Health Center Program Compliance Frequently Asked Questions (FAQ)
Can’t find your answer here? Please submit your question through the BPHC Contact Form and select the appropriate issue type, or call Health Center Program Support at 1-877-464-4772.
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.
Clinical staffing
This question relates to Element c. Procedures for Review of Credentials and Element e. Credentialing and Privileging Records
The site visit team will interview staff to determine how education and training is verified for LIPs. If the health center relies on the state licensing agency and does not conduct its own primary source verification, the health center would describe how the state licensing agency conducts primary source verification of education and training.
(Added: 3/8/2023)
This question relates to Element c. Procedures for Review of Credentials and Element d. Procedures for Review of Privileges
Yes, a health center, in accordance with its credentialing procedures, is required to credential individuals who supervise or train clinical staff (for example, Director of Nursing, Director of Pharmacy) at a health center but who do not provide any direct patient care.
If these supervisors provide patient care in addition to their supervisory or management roles or perform peer review of other health center providers, the health center is also required to privilege them in accordance with the health center's privileging procedures.
(Added: 3/8/2023)
This question relates to Element c. Procedures for Review of Credentials
"Other clinical staff" are clinical staff positions that do not require licensure or certification by the health center's state, territory, or jurisdiction. Examples of other clinical staff could include Medical Assistants or Community Health Workers.
Credentialing requirements apply to other clinical staff. A health center demonstrates compliance with credentialing requirements by ensuring that other clinical staff have the necessary education and training to perform the duties of their positions.
For a health center's credentialing process:
- The health center determines what constitutes necessary education and training for each type of other clinical staff and what sources to use to document education and training.
- The health center is not required to verify licensure or certification for other clinical staff because such licensure or certification does not exist.
(Added: 3/8/2023)
This question relates to Element c. Procedures for Review of Credentials and Element d. Procedures for Review of Privileges
No, a health center governing board is not required to approve credentialing or privileging procedures or individual provider credentials or privileges to demonstrate compliance with requirements in the Health Center Program Compliance Manual Chapter 5: Clinical Staffing.
(Added: 3/8/2023)
This question relates to Element c. Procedures for Review of Credentials
All health center staff classified as clinical by the health center are required to have documentation of basic life support training in their provider files.
Clinical staff include:
- Licensed independent practitioners (for example, Physician, Dentist, Physician Assistant, Nurse Practitioner);
- Other licensed or certified practitioners (for example, Registered Nurse, Licensed Practical Nurse, Registered Dietitian, Certified Medical Assistant); and
- Other clinical staff (for example, Medical Assistants or Community Health Workers in states, territories, or jurisdictions that do not require licensure or certification).
For more information, refer to the Health Center Program Compliance Manual Chapter 5: Clinical Staffing.
In addition, each service site in a health center's scope of project (as documented on Form 5B: Service Sites) is also required to have the clinical capacity to respond to emergencies, as demonstrated by having at least one staff member trained and certified in basic life support present at the site during regularly-scheduled hours of operation. For more information, refer to the Health Center Program Compliance Manual Chapter 7: Coverage for Medical Emergencies During and After Hours.
(Updated: 3/8/2023)
This question relates to Element c. Procedures for Review of Credentials and Element e: Credentialing and Privileging Records
HRSA does not define the specific type of basic life support training required to demonstrate compliance with the credentialing requirements in the Health Center Program Compliance Manual Chapter 5: Clinical Staffing. The health center defines what constitutes basic life support training, including the extent, type, and required documentation and whether there is variation based on provider type.
For example, certain licensed independent practitioners (LIPs) may have documentation of basic life support training included as part of their licensure/certification. In such cases, a health center may determine that such documentation satisfies this aspect of the credentialing process. For other provider types that do not have basic life support training as part of their licensure or certification, the health center ensures completion of separate or additional basic life support training. An example of training documentation could include a certificate of completion or course completion dates.
The health center also determines what role it plays in providing basic life support training for clinical staff. For example, some health centers may contract with an organization that provides periodic basic life support training for all staff. Other health centers may use online basic life support training classes or allow health center staff to independently complete relevant training.
(Updated: 3/8/2023)
This question relates to Element d. Procedures for Review of Privileges and Element e. Credentialing and Privileging Records
Fitness for duty is the ability to perform the duties of the job in a safe, secure, productive, and effective manner.
A health center determines how to assess and document fitness for duty for the purposes of privileging staff to provide clinical care. For example, a health center determines whether its fitness for duty verification procedures include a physical exam.
In addition, a health center determines whether privileging procedures for assessing fitness for duty vary between the initial granting and renewal of privileges.
HRSA assesses compliance by reviewing a health center's privileging procedures to ensure they address verification of fitness for duty. HRSA also assesses compliance by reviewing a health center's clinical staff files to ensure that the health center follows its privileging procedures.
For more information, refer to the Health Center Program Compliance Manual Chapter 5: Clinical Staffing. The Site Visit Protocol (SVP) resource Examples of Credentialing and Privileging Documentation provides common examples of credentialing and privileging documentation, although the examples are not exhaustive. Best practices in verifying fitness for duty are available through the Emergency Care Research Institute (ECRI) risk management resources.
(Added: 3/8/2023)
This question relates to Element e. Credentialing and Privileging Records
No, the Examples of Credentialing and Privileging Documentation resource is intended to complement the Site Visit Protocol by providing common examples of credentialing and privileging documentation methods and sources. This resource helps with the review of a health center's clinical staff file samples. The examples in the Examples of Credentialing and Privileging Documentation resource are not exhaustive.
The health center determines the specific documentation it uses to credential and privilege health center providers, as long as there is consistency with the Health Center Program Compliance Manual and the health center's own procedures.
(Updated: 3/8/2023)