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.
- Project Director/Chief Executive Officer (PD/CEO), Key Management and Administrative Staff
- Chief Medical Officer (CMO) and Other Clinical Staff
- Chief Financial Officer (CFO) and Other Financial Staff
- Health Center Board Members
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
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 |
|
|
Required and Additional Health Services (Elements a) |
C |
|
|
Accessible Locations and Hours (Elements a – c) |
G/A |
|
|
Sliding Fee Discount Program (SFDP) (Elements a, b, f, h, k, and l) |
F |
|
|
Key Management Staff (Elements a, c, and d) |
G/A |
|
|
Contracts and Subawards (Elements a, e, and i) |
F (G/A for Element i) |
|
|
Conflict of Interest (Elements c and d) |
F |
|
|
Collaborative Relationships (Elements a and b) |
G/A |
|
|
Financial Management and Accounting Systems (Elements b and e) |
F |
|
|
Budget (Elements a and d) |
F |
|
|
Program Monitoring and Data Reporting Systems (Element a and b) |
F |
|
|
Board Authority (Element c) |
G/A |
|
|
Eligibility Requirements for Look-Alike Initial Designation Applicants (if applicable) |
G/A |
|
|
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 |
|
|
Clinical Staffing (Elements a – f) |
C |
|
|
Coverage for Medical Emergencies During and After Hours (Elements a – d) |
C |
|
|
Continuity of Care and Hospital Admitting (Elements a – c) |
C |
|
|
Quality Improvement/Assurance (Elements a – f) |
C |
|
|
FTCA Deeming Requirements (if applicable) (Elements a – e: Risk Management) (Elements a – d: Claims Management) |
C |
|
|
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 |
|
|
Contracts and Subawards (Elements e and i) |
F (G/A for Element i) |
|
|
Financial Management and Accounting Systems (Elements a – e) |
F |
|
|
Billing and Collections (Elements a – g, i, and j) |
F |
|
|
Budget (Elements a and d) |
F |
|
|
Eligibility Requirements for Look-Alike Initial Designation Applicants (If applicable) |
G/A |
|
|
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 |
|
Sliding Fee Discount Program (SFDP) (Element b, k, and l) |
F |
Board members |
|
Conflict of Interest (Element c and d) |
G/A |
Board members |
|
Program Monitoring and Data Reporting Systems (Element b) |
F |
Board members |
|
Board Authority (Element c – e) |
G/A |
Board members |
|
Board Composition (Element c, d, and f) |
G/A |
Board members |
|