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

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.

Purpose

This resource helps health centers prepare for the interviews and interactions that take place during site visits. HRSA encourages use of this resource along with the Site Visit Protocol (SVP).

The table organizes the respective interviews and interactions with the site visit team based on common health center staff titles. HRSA realizes staff roles, responsibilities, and titles may differ across health centers; therefore, the health center selects the most appropriate staff to meet with the site visit team.

This resource does not address every methodology or interview and interaction used by the site visit team. Refer to the SVP for guidance on Operational Site Visits (OSVs) and the Health Center Program Compliance Manual for Health Center Program policy.

*Primary Reviewer: C = Clinical; F = Fiscal; G/A = Governance / Administrative

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Project Director/Chief Executive Officer (PD/CEO), Key Management and Administrative Staff

SVP Section

Primary Reviewer*

Interviewees/Participants

Focus of Interviews and Interactions

Needs Assessment

(Elements a and b)

G/A

  • PD/CEO and other key management staff
  • Service area analysis process and utilization of needs assessment(s)

Required and Additional Health Services

(Elements a)

C

  • PD/CEO and/or other relevant staff
  • Accuracy of services provided (Form 5A)

Accessible Locations and Hours

(Elements a – c)

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)

Sliding Fee Discount Program (SFDP)

(Elements a, b, f, h, k, and l)

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

Key Management Staff

(Elements a, c, and d)

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

Contracts and Subawards

(Elements a, e, and i)

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)

Conflict of Interest

(Elements c and d)

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

Collaborative Relationships

(Elements a and b)

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

Financial Management and Accounting Systems

(Elements b and e)

F

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

Budget

(Elements a and d) 

F

  • PD/CEO
  • CFO
  • Budget formulation process
  • Other lines of business (if applicable)

Program Monitoring and Data Reporting Systems

(Element a and b)

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

Board Authority

(Element c)

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)

Eligibility Requirements for Look-Alike Initial Designation Applicants (if applicable)

G/A

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

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Chief Medical Officer (CMO) and Other Clinical Staff

SVP Section

Primary Reviewer*

Interviewees/Participants

Focus of Interviews and Interactions

Required and Additional Health Services

(Elements a – c)

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

Clinical Staffing

(Elements a – f)

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

Coverage for Medical Emergencies During and After Hours

(Elements a – d)

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

Continuity of Care and Hospital Admitting

(Elements a – c)

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 

Quality Improvement/Assurance 

(Elements a – f)

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

FTCA Deeming Requirements (if applicable)

(Elements a – e: Risk Management)

(Elements a – d: Claims Management)

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)

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Chief Financial Officer (CFO) and Other Financial Staff

SVP Section

Primary Reviewer*

Interviewees/Participants

Focus of Interviews and Interactions

Sliding Fee Discount Program (SFDP)

(Elements a, f, and h – l)

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

Contracts and Subawards

(Elements e and i)

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)

Financial Management and Accounting Systems

(Elements a – e)

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)

Billing and Collections

(Elements a – g, i, and j)

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

Budget

(Elements a and d)

F

  • CFO/financial staff
  • Budget formulation process
  • Other lines of business (if applicable)

Eligibility Requirements for Look-Alike Initial Designation Applicants (If applicable)

G/A

  • CFO/financial staff
  • Ownership and operation of the applicant organization

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Health Center Board Members

SVP Section

Primary Reviewer*

Interviewees/Participants

Focus of Interviews and Interactions

Accessible Locations and Hours of Operation

(Element a and b)

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

Sliding Fee Discount Program (SFDP)

(Element b, k, and l)

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)

Conflict of Interest

(Element c and d)

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

Program Monitoring and Data Reporting Systems

(Element b)

F

Board members

  • Receipt and relevance of health center data-based reports

Board Authority

(Element c – e)

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

Board Composition

(Element c, d, and f)

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

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Date Last Reviewed: