Most common deficiencies for AAAHC Chapter 1 “Rights and Responsibilities”
The Rights and Responsibilities for patients – Must be approved by the board, included in the board minutes, and re-approved annually; also include grievance information for patients, such as who to contact at your center, the state medical board phone number, and the website for the Medicare ombudsman (many centers also include AAAHC’s phone number). The R&R should be posted in the waiting room visible to patients, and we suggest enlarging and framing it with the grievance information.
Advanced Directives – If you are Medicare-deemed, you are required to ask patients if they have an advance directive. If they reply “yes”, you must provide them with your policy regarding advance directives. If they reply “no”, you must ask them if they would like information on Advance Directives. If you are not Medicare deemed, you must follow your state requirement.
Physician owned facilities that are Medicare deemed – Must post a statement revealing the facility is physician-owned, such as, “Your physician may have an ownership in this facility.”
Interpretative services for non-English speaking patients – Must have the name and contact information of the organization you use, or plan to use, for translation services for non-English speaking patients, including deaf patients. Note that this requirement applies even if you have not yet encountered a non-English speaking patient, therefore, you must still have this plan in place.
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*Sources:
“AAAHC Quality Roadmap 2019” report: applies to Ambulatory Surgery Centers, Office-Based Surgery practices, and Primary Care settings.
HealthCon Consultant survey experience