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.
Compliance assessment and Progressive Action
HRSA primarily assesses a health center's compliance with Health Center Program requirements through operational site visit (OSV) findings and through the review of Service Area Competition (SAC) or Renewal of Designation (RD) applications.
When HRSA identifies non-compliance, a condition is placed on the health center award or look-alike designation.
HRSA encourages all health centers to use the Health Center Program Compliance Manual, Site Visit Protocol, and Site Visit Resources to resolve any active conditions and to prepare for upcoming SAC/RD applications and OSVs.
(Updated: 3/8/2023)
No, HRSA only assesses a health center's policies or procedures for compliance with the demonstrating compliance elements in the Health Center Program Compliance Manual. Although a health center may choose to include information in its policies or procedures that goes beyond what is required in the Health Center Program Compliance Manual, this additional information is not part of HRSA's compliance review.
(Updated: 3/8/2023)
Yes, the Health Center Program Compliance Manual lists the required timeframes for health centers to review or update policies and procedures. For example, in the Health Center Program Compliance Manual Chapter 19: Board Authority, the Compliance Manual specifies that at least once every three years, the health center board adopts, evaluates, and, as needed, approves updates to policies that support financial management and accounting systems and personnel policies.
However, if the Health Center Program Compliance Manual does not specify a timeframe, then the health center determines the appropriate interval for reviewing or updating its policies and procedures.
(Updated: 3/8/2023)
The Progressive Action process is a structured and time-phased approach for:
- Notifying health centers of failures to demonstrate compliance with the requirements in the Health Center Program Compliance Manual; and
- Receiving health center responses to identified conditions.
The Progressive Action phases are:
- Phase One: A Notice of Award (NoA) / Notice of Look-alike Designation (NLD) is issued with a condition detailing the specific areas where compliance with a requirement has not been demonstrated. Phase One gives the health center 90 days to either submit appropriate documentation that demonstrates compliance or, for a small number of conditions (refer to the Implementation Phase below), submit an adequate action plan outlining how the health center will demonstrate compliance with the program requirement.
- Phase Two: If the health center has not demonstrated compliance in Phase One, Phase Two gives the health center an additional 60 days to either submit appropriate documentation that demonstrates compliance or, for a small number of conditions (refer to the Implementation Phase below), submit an adequate action plan outlining how the health center will demonstrate compliance with the program requirement.
- Phase Three: If the health center has not demonstrated compliance in Phase Two, Phase Three gives the health center an additional 30 days to either submit appropriate documentation that demonstrates compliance or, for a small number of conditions (refer to the Implementation Phase below), submit an adequate action plan outlining how the health center will demonstrate compliance with the program requirement.
- Implementation Phase (for a small number of conditions): Gives the health center 120 days to implement the HRSA-approved action plan and submit appropriate documentation that demonstrates compliance with the program requirement.
(Added: 3/8/2023)
The Progressive Action Conditions Library is a list of conditions applied when a health center fails to demonstrate compliance with Health Center Program requirements.
Each demonstrating compliance element within the Health Center Program Compliance Manual has a matching progressive action condition. Each condition follows the Progressive Action policy outlined in the Health Center Program Compliance Manual Chapter 2: Health Center Program Oversight.
When HRSA determines a health center is not demonstrating compliance with one or more of the Health Center Program requirements, progressive action conditions are placed on the health center's award or look-alike designation. Each condition includes a description of the specific actions the health center can take to remove the condition.
(Updated: 3/8/2023)
The five progressive action conditions listed below allow for a 120-day progressive action implementation phase:
- Required and Additional Health Services-demonstrating compliance element "a": Providing and Documenting Services within Scope of Project
- Clinical Staffing-demonstrating compliance element "a": Staffing to Provide Scope of Services
- Sliding Fee Discount Program-demonstrating compliance element "I": Evaluation of the Sliding Fee Discount Program
- Board Authority-demonstrating compliance element "a": Maintenance of Board Authority Over Health Center Project
- Board Composition-demonstrating compliance element "f": Utilization of Special Population Input
For these progressive action conditions, a health center needs to submit either documentation that demonstrates compliance or an action plan outlining how compliance will be demonstrated. If an action plan is submitted by the health center and approved by HRSA, a 120-day "Implementation Phase" condition will be applied so that the health center can carry out the HRSA-approved action plan and submit appropriate documentation that demonstrates compliance.
Note: Progressive action conditions that allow for a 120-day implementation phase are NOT the same as a 120-day Compliance Achievement Plan (CAP) condition. A 120-day CAP condition is only applied if a health center is awarded a 1-year period of performance.
Health centers may refer to the language in individual conditions for more information.
(Updated: 3/8/2023)
A health center's future FTCA deeming determination may be impacted if the health center has one or more of the following conditions on its award at the time of the deeming determination:
- Clinical Staffing-demonstrating compliance element "c": Procedures for Review of Credentials
- Clinical Staffing-demonstrating compliance element "d": Procedures for Review of Privileges
- Clinical Staffing-demonstrating compliance element "e": Credentialing and Privileging Records
- Quality Improvement/Assurance-demonstrating compliance element "a": QI/QA Program Policies
- Quality Improvement/Assurance-demonstrating compliance element "b": Designee to Oversee QI/QA Program
- Quality Improvement/Assurance-demonstrating compliance element "c": QI/QA Procedures or Processes
- Quality Improvement/Assurance-demonstrating compliance element "d": Quarterly Assessments of Clinician Care
- Quality Improvement/Assurance-demonstrating compliance element "e": Retrievable Health Records
- Quality Improvement/Assurance-demonstrating compliance element "f": Confidentiality of Patient Information
Health centers also need to demonstrate compliance with the requirements related to risk management and claims management to receive FTCA deeming.
For more information on FTCA deeming requirements, refer to the Health Center Program Compliance Manual Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements.
(Updated: 3/8/2023)