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

Introduction

U.S. Department of Health and Human Services (HHS) Secretary Alex Azar issued a declaration of a national public health emergency regarding COVID-19 on January 31, 2020. Due to the potential impact to health care organizations during the COVID-19 public health emergency, the Health Resources and Services Administration (HRSA)/Bureau of Primary Health Care (BPHC) postponed in-person site visits, including look-alike (LAL) initial designation (ID) visits, planned through at least September 30, 20201.

ID operational site visits (OSVs) are a critical part of the LAL designation process. To be designated, applicants must meet eligibility requirements and comply with all Health Center Program requirements at the time of application. In order to continue processing LAL ID applications during the current public health emergency, HRSA/BPHC will conduct virtual LAL ID site visits for those applicants who successfully meet completeness and eligibility requirements. 

This supplement to the Health Center Program Site Visit Protocol (SVP) provides an overview of modifications taken to adapt the on-site LAL ID operational site visits (OSVs) processes to a virtual site visit format. Virtual ID visits will be conducted using the SVP and the modifications identified in this supplement. 

Resources

The following resources are available to assist ID applicants in preparing 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.

Preliminary Review: HRSA will conduct a desk review to assess eligibility and completeness of the application, including a preliminary compliance review, based on the Health Center Program Compliance Manual (“Compliance Manual”).

  • Based on the Preliminary Review, HRSA may provide to 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.

Site Visit: For applications determined eligible and complete, HRSA will schedule a virtual site

Visit to further assess eligibility, operational status, and compliance with Health Center Program requirements.

Pre-Site Visit Preparation

A HRSA representative will contact the LAL ID applicant regarding their readiness for the virtual site visit and identify dates for the visit.

  • Applicants are encouraged to review the Compliance Manual, SVP, this Supplement to Health Center Program Site Visit Protocol, and all resources on the SVP webpage.
  • Applicants are also strongly encouraged to complete the Health Center Self-Assessment Worksheet for Form 5A: Services Provided, using the Form 5A (PDF - 1.1 MB) that was submitted as part of the LAL ID application. This self-assessment will not only provide helpful context to the site visit team, but will also help 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 will participate in a "Pre-Site Visit" conference call with the site visit team and HRSA representative at least 3 weeks prior to the scheduled 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 will provide all documents noted in the SVP (both those indicated as "Prior to the Site Visit" and "Onsite") and those indicated below in the Supplemental Methodology and Documentation for Virtual Site Visits section at least 2 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 by Program Requirements (PDF - 263 KB) is available in the SVP Tools section of the SVP webpage 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.
  • The applicant should also provide any documentation that was included in the LAL ID application that has been updated since the submission of the application. This includes any documentation that was updated in response to the preliminary eligibility/compliance questions provided by HRSA.

HRSA will provide the site visit team with the LAL ID application 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 ater 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 also 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 will schedule 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.
  • To the extent possible, time zone differences between the site visit team and the applicant will be taken into consideration in the development of the structured agenda to facilitate timely conduct of meeting and interview conferencing times.

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 to ensure sessions utilizing 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, interviews and interactions will be conducted via video conferencing. This will include 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) utilizing video conferencing software and the applicant’s equipment (i.e., phone, tablet, computer camera).

  • This tour will 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 also 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 site tour locations will be determined by the applicant.

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 virtual site visit will be conducted 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 to adapt to a virtual site visit format. Applicants must submit the supplemental documentation at least 2 weeks prior to the site visit.

General Information

Contact information for select applicant staff and board members (email and phone numbers) for the purposes of scheduling interviews. (See Onsite Interviews and Interaction Resource tool (PDF - 662 KB) to assist with identifying applicant staff.)

Completed Health Center Self-Assessment Worksheet for Form 5A: Services Provided (PDF 1.1 MB) (optional).

Floor plan of the service site(s) that will be toured.

Eligibility Requirements for LAL Initial Designation Applicants

Patient Service Utilization Report from the date of application (or past 6 months, whichever is longer) to confirm that the applicant is currently delivering all Required Services (See Form 5A: Services Provided (PDF - 1.1. MB)). For an example of patient utilization data, see Table 5: Staffing and Utilization used in the Health Center Program Uniform Data System Report (PDF - 885 KB).

Required and Additional Health Services

Direct Services (Form 5A: Services Provided, Column I): Schedule a brief interview with providers who deliver one or more service to confirm the provision of all required services provided through Column I. If an interview is unable to be scheduled within the week, provide documentation of the provision of this service(s) using a current patient record.

Sliding Fee Discount Program

Walk-through of the Sliding Fee Discount Program screening and enrollment process, including related documentation (for example, standard operating procedures, forms, signage, handouts).

For applicants that provide services through contracts, agreements or referral arrangements (Column II or III), if the contract or referral arrangement does not ensure a sliding fee discount is provided by the Column II or Column III provider, submit other documentation that demonstrates how the applicant ensures such discounts (e.g., documentation that the applicant applies its own sliding fee discount schedule (SFDS) to the amounts owed by eligible patients, documentation that the referral provider applies its own SFDS that meets structural requirements or meets the exception outlined in Element J: Sliding Fee for Column III services).

1 This date may be modified based on CDC guidance, travel restrictions, or other factors.

Date Last Reviewed:  November 2020