NOTE: This resource complements the Site Visit Protocol (SVP), which is the primary tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Refer to the Health Center Program Compliance Manual as the principal resource to assist health centers in understanding and demonstrating compliance with Health Center Program requirements and the SVP for complete guidance on OSVs.
On this page:
- Purpose
- Contracts/Referral Arrangements
- Patient Medical Records
- Reports
- Fiscal and Billing Records
- Provider Files
- Staffing Schedules
- Key Health Center Documents
- Collaboration/Coordination Documentation
Purpose
This resource helps health centers understand the sampling process for site visits. Sampling is a selection process where health centers choose a subset of documents for review. The health center provides samples with other specific documents outlined in the Site Visit Protocol (SVP). HRSA encourages health centers to use this resource along with the SVP.
Note the following:
- Health center staff selects all samples (for example, patient records).
- Here are some examples of sample size methodologies:
- “At least one, but no more than three written contracts/agreements” means the health center chooses whether to provide one, two, or three contracts.
- “Staffing schedules for up to five service delivery sites” means the health center may select staffing schedules from no more than five service delivery sites.
- “Half or five (whichever is less) contracts” means a health center that has six contracts provides three, while a health center that has 20 contracts provides five.
- Health center staff ONLY select samples relevant to the health center project. For example, if the health center does not deliver health services through contracts/agreements, then a sample of contracts/agreements does not apply.
- Staff consider the health center’s size and structure when selecting the number of samples.
- If the health center does not provide an adequate sample to the site visit team for compliance assessment with program requirements, then the site visit team can select additional samples in coordination with the health center.
Contracts/Referral Arrangements
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Required and Additional Health Services | Validate the actual provision of the various required and additional services via Contracts/Agreements (Column II). | For services delivered via Column II of the health center’s current Form 5A (whether or not the service is also delivered via Column I and/or Column III):
Note: The same sample of referral arrangements is to be utilized for the review of both Required and Additional Health Services and Sliding Fee Discount Program. |
Current |
Required and Additional Health Services | Validate the actual provision of the various required and additional services via Formal Referral Arrangements (Column III).
Note: When preparing the sample of referral arrangement(s), ensure any supporting systems or procedures related to making, tracking, and managing referrals are also available for review. |
For services delivered via Column III of the health center’s current Form 5A (whether or not the service is also delivered via Column I and/or Column II):
Note: The same sample of referral arrangements is to be utilized for the review of both Required and Additional Health Services and Sliding Fee Discount Program. |
Current |
Clinical Staffing | Ensure the credentialing and privileging of contracted providers (Column II). | No more than three contracts with contracted provider organizations drawn from the sample that was pulled for the review of Required and Additional Health Services. Prioritize the review of any services that are offered only via Column II. | Current |
Clinical Staffing | Ensure the credentialing and privileging of referral providers (Column III). | No more than three written referral arrangements drawn from the sample that was pulled for the review of Required and Additional Health Services. Prioritize the review of any services that are offered only via Column III. | Current |
Sliding Fee Discount Program | Ensure sliding fee discount provision for in-scope services provided via contracts (Column II). | Same sample of contracts as Required and Additional Health Services, and provide any other supporting documentation demonstrating how the health center ensures discounts for those selected services. | Current |
Sliding Fee Discount Program | Ensure sliding fee discount provision for in-scope services provided via formal referral arrangements (Column III). | Same sample of referral arrangements as Required and Additional Health Services, and provide any other supporting documentation demonstrating how the health center ensures discounts for those selected services. | Current |
Contracts and Subawards | *Not applicable to Look-Alikes
Confirm the health center has records for procurement actions paid for in whole or in part under the federal award. Confirm the health center retains final contracts and related procurement records for procurement actions paid for in whole or in part under the federal award. |
Based on the list of contracts provided prior to the site visit that support the HRSA-approved scope of project:
Note: The same sample of contracts/agreements is to be utilized for the review of both Contracts and Subawards and Conflict of Interest. |
Current or ended less than 3 years ago |
Contracts and Subawards | *Not applicable for Look-Alikes
Confirm the health center’s contracts that support the HRSA-approved scope of project include required provisions. |
Based on the list of contracts provided prior to the site visit that support the HRSA-approved scope of project:
|
Current or ended less than 3 years ago |
Conflict of Interest | *Not applicable to Look-Alikes EXCEPT those look-alikes that have a parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe as identified in the assessment of element “b.”
Confirm the health center’s procurement records document adherence to its standards of conduct. |
Same sample of related supporting procurement documentation as Contracts and Subawards. | Current or ended less than 3 years ago |
Patient Medical Records1
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Required and Additional Health Services | Confirm the health center is directly delivering required and additional health services (Form 5A Column I). | At least one patient record for any service that cannot be verified through the site tours or through interviews. | Current |
Required and Additional Health Services | Confirm patients receive required and additional health services offered via contractual/formal agreements (Form 5A Column II). | For any service delivered via Column II (whether or not the service is also delivered via Column I and/or Column III):
Note: For Column II Services provided by individual contractors who work at a health center Form 5B in-scope site, documentation in the patient record of the services provided would occur in the health center's own patient record system. |
24 months |
Required and Additional Health Services | Confirm patients receive required and additional health services offered via formal referral arrangements (Form 5A Column III). | For any service delivered via Column III (whether or not the service is also delivered via Column I and/or Column II):
|
24 months |
Coverage for Medical Emergencies During and After Hours | Validate the health center is documenting after-hours calls and any follow-up as necessary. | Three patient records that document after-hours clinical advice including associated documentation of follow-up.4
Note: The samples will be based on after-hours calls that necessitated follow-up by the health center.5 If the health center has fewer than three after-hours calls that required follow-up, the health center will make up the difference with after-hours call documentation that did not require follow-up. |
Current |
Continuity of Care and Hospital Admitting | Confirm the health center conducts post-hospitalization tracking and follow-up for its patients. | Five to ten patient records for patients who have been hospitalized or had Emergency Department (ED) visits that clearly document the health center’s entire hospitalization tracking process.6 | 12 months |
Quality Improvement/Assurance | Confirm the health center maintains a retrievable health record for each patient, which is consistent with federal and state laws and requirements. | Five to ten patient records that include clinic visit note(s) and/or summary of care.7 | Current |
Eligibility Requirements for Look-Alike Initial Designation Applicants | Confirm the applicant is delivering primary health care services. | Three to five patient records that document the provision of various Required and Additional Health Services. | Current |
Reports
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Quality Improvement/Assurance | Confirm the health center produces and shares patient satisfaction data that support decision-making and oversight. | Sample of patient satisfaction results. | Current |
Quality Improvement/Assurance | Confirm the health center produces and shares Quality Improvement/Quality Assurance (QI/QA) reports that support decision-making and oversight. | Two QI/QA assessments and/or the related reports resulting from these assessments. | 12 months |
Contracts and Subawards | Confirm the health center has access to contractor records and reports related to health center activities in order to ensure that all activities and reporting requirements are being carried out. | Two to three reports or records (for example, monthly invoices or billing reports, data run of patients served, visits provided) drawn from the sample of contractors selected from the list provided prior to the site visit. | Current or ended less than 3 years ago |
Contracts and Subawards | *Not applicable for Look-Alikes
Confirm oversight and monitoring of the subrecipient by the awardee. |
One or more financial and performance reports from the subrecipient. Sample must represent all subrecipients, not to exceed a total of five subrecipients. For a health center with more than five subrecipients, select the financial and performance reports from subrecipients that receive the largest amounts of Health Center Program subaward funds. | Current project period |
Conflict of Interest | Confirm the health center adheres to conflict of interest standards. | Two most recent annual audits and management letters. | Most recent |
Financial Management and Accounting Systems | Confirm the health center produces reports for the board and key management staff to monitor financial status. | Two periodic financial reports provided to the board and key management staff, including the most recent interim financial statements. | 6 months |
Program Monitoring and Data Reporting Systems | Confirm the health center produces data-based reports to inform and support internal decision-making and oversight by the health center’s key management staff and by the governing board.8 | One to two internal health center data reports (for example, monthly board reports, dashboards, presentations). | Current project period |
Board Authority | Confirm the board receives necessary information for decision-making and to carry out its required authorities. | Two board packets from different board meetings. | 12 months |
Fiscal and Billing Records
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Sliding Fee Discount Program | Verify the health center is consistently assessing and re-assessing patient income and family size. | Sample of 5–10 records, files, or other forms of documentation of patient income and family size. Specifically provide a sample that includes records for:
|
Current |
Financial Management and Accounting Systems | *Not applicable for Look-Alikes
Verify the health center's appropriate use and expenditure of federal award funds. |
Sample of source documentation (for example, financial records, receipts, invoices) that support expenditures made under the federal Health Center Program award, including:
|
Last quarter |
Billing and Collections | Confirm health center billing claims are submitted in a timely and accurate manner to third-party payors. | Sample of claims submissions and resubmissions:
|
Current |
Billing and Collections | Confirm the health center accurately bills self-pay patients and attempts to collect amounts owed. | Sample of billing and payment records for charges requested from patients:
|
Current |
Billing and Collections | Confirm the health center waives or reduces fees or payments due to inability to pay, consistent with its policies and procedures. | Sample of two to three billing records where patient fees were waived or reduced. | Current |
Eligibility Requirements for Look-Alike Initial Designation Applicants | Confirm under what organizational entity or unit billing is conducted. | Sample of up to three Medicare or Medicaid claims or other billing documents. | Current |
Provider Files
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Clinical Staffing | Verify providers are properly credentialed and privileged. | Sample of files that contain credentialing and privileging information:
The selected files should include:
|
Current |
Staffing Schedules
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Coverage for Medical Emergencies During and After Hours | Confirm the health center has at least one staff member trained and certified in basic life support present during the health center’s regularly-scheduled hours of operation. | Staffing schedules for up to five service delivery sites that identify the individual(s) with current certification in basic life support. | Current |
Key Health Center Documents
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Required and Additional Health Services | Confirm the health center enables patients with limited English proficiency (LEP) to have reasonable access to health center services and enables staff to deliver services in a manner that is culturally appropriate for its patient population. | One or more example(s) of key health center documents (for example, materials/application used to assess eligibility for the health center’s sliding fee discount program, intake forms for clinical services, instructions for accessing after-hours services) translated for patients with limited English proficiency. | Current |
Collaboration/Coordination Documentation
SVP Section | Focus of Review | Required Sample | Time Period (most recent) |
---|---|---|---|
Collaborative Relationships | Confirm how the health center’s collaborative relationship(s) support:
|
Documentation of one or more established collaborations with other providers and organizations in the health center’s service area, including local hospitals, specialty providers, and social service organizations. | Current |
Collaborative Relationships | Confirm the health center coordinates and integrates activities with other federally-funded, state, and local health service delivery projects and programs in the service area, including other health centers. | Documentation of one or more coordination efforts with other federally-funded, as well as state and local, health services delivery projects and programs serving similar patient populations in the service area. At a minimum, this includes documentation of efforts to establish coordination with one or more health centers in the service area. | Current |
Footnotes:
1 Health centers may choose to provide samples of patient records prior to or during the site visit. If patient records will be provided during the site visit, this should be communicated prior to the site visit to avoid any disruption or delay in the site visit process.
2 If the same patient has received more than one of these services, the same record can be used for assessing those services.
3 If the same patient has received more than one of these services, the same record can be used for assessing those services.
4 If the health center has fewer than three after-hours calls that required follow-up, the health center will make up the difference with after-hours call documentation that did not require follow-up.
5 For health centers that had no after-hours calls that required follow-up (for example, a newly-funded health center that has just started its operations), a review of operating procedures and results of the interview(s) with health center staff can be used when responding to this question.
6 For a health center that has had no patients who have been hospitalized in the past 12 months (for example, a newly-funded health center that has just started its operations), a review of operating procedures and results of the interview with health center staff can be used to respond to these questions.
7 The same sample of patient records utilized for reviewing other program requirement areas also may be used for this sample.
8 Examples of data health centers may analyze as part of such reports may include patient access to and satisfaction with health center services, patient demographics, quality of care indicators, and health outcomes.