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  5. Supplement to Health Center Program Site Visit Protocol: Guidelines and Logistics for Virtual HRSA/BPHC Look-Alike Initial Designation Visits

Supplement to Health Center Program Site Visit Protocol: Guidelines and Logistics for Virtual HRSA/BPHC Look-Alike Initial Designation Visits

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Introduction

The Look-alike Initial Designation (LAL ID) site visit is a critical step in the LAL designation application process. To be designated as a LAL health center, applicants must meet eligibility requirements, including demonstrating compliance with all Health Center Program requirements at the time of application submission. HRSA first conducts an application review to assess an applicant’s compliance and whether the application meets all completeness and eligibility requirements. If this stage is passed, HRSA conducts a site visit to further assess and verify the applicant’s compliance with Health Center Program requirements. HRSA will use the site visit findings to inform look-alike initial designation determinations. The Health Center Program Site Visit Protocol (SVP) is the tool used for assessing compliance with Health Center Program requirements during LAL ID site visits.

Although HRSA is not currently conducting in-person LAL ID site visits, HRSA continues to process all LAL ID applications and conduct virtual ID site visits. This document, which is a supplement to the SVP, includes an overview of how HRSA adapted the on-site LAL ID site visit process for virtual site visits. Site visit teams will conduct virtual LAL ID visits using the SVP and this supplement.

Resources

The following resources are available to help LAL ID applicants prepare for their ID site visits.

Logistical Guidelines for the Conduct of Virtual Site Visits

Consistent with the LAL ID Instructions (PDF - 672 KB), the LAL ID application review process includes a preliminary application review and site visit.

  1. Preliminary Application Review: HRSA reviews each application for eligibility and completeness. This review includes a preliminary compliance review, based on the Health Center Program Compliance Manual (“Compliance Manual”).

    • Based on the Preliminary Review, HRSA may provide the applicant a list of eligibility and compliance questions. HRSA may hold a call to discuss the findings, if appropriate.
    • HRSA will disapprove incomplete or ineligible applications.
  2. Site Visit: If HRSA determines that the application is eligible and complete, HRSA will schedule a virtual site visit to further assess the applicant’s eligibility, operating status, and compliance with Health Center Program requirements.

Pre-site Visit Preparation

  • A HRSA representative contacts the applicant to discuss the applicant’s readiness for the virtual site visit and identify dates for the visit. HRSA strongly encourages applicants to:

  • At least 3 weeks prior to the scheduled LAL ID site visit start date, the applicant participates in a "Pre-Site Visit" conference call with the site visit team and the HRSA representative.
  • In advance of the Pre-Site Visit conference call, HRSA’s technical assistance contractor, Management Solutions Consulting Group (MSCG), will provide the applicant with file sharing and video/phone conference information to facilitate the virtual site visit.

Documentation

  • At least 2 weeks prior to the scheduled start date of the ID site visit, the applicant must provide all documents listed in the SVP and those listed below in the “Supplemental Methodology and Documentation for Virtual Site Visits” section. The applicant will upload all documents using the MSCG file sharing platform.
  • The applicant should upload documents in the appropriate folders in the file sharing platform. The file sharing platform is organized by each SVP section.
    • A Consolidated Documents Checklist (PDF - 446 KB) is available in SVP Resources to help applicants prepare and organize the documents and materials.
    • Uploaded files should have descriptive file names that align with the documentation referenced in the SVP. For example, the file name for board minutes might be labeled as “Board Minutes” along with the date of the board meeting.
    • The same document may need to be uploaded into more than one folder.
    • Confidential documents should be uploaded without Personally Identifiable Information (PII) and with enough information for the site visit team to assess compliance with Health Center Program requirements.
    • Any documentation that was updated since submission of the LAL ID application should be provided. This includes documentation that was updated in response to the eligibility and compliance questions from HRSA.
  • HRSA will provide the LAL ID application to the site visit team before the "Pre-Site Visit" conference call.

Note: HRSA reserves the right to postpone or cancel virtual site visits for applicants that are unable to provide all documentation prescribed by the SVP and this supplement by the required deadline. In such cases, HRSA may disapprove the application. Organizations are encouraged to reapply when they are prepared to demonstrate compliance with Health Center Program requirements.

Virtual Site Visit Schedule and Logistics

  • To allow for flexibility in scheduling interviews and interactions with applicant staff and board members, the virtual site visit may be spread out over the course of a 1-week period (Monday – Friday).
  • The site visit team and the applicant will develop a mutually agreed upon agenda for the site visit.
    • The agenda will include designated times for:

      • Entrance/exit conferences;
      • Virtual site tours;
      • Meeting with patient and non-patient board members;
      • Interviews and meetings for compliance analysis; and
      • Debrief with the Project Director (PD)/Chief Executive Officer (CEO).
    • Applicant staff and board members must be available during the week of the site visit for the scheduled interviews and meetings required by the SVP.
    • Applicants are encouraged to review the Onsite Interviews and Interactions Resource to prepare.
    • The site visit team will schedule phone interviews and video conferences with applicant staff and board members during or outside of business hours, as agreed upon by the site visit team and applicant.
    • When possible, the site visit team and the applicant consider time zone differences when developing the agenda for meetings and interviews.
  • HRSA representatives may be present at interviews, video conferences, and site tours.
  • The applicant should have staff available to facilitate the use of technology and help ensure sessions using these systems are able to start on time.
  • Recording during the virtual site visit—including during site tours, interviews, entrance conferences, and exit conferences—is not permitted.

Video Conferencing Expectations

  • When possible, site visit participants will use video conferencing to conduct interviews and meetings, including interviews with the board of directors.  
  • If there are times when software, hardware, or connectivity issues prevent a video connection, then an audio-only connection is sufficient.

Live Virtual Tour Expectations

  • The applicant will conduct a live virtual tour for the site visit team of the service site using video conferencing software and the applicant’s equipment (for example, phone, tablet, computer camera).

    • If the applicant has more than one service site, there will be a tour of at least two service sites.
    • Each tour should include both the exterior and interior of the building, front desk, and clinic (consistent with an “in-person” tour).
    • The site visit team may provide direction to the applicant’s tour guide if the team wants to review something further.
    • The site visit team may request to speak informally with staff during the tour.
  • Consistent with the SVP, these virtual tours will be scheduled during the site visit week and, if there are multiple sites, the applicant determines the site tour locations.

Screen Sharing Expectations

  • The site visit team may request screen sharing of documents and systems to facilitate joint review of certain documentation (for example, system walkthrough, Electronic Health Record (EHR) demo, Form 5A walkthrough).

Supplemental Methodology and Documentation for Virtual Site Visits

The site visit team conducts the virtual site visit consistent with the methodology and documentation required by the Health Center Program SVP. However, additional documentation and meetings necessary for a virtual site visit are outlined below. Applicants must submit this additional documentation at least 2 weeks prior to the site visit. 

  • General Information

  • Required and Additional Health Services
    • Direct Services (Form 5A: Services Provided, Column I): The site visit team will confirm that each service delivered via Column I is being directly provided by the health center through:

      • Interviews of clinical staff; or
      • If a Column I service cannot be verified through interviews, review of at least one health center Column I patient record. 
  • Sliding Fee Discount Program
    • Staff walk through the screening and enrollment process for the applicant’s Sliding Fee Discount Program using related documents, such as standard operating procedures, signage, and forms.
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