Health Center Program Compliance Frequently Asked Questions (FAQ)
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The term “site visit” in these FAQ refers to:
- Operational Site Visits (OSVs) conducted for awardees
- OSVs conducted for look-alikes
- Initial Designation (ID) site visits conducted for look-alike applicants
The information in these FAQ only relates to requirements and processes of the HRSA Health Center Program.
Clinical staffing
This question relates to Element d. Procedures for Review of Privileges and Element e. Credentialing and Privileging Records
Fitness for duty is the ability to perform the duties of the job in a safe, secure, productive, and effective manner.
A health center determines how to assess and document fitness for duty for the purposes of privileging staff to provide clinical care. For example, a health center determines whether its fitness for duty verification procedures include a physical exam.
In addition, a health center determines whether privileging procedures for assessing fitness for duty vary between the initial granting and renewal of privileges.
HRSA assesses compliance by reviewing a health center's privileging procedures to ensure they address verification of fitness for duty. HRSA also assesses compliance by reviewing a health center's clinical staff files to ensure that the health center follows its privileging procedures.
For more information, refer to the Health Center Program Compliance Manual Chapter 5: Clinical Staffing. The Site Visit Protocol (SVP) resource Examples of Credentialing and Privileging Documentation provides common examples of credentialing and privileging documentation, although the examples are not exhaustive. Best practices in verifying fitness for duty are available through the Emergency Care Research Institute (ECRI) risk management resources.
(Added: 3/8/2023)
This question relates to Element e. Credentialing and Privileging Records
No, the Examples of Credentialing and Privileging Documentation resource is intended to complement the Site Visit Protocol by providing common examples of credentialing and privileging documentation methods and sources. This resource helps with the review of a health center's clinical staff file samples. The examples in the Examples of Credentialing and Privileging Documentation resource are not exhaustive.
The health center determines the specific documentation it uses to credential and privilege health center providers, as long as there is consistency with the Health Center Program Compliance Manual and the health center's own procedures.
(Updated: 3/8/2023)