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

Introduction

The Look-alike Initial Designation (LAL ID) site visit is a critical step in the LAL designation application process. For designation 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. For organizations that submit an application meeting all completeness and eligibility requirements including a preliminary compliance review, HRSA conducts virtual site visits to assess and verify look-alike initial designation applicants for compliance with Health Center Program requirements to inform initial designation determinations. The Site Visit Protocol is the tool used for assessing compliance with health center program requirements during look-alike initial designation visits.

Although HRSA is not currently conducting in person LAL ID site visits due to the COVID-19 emergency, HRSA continues to process all LAL ID applications and conduct virtual ID site visits. This document is a Supplement to the Health Center Program Site Visit Protocol (SVP). It includes an overview of how HRSA adapted the on-site LAL ID site visit processes for the virtual site visit. Virtual LAL ID visits will be conducted using the SVP and the information in this supplement.

Resources

The following resources are available to assist LAL ID applicants prepare for their site visit.

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 /BPHC 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 preliminary eligibility/compliance questions. A call may be held to discuss the findings, if appropriate.
    • Incomplete or ineligible applications will be disapproved.
  2. Site Visit: For the applications HRSA determines as 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 LAL ID applicant to discuss their readiness for the virtual site visit and identify dates for the visit. HRSA/BPHC strongly encourages applicants to:
    • Review the Compliance Manual, SVP, this Supplement to Health Center Program Site Visit Protocol, and all SVP Resources.
    • Complete the Health Center Self-Assessment Worksheet for Form 5A: Services Provided (PDF - 1.13 MB), using the Form 5A submitted as part of the LAL ID application. This self-assessment provides helpful context to the site visit team and helps the applicant to self-assess the accuracy of their Form 5A. If the applicant has any questions while completing the self-assessment, they may reach out to their HRSA representative.
  • The applicant participates in a "Pre-Site Visit" conference call with the site visit team and the HRSA representative at least three weeks prior to the scheduled LAL ID site visit start date.
  • In advance of this 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

  • The applicant provides all documents listed in the SVP and those listed below in the Supplemental Methodology and Documentation for Virtual Site Visits section. The applicant uploads all documents at least two weeks prior to the scheduled start date of the ID site visit using the file sharing platform.
  • The file sharing platform is structured to align with the SVP sections. The applicant should place documents in the appropriate folders, which is organized by each SVP section.
    • A Consolidated Documents Checklist (PDF - 442 KB) is available in SVP Resources to help applicants prepare and organize the documents and materials.
    • Uploaded files should have descriptive file names aligned 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), so long as enough information remains for the site visit team to assess compliance with health center program requirements.
    • Documentation included as a part of the LAL ID application that was updated since submission of the application. 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. These organizations will be encouraged to reapply at a later date 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 one-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, and interviews and interactions necessary to support the compliance analysis. The agenda will include debriefs with the Project Director (PD)/Chief Executive Officer (CEO).
    • In order to complete the site visit, applicant staff and board members must be available during the week of the site visit for the scheduled interviews and interactions required by the SVP.
    • Applicants are encouraged to review the Onsite Interviews and Interactions Resource (PDF - 662 KB) to prepare.
    • The site visit team schedules any necessary 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 representative(s) 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 site tours, interviews, entrance conferences, and exit conferences, is not permitted.

Video Conferencing Expectations

  • When possible, site visit participants use video conferencing to conduct interviews and interactions. This includes interviews with the board of directors, unless precluded by software, hardware, and/or connectivity issues. In such cases, audio-only is sufficient.

Live Virtual Tour Expectations

  • The applicant will conduct a live virtual tour for the site visit team of the service site (or, if the applicant has multiple service sites, at least two service sites) using video conferencing software and the applicant’s equipment (i.e., phone, tablet, computer camera).
    • This 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 as they 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 (i.e., 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 Site Visit Protocol. This section outlines the supplemental documentation and additional interactions necessary in a virtual site visit format. Applicants must submit the supplemental documentation at least two weeks prior to the site visit.

General Information

Required and Additional Health Services

  • Direct Services (Form 5A: Services Provided, Column I): When possible, the site visit team will schedule interviews with providers to confirm the delivery of services provided directly by the applicant (Column I). If an interview is not possible, the site visit team reviews the record of a current patient and other documentation to confirm the provision of the service(s).

Sliding Fee Discount Program

  • Staff walk through the screening and enrollment process for Sliding Fee Discount Program, using related documents such as standard operating procedures, signage, and forms.
Date Last Reviewed:  May 2021