or state confidentiality laws and regulations. C. Providing Medical Records to Patients or Other Providers 1. Per RCW 70.02.080, a practitioner is legally obligated to make medical records available to a patient to examine or copy within 15 days of the request. A practitioner may deny the request under circumstances specified in RCW 70.02.090. 2. A practitioner must honor a request by a patient to disclose health care information to another provider or third party. The practitioner may charge a reasonable fee and is not required to honor the request until the fee is paid. 3. The failure to provide medical records to patients in violation of RCW 70.02 can result in disciplinary action by the Commission. 4. The Commission recognizes that electronic health records systems may not be compatible, making it challenging to send records to a practitioner in another electronic health record system. Practitioners should do the best they can to get medical records to patients and subsequent providers in a usable format. D. Disposing of Records 1. When retention is no longer required, records should be destroyed by secure means. The Privacy Rule in the Health Insurance Portability and Accountability Act (HIPAA) prohibits digital and paper records containing confidential information from being thrown away in a public dumpster or recycling bin until they have been rendered unreadable or indecipherable by shredding, burning or other destruction. 2. A practitioner should give patients an opportunity to claim records of have them sent to another provider before records are destroyed. E. Closing a Medical Practice 1. The obligation to make medical records available to patients and other providers continues even after a practitioner closes a medical practice. 2. The recommendations in this section do not apply to: a. Practitioners who leave a multi-practitioner practice. In that instance, the remaining physicians in the practice typically assume care of the patients and retain the medical records.Retention of Medical Records Page 2 of 3 11/27/2017 11 Xxxxxxxxxxxxb. Specialists or other practitioners who do not have ongoing relationships with patients. These practitioners typically provide patient records to the referring practitioner, the patient’s primary care provider, or directly to the patient. 3. Prior to closing a practice, a practitioner should notify active patients and patients seen within three years. 4. The notice should be given at least 30 days in advance, with 90 days being the best practice. 5. The notice should be given by: a. individual letter to the last known patient address; and b. electronically, if this is a normal method of clinical communication with the patient; and c. notice in the local newspaper. 6. The notice should include: a. the name of the responsible entity or agent to contact to obtain records or request transfer of records, telephone number and mailing address; b. how the records can be obtained or transferred; c. the format of the records, whether hard copy or electronic; d. how long the records will be maintained before they are destroyed; and e. the cost of recovering records or transferring records as defined in Chapter 70.02 RCW. 7. The practitioner should also provide notice to the local medical society, whether the practitioner is a member or not. 8. If the practice closes due to the practitioner’s death, the practitioner’s estate becomes the owner of the medical records and should provide this notification to patients.Retention of Medical Records Page 3 of 3 11/27/2017 12 XxxxxxxxxxxxAPPENDIX B Xxxxxxxxxxxx Business Associate Agreement Provisions Words or phrases contained in brackets are intended as either optional language or as instructions to the users of these sample provisions. Definitions Catch-all definition: The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use. Specific definitions: (a) Business Associate. “Business Associate” shall generally have the same meaning as the term “business associate” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean Rue & Primavera Occupational and Physical Therapy, PLLC. (b) Covered Entity. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 CFR 160.103, and in reference to the party to this agreement, shall mean Xxxxxxxxxxxxand/or its member Xxxxxxxxxxxx, PT, DSc, ECS. (c) HIPAA Rules. “HIPAA Rules” shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164. Obligations and Activities of Business Associate Business Associate agrees to: (a) Not use or disclose protected health information other than as permitted or required by the Agreement or as required by law; (b) Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information, to prevent use or disclosure of protected health information other than as provided for by the Agreement; (c) Report to covered entity any use or disclosure of protected health information not provided for by the Agreement of which it becomes aware, including breaches of unsecured protected health information as required at 45 CFR 164.410, and any security incident of which it becomes aware; (d) In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any subcontractors that create, receive, maintain, or transmit protected health information on behalf of the business associate agree to the same restrictions, conditions, and requirements that apply to the business associate with respect to such information; (e) Make available protected health information in a designated record set to the covered entity as necessary to satisfy covered entity’s obligations under 45 CFR 164.524; (f) Make any amendment(s) to protected health information in a designated record set as directed or agreed to by the covered entity pursuant to 45 CFR 164.526, or take 11/27/2017 13 Xxxxxxxxxxxxother measures as necessary to satisfy covered entity’s obligations under 45 CFR 164.526; (g) Maintain and make available the information required to provide an accounting of disclosures to the covered entity as necessary to satisfy covered entity’s obligations under 45 CFR 164.528; (h) To the extent the business associate is to carry out one or more of covered entity's obligation(s) under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to the covered entity in the performance of such obligation(s); and (i) Make its internal practices, books, and records available to the Secretary for purposes of determining compliance with the HIPAA Rules. Permitted Uses and Disclosures by Business Associate (a) Business associate may only use or disclose protected health information as necessary to perform the services set forth in the Professional Services Agreement. (b) Business associate may use or disclose protected health information as required by law. (c) Business associate agrees to make uses and disclosures and requests for protected health information consistent with covered entity’s minimum necessary policies and procedures. (d) Business associate may not use or disclose protected health information in a manner that would violate Subpart E of 45 CFR Part 164 if done by covered entity except for the specific uses and disclosures set forth below. (e) Business associate may use protected health information for the proper management and administration of the business associate or to carry out the legal responsibilities of the business associate. (f) Business associate may disclose protected health information for the proper management and administration of business associate or to carry out the legal responsibilities of the business associate, provided the disclosures are required by law, or business associate obtains reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies business associate of any instances of which it is aware in which the confidentiality of the information has been breached. (g) Business associate may provide data aggregation services relating to the health care operations of the covered entity. Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions (a) Covered entity shall notify business associate of any limitation(s) in the notice of privacy practices of covered entity under 45 CFR 164.520, to the extent that such limitation may affect business associate’s use or disclosure of protected health information. (b) Covered entity shall notify business associate of any changes in, or revocation of, the permission by an individual to use or disclose his or her protected health 11/27/2017 14 Xxxxxxxxxxxxinformation, to the extent that such changes may affect business associate’s use or disclosure of protected health information. (c) Covered entity shall notify business associate of any restriction on the use or disclosure of protected health information that covered entity has agreed to or is required to abide by under 45 CFR 164.522, to the extent that such restriction may affect business associate’s use or disclosure of protected health information. Permissible Requests by Covered Entity Covered entity shall not request business associate to use or disclose protected health information in any manner that would not be permissible under Subpart E of 45 CFR Part 164 if done by covered entity, except if the business associate will use or disclose protected health information for, and the agreement includes provisions for, data aggregation or management and administration and legal responsibilities of the business associate. Term and Termination (a) Term. The Term of this Agreement shall be effective as of September 1, 2013 shall terminate on the dissolution of the Professional Services Agreement contract or on the date covered entity terminates for cause as authorized in paragraph (b) of this Section, whichever is sooner. (b) Termination for Cause. Business associate authorizes termination of this Agreement by covered entity, if covered entity determines business associate has violated a material term of the Agreement [and business associate has not cured the breach or ended the violation within the time specified by covered entity]. (c) Obligations of Business Associate Upon Termination. [Option 1 – if the business associate is to return or destroy all protected health information upon termination of the agreement] Upon termination of this Agreement for any reason, business associate shall return to covered entity [or, if agreed to by covered entity, destroy] all protected health information received from covered entity, or created, maintained, or received by business associate on behalf of covered entity, that the business associate still maintains in any form. Business associate shall retain no copies of the protected health information. [Option 2—if the agreement authorizes the business associate to use or disclose protected health information for its own management and administration or to carry out its legal responsibilities and the business associate needs to retain protected health information for such purposes after termination of the agreement] Upon termination of this Agreement for any reason, business associate, with respect to protected health information received from covered entity, or created, maintained, or received by business associate on behalf of covered entity, shall: 1. Retain only that protected health information which is necessary for business associate to continue its proper management and administration or to carry out its legal responsibilities; 2. Return to covered entity [or, if agreed to by covered entity, destroy] the remaining protected health information that the business associate still maintains in any form;11/27/2017 15 Xxxxxxxxxxxx3. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect to electronic protected health information to prevent use or disclosure of the protected health information, other than as provided for in this Section, for as long as business associate retains the protected health information; 4. Not use or disclose the protected health information retained by business associate other than for the purposes for which such protected health information was retained and subject to the same conditions set out at Permitted Uses and Disclosures By Business Associate paragraphs (e) and (f) above which applied prior to termination; and 5. Return to covered entity [or, if agreed to by covered entity, destroy] the protected health information retained by business associate when it is no longer needed by business associate for its proper management and administration or to carry out its legal responsibilities. 6. The business associate will transmit the protected health information to another business associate of the covered entity at termination, and/or could add terms regarding a business associate’s obligations to obtain or ensure the destruction of protected health information created, received, or maintained by subcontractors. (d) Survival. The obligations of business associate under this Section shall survive the termination of this Agreement. Miscellaneous [Optional] (a) Regulatory References. A reference in this Agreement to a section in the HIPAA Rules means the section as in effect or as amended. (b) Amendment. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for compliance with the requirements of the HIPAA Rules and any other applicable law. (c) Interpretation. Any ambiguity in this Agreement shall be interpreted to permit compliance with the HIPAA Rules.11/27/2017 16 XxxxxxxxxxxxAPPENDIX C PATIENT BROCHURE Your Information. 19050-308135Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record Ask us to correct your medical record Request confidential communications U You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. U?We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. U?You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. U?We may say “no” to your request, but we’ll tell you why in writing within 60 days. U?You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. U?We will say “yes” to all reasonable requests. continued on next page ?Vi?v?*??>V??*?>V?Vi???U??*>}i?? 11/27/2017 17 XxxxxxxxxxxxYour Rights continuedAsk us to limit what we use or share Get a list of those with whom we’ve shared information Get a copy of this privacy notice Choose someone to act for you File a complaint if you feel your rights are violated U?You can ask us not to use or share certain health information for treatment, payment, or our operations. U?We are not required to agree to your request, and we may say “no” if it would affect your care. U?If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. U?We will say “yes” unless a law requires us to share that information. U?You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. U?We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within ?????°? U?You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. U?If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. U?We will make sure the person has this authority and can act for you before we take any action. U?You can complain if you feel we have violated your rights by contacting us ??}??i?v?>????>}i??° U?You can file a complaint with the U.S. Department of Health and Human -i??Vi??"vwVi?v????,}???L???i`}?>?i??i???????? `i?i`iVi? ?i?i]?-°7°]?7>?}?]? °°??????]?V>}??n???????x]???visiting ocr/privacy/hipaa/complaints/. U?We will not retaliate against you for filing a complaint. ?Vi?v?*??>V??*?>V?Vi???U??*>}i?? 11/27/2017 18 Xxxxxxxxxxxx Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: In these cases we never share your information unless you give us written permission: U??Share information with your family, close friends, or others involved in your care U??Share information in a disaster relief situation U??Include your information in a hospital directory U??Contact you for fundraising efforts If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. U??Marketing purposes U??Sale of your information U??Most sharing of psychotherapy notes In the case of fundraising: U??We may contact you for fundraising efforts, but you can tell us not to contact you again. Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you U We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Run our organization Bill for your services U We can use and share your health information to run our practice, improve your care, and contact you when necessary. U We can use and share your health information to bill and get payment from health plans or other entities. Example: We use health information about you to manage your treatment and services. Example: We give information about you to your health insurance plan so it will pay for your services. continued on next page ?Vi?v?*??>V??*?>V?Vi???U??*>}i?? 11/27/2017 19 XxxxxxxxxxxxHow else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues U?We can share health information about you for certain situations such as: U?Preventing disease U?Helping with product recalls U?Reporting adverse reactions to medications U?Reporting suspected abuse, neglect, or domestic violence U?Preventing or reducing a serious threat to anyone’s health or safety Do research U?We can use or share your information for health research. Comply with the law U We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions ?Vi?v?*??>V??*?>V?Vi???U??*>}i?{ U?We can share health information about you with organ procurement organizations. U?We can share health information with a coroner, medical examiner, or funeral director when an individual dies. U?We can use or share health information about you: U?For workers’ compensation claims U For law enforcement purposes or with a law enforcement official U With health oversight agencies for activities authorized by law U For special government functions such as military, national security, and presidential protective services U We can share health information about you in response to a court or administrative order, or in response to a subpoena.11/27/2017 20 XxxxxxxxxxxxOur Responsibilities U We are required by law to maintain the privacy and security of your protected health information. U We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. U??We must follow the duties and privacy practices described in this notice and give you a copy of it. U??We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. This Notice of Privacy Practices applies to the following organizations. ?Vi?v?*??>V??*?>V?Vi???U??*>}i?x 11/27/2017 21 XxxxxxxxxxxxAPPENDIX D Protected Health Information Employee Confidentiality Agreement Xxxxxxxxxxxx(herein “Clinic”) has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their health information. In order to meet this responsibility, the Clinic must assure that our employees and other workforce members keep patients’ protected health information confidential. All employees and members of our workforce will receive training on the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, Breach Notification Rule, and the Clinic’s associated policies. In order to ensure the confidentiality of patients’ protected health information, employees and other workforce members must comply with the following: 1. Employees and other workforce members must not disclose or discuss any patient, human resources, and/or management information with others, including other staff, friends and family, who do not have a “need to know.” “Need to know” staff includes only those staff members with a need to know the particular information for the purpose of performing employment responsibilities for Clinic. 2. Employees and other workforce members must not access any information, or utilize equipment, other than what is required to perform their job. 3. Employees and other workforce members must not discuss patient, human resources, or administrative information where others can overhear the conversation, e.g. in hallways, elevators, public transportation, at restaurants or social events. It is not acceptable to discuss clinical information in public areas even if a patient’s name is not used. This can raise doubts with patients and other providers about Clinic’s respect for patients’ privacy. 4. Employees and other workforce members must not make inquiries or look up information for other personnel who do not have proper authority. 5. Employees and other workforce members must not willingly tell another person their computer password or knowingly use another person’s computer password instead of their own for any reason. Employees and other workforce members must not log on and allow another person to use a computer under their password. Passwords must not be written down where others can find and/or use them. 6. Employees and other workforce members must not make unauthorized transmissions, inquiries, modifications, or purging of data through the Clinic’s computer system. Unauthorized transmissions include, but are not limited to, removing and/or transferring data from the computer system to unauthorized locations, e.g. an employee’s home. 11/27/2017 22 Xxxxxxxxxxxx7. Employees and other workforce members must log off prior to leaving any computer or terminal unattended. 8. Employees and other workforce members must keep papers with protected health information in a secure place, promptly remove them from un-secured locations such as copy and fax machines and conference rooms, and place them in the appropriate bin for shredding when they are no longer needed. 9. Employees and other workforce members must not access data simply to satisfy a curiosity. Information may only be viewed when required for carrying out the employee’s job responsibility. 10. If assigned a key to the facilities, the employee or other workforce member must (a) not make a copy of the key; (b) not allow any person not employed by the Clinic to use the key; (c) turn in the key immediately upon termination of employment; and (d) report immediately any loss of the key to the Privacy Officer and/or the employee’s or workforce member’s supervisor. 11. The last employee or other workforce member to leave the facility has responsibility to insure that all access doors are locked. Employees and other workforce members must also ensure that co-workers, patients, and others are not subject to intimidation, threats, coercion, discrimination, or retaliation for complying with HIPAA or the Clinic’s privacy policies. Employees or other workforce members failing to comply with the above responsibilities may be subject to discipline as determined by Clinic management in its discretion. By signing this Confidentiality Agreement, I agree to comply with the above confidentiality requirements. I also acknowledge that I have received training on and reviewed a copy of the Clinic’s HIPAA Privacy Policies and Notification of Breach of Unsecured Protected Health Information Policy. DATED this 23rd day of October 2016. Signature of Employee or Workforce Member , PT, DSc, ECS Printed Name Signature of Clinic Privacy Officer , PT, DSc, ECS Printed Name of Clinic Privacy Officer11/27/2017 23 XxxxxxxxxxxxAPPENDIX E NCS and EMG Procedures Documentation shall include referring provider name (required by state law), date of service, patient name, patient gender, patient date of birth, patient height, reason for visit/medical necessity, medical history and review of systems, medication list, abbreviated neuromuscular examination, skin temperature, recording distance, recording site, stimulation site, amplitude, conduction velocity, needle type, data table with normative values, wave forms, summary of findings, impression and signature. For specific nerve conduction study procedures Xxxxxxxxxxxx follows those published in: ? Kimura, Jun. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. Fourth Ed. 2013. Oxford Press, New York, New York. ? Chen, M Andary, R Buschbacher, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve;54:371– 377, 2016. The following represent the general oscilloscope settings. These may be changed as needed during the clinical testing or for special recordings. Motor nerve conduction studies upper extremities Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature hand 8.0 cm 10 kHz 2-3 Hz 5 ms/div 5 mV/div orthodromic ≥32° C Motor nerve conduction studies lower extremities Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature foot 8.0 cm 10 kHz 2-3 Hz 5 ms/div 5 mv/div orthodromic ≥31° C Sensory nerve conduction studies upper extremities Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature hand 14.0 cm 2 kHz 20 Hz 1 ms/div 10 ?V/div antidromic ≥32° C Sensory nerve conduction studies lower extremities Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature foot 14.0 cm 2 kHz 20 Hz 1 ms/div 5 ?V/div antidromic ≥31° C11/27/2017 24 XxxxxxxxxxxxMixed nerve conduction studies Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature hand/foot 8.0 cm 2 kHz 20 Hz 1 ms/div 5 ?V/div orthodromic ≥32° C/≥31° C F waves Distance High cut filter Low cut filter Sweep Speed Gain Direction Temperature hand/foot 8.0 cm 10 kHz 2-3 Hz 5 ms/div 5 mv/div antidromic ≥32° C/≥31° C H Reflexes Distance High cut filter Low cut filter Sweep Speed Gain Temp foot ? distance between the proximal medial malleolus and popliteal space Repetitive stimulation* 2 kHz 20 Hz 1 ms/div 5 ?V/div ≥31° C Distance High cut filter Low cut filter Sweep Speed Gain Rate Direction Temp hand/ foot 8.0 cm 10 kHz 2-3 Hz 5 ms/div 5 mv/div 3 Hz orthodromic ≥32° C/ ≥31° C *First to fifth evoked response amplitude comparison. May include post-exercise protocol: ? Baseline ? Immediate post 30 second tetanic contraction ? 30 seconds post exercise ? 1 minute post exercise ? 2 minutes post exercise ? 5 minutes post exercise Needle electromyography High cut filter Low cut filter Sweep Speed Gain 10 kHz 10 Hz 10 ms/div 100 mV and 1 mV/div 11/27/2017 25 XxxxxxxxxxxxAPPENDIX F Normal Values SENSORY Technique parameters: 20 Hz (low); 2 kHz (high); 1 ms/div Sweep; 5-10 ?V/div GainDistance cm Electrode Distal Latency/Peak ms Amplitude/Peak to Peak ?VMedian digit II 14 4.0 13Ulnar digit V 14 4.0 9Superficial Radial 10 2.8 11Median digit II to Ulnar digit V ? ? 0.4Lateral Antebrachial Cutaneous 10 Bar 2.5 6Medial Antebrachial Cutaneous 10 Bar 2.6 3Sural 14 Bar 4.5 4MOTOR Technique parameters: 2-3 Hz (low); 10 kHz (high); 2-5 ms/div Sweep; 5 mV/div GainDistance cm Distal Latency Onset msAmplitude Baseline to Peak mVConduction Velocity m/sMedian 8 4.5 4.1 49Ulnar 8 3.7 7.9 52 m/s Below elbow43 m/s Across elbow15 m/s drop across the elbow23% drop across the elbowM to U ? ? 1.5Peroneal 8 6.5 1.3 38 Below fibular headAge 19-39 2.6 42 Across fibular headAge 40-79 1.1 6 m/s drop across the fibular head25% drop across the fibular head 12% drop across the fibular headTibial 8 6.1 4.4 39>32°C dorsum hand/>31°C dorsum footS Chen, M Andary, R Buschbacher, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve;54:371–377, 2016. Prevalance of accessory deep peroneal nerve 13.5% 11/27/2017 26 XxxxxxxxxxxxAPPENDIX G Universal Precautions and/or Blood Borne Pathogens Infection Control Procedures for NCS/EMG studies Xxxxxxxxxxxxfollows the FDA and CDC guidelines for cleaning and disinfecting in the healthcare setting. 1. Washing/Disinfecting a. All staff shall wash hands or use hand disinfectant before and after every patient contact b. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or other body fluids 2. Barrier Protection a. All staff should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated b. Gloves should be worn for all needle EMG procedures, touching blood and body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids c. Gloves should be changed after contact with each patient 3. Sterile, single-use, disposable EMG needles shall be used with each patient 4. Homeostasis a. In the event of bleeding: i. The wound shall be compressed until the bleeding stops ii. Use of a band aid is optional b. The patient shall be notified to monitor the site after the end of the procedure 5. Sharps Containers a. Sharps container must be maintained in rooms where procedures using sharps are being performed b. To prevent needle stick injuries, EMG needles should be recapped using a one-handed method, but shouldn’t be purposely bent or broken by hand, or otherwise manipulated by hand c. After sharps are used, they should be placed in puncture-resistant containers for disposal; the puncture-resistant containers should be located as close as practical to the use area 6. Disinfection of equipment used in procedures a. Staff should be aware of the appropriate disinfection and sterilization procedures for their equipment b. Those staff members who perform disinfection must be specifically trained in these procedures. This includes: 11/27/2017 27 Xxxxxxxxxxxxi. Disinfection with isopropyl alcohol for items such as surface electrodes and stimulator probes (specifically if skin abrasion is involved) ii. Surface electrodes stimulator probes that are used without prior abrading of the skin may be cleaned with soap and water 7. Inadvertent needle stick a. In the event of an inadvertent needle stick, the provider shall: i. Immediately wash the area with soap and water ii. Seek emergent health care attention (go to the nearest emergency room) b. The patient shall be notified of the inadvertent needle stick 9/8/13 CDC: guidelines.pdf guidelines.pdf FDA: idancedocuments/ucm253010.pdf11/27/2017 28 XxxxxxxxxxxxGuideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Table 1. Methods of sterilization and disinfection. Sterilization Disinfection High-level (semicritical Critical items (will enter tissue or vascular system or blood will flow through them) Object Procedure Exposure time items; [except dental] will come in contact with mucous membrane or nonintact skin) Procedure (exposure time 12-30 min at ≥20oC)2,3 Intermediate level (some semicritical items1 and noncritical items) Procedure (exposure time > 1 m) 9 Low-level (noncritical items; will come in contact with intact skin) Procedure (exposure time > 1 m) 9 Smooth, hard Surface1,4 Rubber tubing and catheters3,4 Polyethylene tubing and catheters3,4,7 A B C D F G H A B C D F G H A B C D F G H MR MR MR 10 h at 20-25oC 6 h 12 m at 50-56oC 3-8 h MR MR MR 10 h at 20-25oC 6 h 12 m at 50-56oC 3-8 h MR MR MR 10 h at 20-25oC 6 h 12 m at 50-56oC 3-8 h D E F H I6 J D E F H I6 J D E F H I6 J K L5 M N K L M N O Lensed instruments4 A B C D F G H Thermometers (oral and rectal)8 Hinged instruments4 A B C D F G H MR MR MR 10 h at 20-25oC 6 h 12 m at 50-56oC 3-8 h MR MR MR 10 h at 20-25oC 6 h 12 m at 50-56oC 3-8 h D E F H J D E F H I6 J K8 Modified from Rutala and Simmons. 15, 17, 18, 421 The selection and use of disinfectants in the healthcare field is dynamic, and products may become available that are not in existence when this guideline was written. As newer disinfectants become available, persons or committees responsible for selecting disinfectants and sterilization processes should be guided by products cleared by the FDA and the EPA as well as information in the scientific literature. 10411/27/2017 29 XxxxxxxxxxxxGuideline for Disinfection and Sterilization in Healthcare Facilities, 2008 A, Heat sterilization, including steam or hot air (see manufacturer's recommendations, steam sterilization processing time from 3-30 minutes) B, Ethylene oxide gas (see manufacturer's recommendations, generally 1-6 hours processing time plus aeration time of 8-12 hours at 50-60oC) C, Hydrogen peroxide gas plasma (see manufacturer’s recommendations for internal diameter and length restrictions, processing time between 45-72 minutes). D, Glutaraldehyde-based formulations (>2% glutaraldehyde, caution should be exercised with all glutaraldehyde formulations when further in-use dilution is anticipated); glutaraldehyde (1.12%) and 1.93% phenol/phenate. One glutaraldehyde-based product has a high-level disinfection claim of 5 minutes at 35oC. E, Ortho-phthalaldehyde (OPA) 0.55% F, Hydrogen peroxide 7.5% (will corrode copper, zinc, and brass) G, Peracetic acid, concentration variable but 0.2% or greater is sporicidal. Peracetic acid immersion system operates at 50-56oC. H, Hydrogen peroxide (7.35%) and 0.23% peracetic acid; hydrogen peroxide 1% and peracetic acid 0.08% (will corrode metal instruments) I, Wet pasteurization at 70oC for 30 minutes with detergent cleaning J, Hypochlorite, single use chlorine generated on-site by electrolyzing saline containing >650-675 active free chlorine; (will corrode metal instruments) K, Ethyl or isopropyl alcohol (70-90%) L, Sodium hypochlorite (5.25-6.15% household bleach diluted 1:500 provides >100 ppm available chlorine) M, Phenolic germicidal detergent solution (follow product label for use-dilution) N, Iodophor germicidal detergent solution (follow product label for use-dilution) O, Quaternary ammonium germicidal detergent solution (follow product label for use-dilution) MR, Manufacturer's recommendations NA, Not applicable 1 See text for discussion of hydrotherapy. 2 The longer the exposure to a disinfectant, the more likely it is that all microorganisms will be eliminated. Follow the FDA-cleared high-level disinfection claim. Ten-minute exposure is not adequate to disinfect many objects, especially those that are difficult to clean because they have narrow channels or other areas that can harbor organic material and bacteria. Twenty-minute exposure at 20oC is the minimum time needed to reliably kill M. tuberculosis and nontuberculous mycobacteria with a 2% glutaraldehyde. Some high-level disinfectants have a reduced exposure time (e.g., ortho-phthalaldehyde at 12 minutes at 20oC) because of their rapid activity against mycobacteria or reduced exposure time due to increased mycobactericidal activity at elevated temperature (e.g., 2.5% glutaraldehyde at 5 minutes at 35oC, 0.55% OPA at 5 min at 25oC in automated endoscope reprocessor). 3 Tubing must be completely filled for high-level disinfection and liquid chemical sterilization; care must be taken to avoid entrapment of air bubbles during immersion. 4 Material compatibility should be investigated when appropriate. 5 A concentration of 1000 ppm available chlorine should be considered where cultures or concentrated preparations of microorganisms have spilled (5.25% to 6.15% household bleach diluted 1:50 provides > 1000 ppm available chlorine). This solution may corrode some surfaces. 6 Pasteurization (washer-disinfector) of respiratory therapy or anesthesia equipment is a recognized alternative to high level disinfection. Some data challenge the efficacy of some pasteurization units. 7 Thermostability should be investigated when appropriate. 8 Do not mix rectal and oral thermometers at any stage of handling or processing. 9 By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered products label, the user assumes liability from any injuries resulting from off-label use and is potentially subject to enforcement action under FIFRA. 10511/27/2017 30 XxxxxxxxxxxxReprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff Document issued on: March 1 , 2015 This document supersedes: “Labeling Reusable Medical Devices for Reprocessing in Health Care Facilities: FDA Reviewer Guidance” issued April 1996. The draft of this document was issued on May 2, 2011. For questions regarding devices regulated by the Center for Devices and Radiological Health, contact the Infection Control Devices Branch (INCB) at (301) 796-5580. For questions regarding devices regulated by the Center for Biologics Evaluation and Research (CBER), contact the Office of Communication, Outreach and Development at 800-835-4709 or 240-402-7800. U.S. Department of Health and Human Services 19050489511905027492Food and Drug Administration Center for Devices and Radiological Health Office of Office of Device Evaluation Center for Biologics Evaluation and Research11/27/2017 31 XxxxxxxxxxxxAPPENDIX H Patient Satisfaction Survey CONFIDENTIAL Circle the best choice: 1. It was easy to schedule an appointment with this clinic. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Completely Neutral Completely disagree agree 2. I didn’t have to wait (beyond my appointment time) to be seen by the provider. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Completely Neutral Completely disagree agree 3. I’m satisfied with the cleanliness and appearance of this clinic. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Completely Neutral Completely Disagree agree 4. I’m pleased with the overall care I received from the provider. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Completely Neutral Completely disagree agree 5. I will recommend this clinic and the provider to a friend or family member. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Completely Neutral Completely disagree agree11/27/2017 32 XxxxxxxxxxxxAPPENDIX I REFERRAL SOURCE SATISFACTION SURVEY SURVEY: Referral Source Satisfaction for NCS/EMG Studies 1. My patients are able to schedule the NCS/EMG study promptly (within two weeks). 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 2. My staff informs me that the NCS/EMG office is easy to contact and pleasant to work with over the phone. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 3. My office receives the NCS/EMG study results in a timely fashion (within 24 hours after testing). 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 4. My patients are satisfied with the care they received in spite of their discomfort during the NCS/EMG procedures. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 5. The appropriate number of nerves and muscles are tested (not too many or too few) during the NCS/EMG study. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree11/27/2017 33 Xxxxxxxxxxxx6. The NCS/EMG study is thorough and comprehensive. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 7. The NCS/EMG study written report is easy to understand. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 8. The clinical question posed on the referral is adequately addressed by the NCS/EMG study. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 9. The NCS/EMG study results are useful in helping to determine the definitive diagnosis. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree 10. I’m satisfied with the NCS/EMG services. 1……….2……....3…..…..4……....5……....6……....7……....8……....9……....10 Not Applicable Completely Neutral Completely disagree agree Comments (optional):11/27/2017 34 XxxxxxxxxxxxAPPENDIX J PEER REVIEW CHECK LISTS FOR FOUR CLINICAL DIAGNOSES Checklist Carpal Tunnel Syndrome Items weighted based on literature classification criteria relating to the procedure: Grade each item from 0 to 6 points (maximum) ITEM POINTS 1. Clinical diagnosis included: a. History and symptoms ________/6 b. Physical examination including strength, sensation, and provocative tests ________/6 2. Procedure details included: a. Distances listed ________/6 b. Orthodromic or antidromic recording designations ________/6 3. Stimulation sites listed ________/6 4. Recording sites listed ________/6 5. Limb temperature recorded ________/6 6. Criteria for abnormal values threshold listed ________/6 Items weighted based on the practice recommendations: Standard Class A: High (study met six out of six criteria): Grade each item 0 to 6 points (maximum) 7. Median nerve sensory at 13cm or 14cm ________/6 8. Ulnar or radial nerve sensory same hand ________/6 9. If median nerve sensory at 13cm or 14cm is normal then: median mixed nerve at 7cm or 8cm ________/6 Items weighted based on the practice recommendations: Guideline Class B: Moderate (study met four or five out of six criteria): Grade each item 0 to 4 points (maximum) 10. Median nerve motor ________/4 11. Other motor nerve same hand ________/4 Items weighted based on the practice recommendations: Option Class C: Uncertain (study met three or less out of six criteria): Grade each item 0 to 2 points (maximum) 12. Needle EMG screen of C5 through C8 innervated muscles, including a median innervated thenar muscle ________/211/27/2017 35 XxxxxxxxxxxxTOTAL SCORE including Item 9: _______/76 =_______% TOTAL SCORE excluding Item 9: _______/70 =_______%11/27/2017 36 XxxxxxxxxxxxChecklist Ulnar Neuropathy At The Elbow Items weighted based on literature classification criteria relating to the procedure: Grade each item 0 to 6 points (maximum) ITEM POINTS 1. Clinical diagnosis included: a. History and symptoms ________/6 b. Physical examination including strength, sensation, and provocative tests ________/6 2. Procedure details included: a. Distances listed ________/6 b. Orthodromic or antidromic recording designations ________/6 c. Stimulation sites listed ________/6 d. Recording sites listed ________/6 3. Limb temperature recorded ________/6 4. Criteria for abnormal values threshold listed ________/6 Items weighted based on the practice recommendations: Standard Class A: High (study met six out of six criteria): Grade each item 0 to 6 points (maximum) 5. Ulnar nerve motor recording from the ADV muscle ________/6 6. Ulnar nerve sensory ________/6 7. If Item 5 or Item 6 are abnormal then other nerve are tested to exclude a more diffuse process ________/6 8. Elbow position maintained between 70° and 90° of flexion ________/6 Items weighted based on the practice recommendations: Guideline Class B: Moderate (study met four or five out of six criteria): Grade each item 0 to 4 points (maximum) 9. Ulnar nerve motor below elbow stimulation site is less than 3cm below the medial epicondyle is listed ________/4 At least one of the following in order of strength of evidence is present: Points scored on one item only: 10-13 10. Ulnar nerve motor conduction velocity across the elbow is <50 M/S ________/4 11. Ulnar nerve motor conduction velocity across the elbow segment slows >10 M/S when compared to the forearm segment ________/4 12. The ulnar nerve motor CMAP at the above elbow site drops >20% when compared to the below elbow CMAP ________/4 13. There is a significant change in the ulnar nerve motor configuration at the above elbow site compared to the below elbow site ________/411/27/2017 37 XxxxxxxxxxxxIf the above items 9-13 are inconclusive then at least one of the following: Points scored on one item only: 14-16 ITEM POINTS 14. Ulnar nerve motor recording from the FDI ________/4 15. Inching in 1-2cm increments across the elbow looking for abnormal changes in latency, amplitude, area, or configuration ________/4 16. Needle EMG to include the FDI and an ulnar innervated forearm muscle, if abnormal then include C8/medial cord/lower trunk innervated muscles and cervical paraspinal muscles ________/4 Items weighted based on the practice recommendations: Option Class C: Uncertain (study met three or less out of six criteria): Grade each item 0 to 2 points (maximum) 17. Ulnar nerve motor conduction velocity across the elbow segment compared to the upper arm segment ________/2 18. Ulnar nerve motor recording from a forearm flexor muscle ________/2 TOTAL SCORE including Item 7: _______/88 =_______% TOTAL SCORE excluding Item 7: _______/82 =_______%11/27/2017 38 XxxxxxxxxxxxChecklist Cervical Radiculopathy Items weighted based on literature classification criteria relating to the procedure: Grade each item 0 to 6 points (maximum) ITEM POINTS 1. Clinical diagnosis included: a. History and symptoms ________/6 b. Physical examination including strength, sensation, and provocative tests and reflexes ________/6 c. Screen for other confounding conditions that mimic or are concomitant with cervical radiculopathy (CTS, ulnar neuropathy at the elbow, TOS, brachial plexopathy, peripheral neuropathy, MND) ________/6 2. Procedure details (type of needle, muscles listed) ________/6 3. Clearly stated criteria for needle EMG abnormality identification (activity: insertional, rest, voluntary, and maximum effort) ________/6 Items weighted based on the practice recommendations: Standard Class A: High (study met six out of six criteria): 0 to 6 points (maximum) None. Items weighted based on the practice recommendations: Guideline Class B: Moderate (study met four or five out of six criteria): Grade each item 0 to 4 points (maximum) 4. Needle EMG of symptomatic limb a. At least one muscle innervated by the C5, C6, C7, C8, and T1 spinal roots ________/4 b. At least one level of the cervical paraspinals ________/4 5. One or two additional muscles innervated by the suspected root and by a different peripheral nerve ________/4 6. Demonstration of normal muscles innervated above and below the suspected root level ________/4 7. At least one motor NCS ________/4 8. At least one sensory NCS ________/4 If Item 7 and/or Item 8 are abnormal, then in order to exclude a more diffuse process: 9. Other motor and/or sensory NCS ________/4 Items weighted based on the practice recommendations: Option Class C: Uncertain (study met three or less out of six criteria): Grade each item 0 to 2 points (maximum)11/27/2017 39 XxxxxxxxxxxxITEM POINTS Points scored on one item only: 10-13 10. Cervical root stimulation ________/2 11. H Reflex study of the FCR to assist in identifying C6 or C7 pathology ________/2 If needle EMG is abnormal then in order to exclude a more diffuse process: 12. Needle EMG of one or more muscles on the contralateral side ________/2 If C8 or T1 radiculopathy is suspected then: 13. Median and/or ulnar nerve F waves including contralateral side for comparison if necessary ________/2 TOTAL SCORE including Item 9: _______/60 =_______% TOTAL SCORE excluding Item 9: _______/56 =_______%11/27/2017 40 XxxxxxxxxxxxChecklist Distal Symmetrical Polyneuropathy ITEM POINTS Items weighted based on literature classification criteria relating to the procedure: Grade each item 0 to 6 points (maximum). Level A evidence 1. Distances listed ________/6 2. Orthodromic or antidromic recording designations ________/6 3. Stimulation sites listed ________/6 4. Recording sites listed ________/6 5. Limb temperature recorded ________/6 6. Criteria for abnormal values threshold listed ________/6 7. Needle type recorded ________/6 Clinical diagnosis includes: Items weighted based on literature classification criteria relating to the procedure: Grade each item 0 to 4 points (maximum). Level B evidence 8. History and symptoms including numbness, altered sensation or pain in the feet ________/4 9. Physical examination signs including decreased or absent ankle reflexes, decreased distal sensation and distal muscle weakness or atrophy ________/4 10. Screen for other confounding conditions that mimic or are concomitant with distal symmetrical polyneuropathy (lumbosacral radiculopathy, lumbar plexopathy, sacral plexopathy, focal neuropathy) ________/4 Simplified nerve conduction protocol: Grade each item 0 to 4 points (maximum). Level B evidence 11. Sural nerve sensory recorded on one lower extremity ________/4 12. Peroneal/fibular nerve motor recorded on one lower extremity ________/4 13. Peroneal/fibular nerve F waves recorded one lower extremity ________/4 If any aspects of the sural nerve sensory and/or the peroneal/fibular nerve motor are abnormal, then: Grade each item 0 to 4 points (maximum). Level B evidence 14. Contralateral limb sural nerve sensory recording ________/4 15. Contralateral limb tibial nerve motor recording ________/4 16. Contralateral limb tibial nerve F waves recorded ________/4 17. Median nerve sensory recording in one upper extremity ________/4 18. Ulnar nerve sensory recording in one upper extremity ________/4 19. Ulnar nerve motor recording in one upper extremity ________/4 20. Ulnar nerve F waves recorded one upper extremity ________/4 21. Needle EMG of at least two (2) limbs ________/4 ITEM POINTS11/27/2017 41 XxxxxxxxxxxxIf any of the above nerves tested (Items 11-21) are absent, then: Grade each item 0 to 4 points (maximum). Level B evidence 22. Contralateral sensory nerve/s recorded ________/4 23. Contralateral motor nerve/s recorded ________/4 24. Contralateral motor nerve F waves recorded ________/4 If the peroneal/fibular motor nerve is absent, then: Grade each item 0 to 4 points (maximum). Level B evidence 25. Ipsilateral tibial nerve motor recording ________/4 26. Ipsilateral tibial nerve F waves recorded ________/4 TOTAL SCORE including Items 1-26: ______/118 =_______% TOTAL SCORE excluding Items 22-26: _______/98 =_______% TOTAL SCORE excluding Items 25-26: ______/110 =_______%11/27/2017 42 XxxxxxxxxxxxAPPENDIX K EMERGENCY PREPAREDNESS Emergency Action and Evacuation Policy A. The Laboratory Director at Xxxxxxxxxxxxis responsible for reviewing and following each clinic’s emergency preparedness plan as well as developing and following it’s own emergency preparedness document. Xxxxxxxxxxxxpolicy includes: 1. Means of reporting fires: a. Activate R.A.C.E. (Rescue, Alarm, Contain, Extinguish/Evacuate) b. Activate P.A.S.S. (Pull, Aim, Squeeze, Sweep) if needed c. Call 911 2. Means of reporting other emergencies: a. Earthquake: i. Shelter in place and direct others including patients to shelter under a table/desk ii. Remain inside unless there is eminent danger b. Tsunami: i. Attain and direct others to higher ground c. Hostile situation: i. Call 911 if possible ii. Leave the area or if not possible iii. Hide behind a secure door 3. Evacuation procedures and emergency escape route assignments: Laboratory Director 4. The Laboratory Director is to account for all employees and patients after an emergency evacuation has been completed 5. The Laboratory Director is responsible for the rescue and medical duties for those employees who are not to perform them 6.The Laboratory Director can be contacted for further information or explanation of duties under the plan B. Specifics describing the emergency action and evacuation policies are found at each Xxxxxxxxxxxxcontract site: 1. Island Hospital Medical Arts Pavilion Physical Therapy and Rehabilitation Anacortes, WA 2. Rue and Primavera Occupational and Physical Therapy, PLLC Oak Harbor, WA 3. Olympic Medical Sleep Center, Sequim, WA C. In the event of a natural disaster, Xxxxxxxxxxxxshall maintain patient report back up files on a secure cloud server. 9/8/1311/27/2017 43 XxxxxxxxxxxxTHE R.A.C.E. ACRONYM AND FIRE EXTINGUISHER USE If you are involved in a fire, remember R.A.C.E. to help you respond safely and correctly: R = RESCUE anyone in immediate danger from the fire, if it does not endanger your life A = ALARM: sound the alarm by calling “2600” (on campus locations only) and activating a pull station alarm box C = CONFINE the fire by closing all doors and windows E = EXTINGUISH the fire with a fire extinguisher, or EVACUATE the area if the fire is too large for a fire extinguisher. PROPER USE OF FIRE EXTINGUISHERS (P.A.S.S.) To use fire extinguishers correctly, remember the P.A.S.S. acronym: P = PULL the pin on the fire extinguisher A = AIM the extinguisher nozzle at the base of the fire S = SQUEEZE or press the handle S = SWEEP from side to side until the fire appears to be out11/27/2017 44 ................
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