Health Center Program Site Visit Protocol

1 Health Center Program site Visit Protocol Last updated: May 27, 2021 Health Center Program site Visit Protocol Table of Contents INTRODUCTION ..1 Purpose ..1 site Visit Report and Compliance site Visit Protocol NEEDS ASSESSMENT ..5 Document Checklist for Health Center Demonstrating Compliance ..5 Element a: Service Area Identification and Annual Element b: Update of Needs REQUIRED AND ADDITIONAL Health SERVICES ..9 Document Checklist for Health Center Demonstrating Compliance ..11 Element a: Providing and Documenting Services within Scope of Element b: Ensuring Access for Limited English Proficient Patients ..16 Element c: Providing Culturally Appropriate Care.

2 17 CLINICAL STAFFING ..18 Document Checklist for Health Center Demonstrating Compliance ..19 Element a: Staffing to Provide Scope of Services ..19 Element b: Staffing to Ensure Reasonable Patient Element c: Procedures for Review of Credentials ..20 Element d: Procedures for Review of Element e: Credentialing and Privileging Records ..24 Element f: Credentialing and Privileging of Contracted or Referral ACCESSIBLE LOCATIONS AND HOURS OF Document Checklist for Health Center Demonstrating Compliance ..28 Element a: Accessible Service Sites ..28 Element b: Accessible Hours of Element c: Accurate Documentation of Sites within Scope of COVERAGE FOR MEDICAL EMERGENCIES DURING AND AFTER Document Checklist for Health Center Demonstrating Compliance ..32 Element a: Clinical Capacity for Responding to Emergencies During Hours of Operation ..32 Element b: Procedures for Responding to Emergencies During Hours of Element c: Procedures or Arrangements for After-Hours Coverage.

3 33 Element d: After-Hours Call CONTINUITY OF CARE AND HOSPITAL Document Checklist for Health Center Page | i Health Center Program site Visit Protocol Demonstrating Compliance ..37 Element a: Documentation of Hospital Admitting Privileges or Arrangements ..37 Element b: Procedures for Hospitalized Patients ..38 Element c: Post-Hospitalization Tracking and SLIDING FEE DISCOUNT Program ..41 Document Checklist for Health Center Demonstrating Compliance ..42 Element a: Applicability to In-Scope Services ..42 Element b: Sliding Fee Discount Program Policies ..43 Element c: Sliding Fee for Column I Services ..45 Element d: Multiple Sliding Fee Discount Schedules.

4 47 Element e: Incorporation of Current Federal Poverty Guidelines ..47 Element f: Procedures for Assessing Income and Family Size ..48 Element g: Assessing and Documenting Income and Family Element h: Informing Patients of Sliding Fee Element i: Sliding Fee for Column II Services ..49 Element j: Sliding Fee for Column III Services ..51 Element k: Applicability to Patients with Third-Party Element l: Evaluation of the Sliding Fee Discount Program ..54 QUALITY IMPROVEMENT/ASSURANCE ..56 Document Checklist for Health Center Demonstrating Compliance ..57 Element a: QI/QA Program Policies ..57 Element b: Designee to Oversee QI/QA Program ..57 Element c: QI/QA Procedures or Processes ..58 Element d: Quarterly Assessments of Clinician Element e: Retrievable Health Element f: Confidentiality of Patient KEY MANAGEMENT Document Checklist for Health Center Demonstrating Compliance ..63 Element a: Composition and Functions of Key Management Staff.

5 63 Element b: Documentation for Key Management Staff Element c: Process for Filling Key Management Vacancies ..64 Element d: CEO Element e: HRSA Approval for Project Director/CEO Changes ..66 CONTRACTS AND Document Checklist for Health Center Demonstrating Compliance ..70 Contracts: Procurement and Element a: Procurement Element b: Records of Procurement Element c: Retention of Final Contracts ..72 Element d: Contractor Reporting ..72 Element e: HRSA Approval for Contracting Substantive Programmatic Work ..73 Page | ii Health Center Program site Visit Protocol Element f: Required Contract Subawards: Monitoring and Element g: HRSA Approval to Subaward ..75 Element h: Subaward Element i: Subrecipient Element j: Retention of Subaward Agreements and Records.

6 82 CONFLICT OF INTEREST ..84 Document Checklist for Health Center Demonstrating Compliance ..84 Element a: Standards of Element b: Standards for Organizational Conflicts of Element c: Dissemination of Standards of Conduct ..87 Element d: Adherence to Standards of Conduct ..88 COLLABORATIVE RELATIONSHIPS ..90 Document Checklist for Health Center Demonstrating Compliance ..90 Element a: Coordination and Integration of Element b: Collaboration with Other Primary Care Element c: Expansion of HRSA-Approved Scope of FINANCIAL MANAGEMENT AND ACCOUNTING SYSTEMS ..94 Document Checklist for Health Center Demonstrating Compliance ..95 Element a: Financial Management and Internal Control Element b: Documenting Use of Federal Element c: Drawdown, Disbursement and Expenditure Element d: Submitting Audits and Responding to Element e: Documenting Use of Non-Grant Funds ..99 BILLING AND COLLECTIONS.

7 101 Document Checklist for Health Center Demonstrating Compliance ..102 Element a: Fee Schedule for In-Scope Element b: Basis for Fee Schedule ..102 Element c: Participation in Insurance Element d: Systems and Procedures ..104 Element e: Procedures for Additional Billing or Payment Element f: Timely and Accurate Third-Party Billing ..106 Element g: Accurate Patient Element h: Policies or Procedures for Waiving or Reducing Fees ..107 Element i: Billing for Supplies or Element j: Refusal to Pay BUDGET ..111 Document Checklist for Health Center Demonstrating Compliance ..111 Page | iii Health Center Program site Visit Protocol Element a: Annual Budgeting for Scope of Element b: Revenue Element c: Allocation of Federal and Non-Federal Element d: Other Lines of Business.

8 113 Program MONITORING AND DATA REPORTING SYSTEMS ..115 Document Checklist for Health Center Demonstrating Compliance ..115 Element a: Collecting and Organizing Element b: Data-Based BOARD AUTHORITY ..118 Document Checklist for Health Center Demonstrating Compliance ..119 Element a: Maintenance of Board Authority Over Health Center Element b: Required Authorities and Element c: Exercising Required Authorities and Element d: Adopting, Evaluating, and Updating Health Center Element e: Adopting, Evaluating, and Updating Financial and Personnel Policies ..126 BOARD Document Checklist for Health Center Demonstrating Compliance ..127 Element a: Board Member Selection and Removal Element b: Required Board Composition ..129 Element c: Current Board Composition ..131 Element d: Prohibited Board Element e: Waiver Requests ..134 Element f: Utilization of Special Population Input ..135 FEDERAL TORT CLAIMS ACT (FTCA) DEEMING Document Checklist for Health Center Demonstrating Compliance.

9 138 Risk Management ..138 Element a: Risk Management Element b: Risk Management Procedures ..138 Element c: Reports on Risk Management Element d: Risk Management Training Plan ..139 Element e: Individual who Oversees Risk Management ..139 Claims Management ..142 Element a: Claims Management Element b: Claims Activities Point-of-Contact ..142 Element c: Informing Patients of FTCA Deemed Element d: History of Claims: Cooperation and Mitigation ..142 PROMISING site Visit Team Page | iv Health Center Program site Visit Protocol site Visit Findings ..145 ELIGIBILITY REQUIREMENTS FOR LOOK-ALIKE INITIAL DESIGNATION APPLICANTS ..146 Document Checklist for Health Center Primary Care Operational Status of Look-Alike Applicant Ownership and Control of Look-Alike Applicant Page | v Health Center Program site Visit Protocol Introduction INTRODUCTION Purpose The purpose of Health Resources and Services Administration (HRSA) site visits1 is to support the effective oversight of the Health Center Program .

10 1 The Department of Health and Human Services (HHS) Uniform Administrative Requirements (45 CFR ) permit HRSA to make site visits, as warranted by Program needs. In addition, 45 CFR states that, The HHS awarding agency, Inspectors General, the Comptroller General of the United States, and the pass-through entity, or any of their authorized representatives, must have the right of access to any documents, papers, or other records of the non-federal entity which are pertinent to the federal award, in order to make audits, examinations, excerpts, and transcripts. The right also includes timely and reasonable access to the non-federal entity's personnel for the purpose of interview and discussion related to such documents. Operational site Visits (OSVs) provide an objective assessment and verification of the status of each Health Center Program awardee or look-alike s compliance with the statutory and regulatory requirements of the Health Center Program .