Health Center Program Site Visit Protocol - bphc.hrsa.gov

1 Health Center Program Site Visit Protocol Last updated: April 18 , 201 9 Health Center Program Site Visit Protocol Page | i Table of Contents INTRODUCTION .. 1 Purpose .. 1 Site Visit Report and Compliance Determinations .. 2 Site Visit Protocol Structure .. 2 NEEDS ASSESSMENT .. 5 Document Checklist for Health Center Staff .. 5 Demonstrating Compliance .. 5 Element a: Service Area Identification and Annual Review .. 5 Element b: Update of Needs Assessment .. 6 REQUIRED AND ADDITIONAL Health SERVICES .. 9 Document Checklist for Health Center Staff .. 9 Demonstrating Compliance ..11 Element a: Providing and Documenting Services within Scope of Project ..11 Element b: Ensuring Access for Limited English Proficient Patients ..15 Element c: Providing Culturally Appropriate Care.

2 15 CLINICAL STAFFING ..17 Document Checklist for Health Center Staff ..17 Demonstrating Compliance ..18 Element a: Staffing to Provide Scope of Services ..18 Element b: Staffing to Ensure Reasonable Patient Access ..18 Element c: Procedures for Review of Credentials ..19 Element d: Procedures for Review of Privileges ..21 Element e: Credentialing and Privileging Records ..23 Element f: Credentialing and Privileging of Contracted or Referral Providers ..24 ACCESSIBLE LOCATIONS AND HOURS OF OPERATION ..26 Document Checklist for Health Center Staff ..26 Demonstrating Compliance ..26 Element a: Accessible Service Sites ..26 Element b: Accessible Hours of Operation ..27 Element c: Accurate Documentation of Sites within Scope of Project ..28 COVERAGE FOR MEDICAL EMERGENCIES DURING AND AFTER HOURS.

3 29 Document Checklist for Health Center Staff ..29 Demonstrating Compliance ..30 Element a: Clinical Capacity for Responding to Emergencies During Hours of Operation ..30 Element b: Procedures for Responding to Emergencies During Hours of Operation ..30 Element c: Procedures or Arrangements for After Hours Coverage ..31 Element d: After Hours Call Documentation ..33 Health Center Program Site Visit Protocol Page | ii CONTINUITY OF CARE AND HOSPITAL ADMITTING ..35 Document Checklist for Health Center Staff ..35 Demonstrating Compliance ..35 Element a: Documentation of Hospital Admitting Privileges or Arrangements ..35 Element b: Procedures for Hospitalized Patients ..36 Element c: Post-Hospitalization Tracking and Follow-up ..37 SLIDING FEE DISCOUNT Program .

4 39 Document Checklist for Health Center Staff ..39 Demonstrating Compliance ..40 Element a: Applicability to In-Scope Services ..40 Element b: Sliding Fee Discount Program Policies ..41 Element c: Sliding Fee for Column I Services ..42 Element d: Multiple Sliding Fee Discount Schedules ..44 Element e: Incorporation of Current Federal Poverty Guidelines ..44 Element f: Procedures for Assessing Income and Family Size ..45 Element g: Assessing and Documenting Income and Family Size ..46 Element h: Informing Patients of Sliding Fee Discounts ..46 Element i: Sliding Fee for Column II Services ..47 Element j: Sliding Fee for Column III Services ..49 Element k: Applicability to Patients with Third Party Coverage ..50 Element l: Evaluation of the Sliding Fee Discount QUALITY IMPROVEMENT/ASSURANCE.

5 53 Document Checklist for Health Center Staff ..53 Demonstrating Compliance ..54 Element a: QI/QA Program Policies ..54 Element b: Designee to Oversee QI/QA Program ..54 Element c: QI/QA Procedures or Processes ..55 Element d: Quarterly Assessments of Clinician Care ..57 Element e: Retrievable Health Records ..58 Element f: Confidentiality of Patient Information ..59 KEY MANAGEMENT STAFF ..60 Document Checklist for Health Center Staff ..60 Demonstrating Compliance ..60 Element a: Composition and Functions of Key Management Staff ..60 Element b: Documentation for Key Management Staff Element c: Process for Filling Key Management Vacancies ..61 Element d: CEO Responsibilities ..62 Element e: hrsa Approval for Project Director/CEO Changes ..63 CONTRACTS AND SUBAWARDS.

6 65 Document Checklist for Health Center Staff ..65 Demonstrating Compliance ..66 Contracts: Procurement and Monitoring ..66 Element a: Procurement Procedures ..66 Element b: Records of Procurement Actions ..67 Health Center Program Site Visit Protocol Page | iii Element c: Retention of Final Contracts ..68 Element d: Contractor Reporting ..68 Element e: hrsa Approval for Contracting Substantive Programmatic Work ..69 Element f: Required Contract Provisions ..70 Subawards: Monitoring and Management ..71 Element g: hrsa Approval to Subaward ..71 Element h: Subaward Agreement ..72 Element i: Subrecipient Monitoring ..73 Element j: Retention of Subaward Agreements and Records ..74 CONFLICT OF Document Checklist for Health Center Staff ..76 Demonstrating Compliance.

7 76 Element a: Standards of Conduct ..77 Element b: Standards for Organizational Conflicts of Interest ..78 Element c: Dissemination of Standards of Element d: Adherence to Standards of Conduct ..80 COLLABORATIVE RELATIONSHIPS ..82 Document Checklist for Health Center Staff ..82 Demonstrating Compliance ..82 Element a: Coordination and Integration of Activities ..82 Element b: Collaboration with Other Primary Care Providers ..83 Element c: Expansion of hrsa -Approved Scope of Project ..84 FINANCIAL MANAGEMENT AND ACCOUNTING SYSTEMS ..86 Document Checklist for Health Center Staff ..86 Demonstrating Compliance ..86 Element a: Financial Management and Internal Control Systems ..87 Element b: Documenting Use of Federal Funds ..88 Element c: Drawdown, Disbursement and Expenditure Procedures.

8 89 Element d: Submitting Audits and Responding to Findings ..90 Element e: Documenting Use of Non-Grant Funds ..91 BILLING AND COLLECTIONS ..93 Document Checklist for Health Center Staff ..93 Demonstrating Compliance ..94 Element a: Fee Schedule for In-Scope Services ..94 Element b: Basis for Fee Schedule ..94 Element c: Participation in Insurance Programs ..95 Element d: Systems and Procedures ..96 Element e: Procedures for Additional Billing or Payment Options ..97 Element f: Timely and Accurate Third Party Billing ..98 Element g: Accurate Patient Billing ..98 Element h: Policies or Procedures for Waiving or Reducing Fees ..99 Element i: Billing for Supplies or Equipment .. 100 Element j: Refusal to Pay Policy .. 101 Health Center Program Site Visit Protocol Page | iv BUDGET.

9 103 Document Checklist for Health Center Staff .. 103 Demonstrating Compliance .. 103 Element a: Annual Budgeting for Scope of Project .. 103 Element b: Revenue Sources .. 104 Element c: Allocation of Federal and Non-Federal Funds .. 105 Element d: Other Lines of Business .. 105 Program MONITORING AND DATA REPORTING SYSTEMS .. 107 Document Checklist for Health Center Staff .. 107 Demonstrating Compliance .. 107 Element a: Collecting and Organizing Data .. 107 Element b: Data-Based 108 BOARD AUTHORITY .. 110 Document Checklist for Health Center Staff .. 110 Demonstrating Compliance .. 111 Element a: Maintenance of Board Authority Over Health Center Project .. 111 Element b: Required Authorities and Responsibilities .. 112 Element c: Exercising Required Authorities and Responsibilities.

10 114 Element d: Adopting, Evaluating, and Updating Health Center Policies .. 117 Element e: Adopting, Evaluating, and Updating Financial and Personnel Policies .. 118 BOARD COMPOSITION .. 119 Document Checklist for Health Center Staff .. 119 Demonstrating Compliance .. 119 Element a: Board Member Selection and Removal Process .. 120 Element b: Required Board Composition .. 121 Element c: Current Board Composition .. 123 Element d: Prohibited Board 126 Element e: Waiver Requests .. 127 Element f: Utilization of Special Population Input .. 128 FEDERAL TORT CLAIMS ACT (FTCA) DEEMING REQUIREMENTS .. 129 Document Checklist for Health Center Staff .. 129 Demonstrating Compliance .. 130 Risk Management .. 130 Element a: Risk Management 130 Element b: Risk Management Procedures.