Health Center Program Site Visit Protocol: Onsite Interviews and Interactions Resource

G/A

• PD/CEO and other key management staff

• Service area analysis process and utilization of needs assessment(s)

C

• PD/CEO and/or other relevant staff

• Accuracy of services provided (Form 5A)

G/A

• PD/CEO and other key management staff

• Patient access considerations for either:
  • One to two sites already in scope, or
  • A site added to scope within the past 12 months
• How hours are responsive to patient need
• Accuracy of scope of project (Form 5B)

F

• Health center staff involved in implementing SFDP (for example, key management staff, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers)

• SFDP policy(ies)
• Implementation of SFDP procedures
• SFDP screening and enrollment process (if time permits)
• Mechanisms for informing patients of the SFDP
• Out-of-pocket costs for patients eligible for the SFDP and who have third-party coverage
• If applicable, legal or contractual restrictions on sliding fee discounts for patients with third-party coverage
• Process for evaluating the SFDP

G/A

• PD/CEO
• Key management staff
• Staff responsible for health center hiring/Human Resources (HR) functions and documentation

• How key functions are distributed and carried out
• Status of key management vacancies and HR procedures for filling any current key management vacancies
• PD/CEO roles and responsibilities
• Reporting structures of PD/CEO and other key management staff to Board

F

(G/A for Element i)

• Key management staff

• Procedures for purchasing and procurement
• Monitoring and oversight of contractual activities
• Monitoring and oversight of subrecipient activities (if applicable)

F

• PD/CEO
• Board Members
• Staff involved in procurement and/or HR

• Mechanisms or procedures for informing employees, officers, board members, and agents of the health center’s standards of conduct
• How identified conflicts of interest are addressed

G/A

• PD/CEO
• Key management staff

• Collaboration activities with other providers/programs in the service area (including local hospitals, specialty providers, and social service organizations) that support:
  • Reductions in non-urgent use of hospital emergency departments
  • Continuity of care across providers
  • Access to other health or community services that impact the patient population
• Coordination and integration of activities with other federally-funded, state, and local health services delivery projects/programs serving similar patient populations in the service area

F

• PD/CEO
• CFO

• Financial management system and records of federal award expenditures from the last quarter
• Use of non-grant funds (if applicable)

F

• PD/CEO
• CFO

• Budget formulation process
• Other lines of business (if applicable)

F

• PD/CEO
• Key management staff
• Board members
• Health information technology personnel, or other staff tasked with data management, collection or reporting

• Data management, collection, and reporting
• EHR, practice management system or other data collection systems or methods
• Receipt and relevance of health center data-based reports

G/A

• PD/CEO
• Relevant public agency staff (for example, leadership, staff within the unit of the public agency related to the health center project) (for public agency health centers only)

• How PD/CEO reports to the board
• Board roles and responsibilities (for example evaluating health center performance, approving applications, conducting long-range planning)

G/A

• PD/CEO

• Ownership and operation of the applicant organization
• Independent oversight of health center activities

C

• PD/CEO and/or other relevant staff
• CMO/Clinical Director or equivalent leadership

• Clinical staff responsible for service delivery, including contracted or referred services

• Tour at least two health center sites where the majority of required services are delivered
• Service delivery, including contracted or referred services, and accuracy of scope of project (Form 5A)

• Patient language needs and the role of cultural competency in the delivery of health center services

C

• CMO/Clinical Director or equivalent leadership
• Other relevant clinical staff (for example,  Nurse Manager, Dental Director, Human Resources  Director, Credentialing Coordinator, individual(s) or committee with approval authority for privileging)

• Tour at least two health center sites where the majority of required services are delivered
• Number and mix of clinical staff

• Recruitment and retention process
• Credentialing and privileging procedures
• Credentialing and privileging files
• Process for documenting and updating provider credentialing and privileging information

• Provisions for provider credentialing and privileging in contract(s)/agreement(s), referral agreements and/or related documentation

C

• CMO/Clinical Director or equivalent leadership

• Outreach or front desk staff

• Procedures for responding to on-site patient emergencies during regularly scheduled hours of operation
• Methods for informing patients on how to access after-hours coverage
• Addressing barriers for patients with limited English proficiency (LEP) or literacy level challenges

• Documentation of after-hours call(s) and any necessary follow-up

C

• CMO/Clinical Director or equivalent leadership
• Other relevant clinical staff

• Processes for ensuring continuity of care for patients that require inpatient hospitalization
• Procedures for receipt and recording of medical information and follow-up related to the hospital or emergency department (ED) visit
• Procedures and/or documentation of arrangements with non-health center provider(s) or entity(ies) to assess continuity of care provisions 
• Patient medical information (for example discharge instructions, radiology results) related to hospital and ED visits
• Associated follow-up actions by health center staff 

C

• CMO/Clinical Director or equivalent leadership
• Staff designated to oversee/responsible for the Quality Improvement/Quality Assurance (QI/QA) program and related staff that support QI/QA
• Other relevant clinical staff
• Health information technology personnel
• Compliance or Security Officer

• Implementation of the QI/QA program, including related operating procedures and/or processes
• QI/QA program staff roles and responsibilities
• Provider adherence to clinical guidelines, standards of care, and/or standards of practice
• Patient safety and adverse events, including implementation of follow-up actions
• Patient satisfaction and grievances
• Systems or documentation that support QI/QA assessments
• QI/QA report generation and oversight
• Health center patient records
• Compliance with current federal and state requirements related to confidentiality, privacy and security of health information

C

• Staff who oversee and coordinate risk and claims management activities
• Other relevant clinical staff

• Methods for identifying and mitigating areas/activities of highest patient safety risk
• Examples of documenting, analyzing and addressing clinically-related complaints and “near misses”
• Implementation of risk management policies, procedures, training, assessment, reporting and follow-up actions, including:
  • Quarterly risk management assessments
  • Status of risk management activities and progress in meeting risk management goals
  • Follow-up actions implemented based on risk management assessments and
  • Risk management reporting to board and key management staff
  • Training for relevant clinical staff on obstetrical procedures and infection control
• Training for all relevant staff on Health Insurance Portability and Accountability Act (HIPAA) medical record confidentiality requirements
• Oversight and coordination of risk and claims management activities
• Claims management policies and procedures

• Claims history and mitigation of risk of such claims (if applicable)

F

• Staff involved in:
  • Implementing SFDP (for example eligibility and outreach staff, front desk staff, billing staff, office manager, case managers)
  • Administering contracts for services
  • Administering referral arrangements for services
  • Evaluating the SFDP

• Implementation of SFDP procedures
• SFDP screening and enrollment process
• Mechanisms for informing patients of the SFDP
• Sliding fee discounts for contracted and referred services
• Out-of-pocket costs for patients eligible for the SFDP and who have third-party coverage
• Legal or contractual restrictions on sliding fee discounts for patients with third-party coverage (if applicable)
• Process for evaluating the SFDP

F

(G/A for Element i)

• Staff involved in:
  • Procurement or contract oversight
  • Oversight of subrecipient activities

• Procurement and contract oversight
• Oversight of subrecipient activities (if applicable)

F

• CFO and/or other relevant financial staff
• If applicable, contractors who have responsibility for the health center’s financial management systems
• Any other individual(s):
  • authorized to draw down and expend federal award funds
  • responsible for the health center’s financial management systems

• Financial management, accounting and internal control systems
• Procedures for drawdown, disbursement and expenditure of federal award funds
• Financial management system and records from the last quarter
• Findings, questioned costs, reportable conditions, material weaknesses or significant deficiencies cited in audit (if applicable)
• Status of corrective actions (if applicable)
• Use of non-grant funds (if applicable)

F

• CFO/financial or billing staff
• Staff involved in billing and collections processes, including oversight of any contracts for billing and collections
• Staff involved in educating patients on insurance options

• Fee schedule, including data and analysis used for setting fees
• Health center participation in public and private assistance or health insurance programs
• Educating patients on available insurance and related third-party coverage options
• Billing and collections systems and procedures
• Methods for notifying patients of out-of-pocket costs for supplies and equipment related to but not included in the service
• Contracts with outside organizations that conduct billing or collections on behalf of the health center (if applicable)
• Refusal to pay policy

F

• CFO/financial staff

• Budget formulation process
• Other lines of business (if applicable)

G/A

• CFO/financial staff

• Ownership and operation of the applicant organization

G/A

Board members

• Patient access considerations for either:
  • One to two sites already in scope, or
  • A site added to scope within the past 12 months
  • How hours are responsive to patient need

F

Board members

• SFDP policy(ies)
• Out-of-pocket costs for SFDP-eligible patients who have third-party coverage
• Process for evaluating the SFDP
• Setting nominal charges at a level that is nominal from the patient perspective (if applicable)

G/A

Board members

• Mechanisms or procedures for informing employees, officers, board members, and agents of the health center’s standards of conduct
• How identified conflicts of interest are addressed

F

Board members

• Receipt and relevance of health center data-based reports

G/A

Board members

• How PD/CEO reports to the board
• Board roles and responsibilities (for example evaluating health center performance, approving applications, conducting long-range planning)
• Process for evaluating health center policies

G/A

Board members

• Composition of the current board
• Process for verifying board membership eligibility
• For health centers with approved waivers, utilization of special population input