Coverage for Medical Emergencies During and After Hours

Primary Reviewer: Clinical Expert

Secondary Reviewer: TBD

Authority: Section 330(b)(1)(A)(IV) and Section 330(k)(3)(A) of the Public Health Service (PHS) Act; and 42 CFR 51c.102(h)(4), 42 CFR 56.102(l)(4), 42 CFR 51c.303(a), and 42 CFR 56.303(a)

Health Center Program Compliance Manual Related Considerations

Document Checklist for Health Center Staff

  • Operating procedures for addressing medical emergencies during health center’s hours of operation.
  • Operating procedures for responding to patient medical emergencies after hours.
  • Staffing schedules for up to five service delivery sites that identify the individual(s) with current certification in basic life support at each site.
  • Provider on-call schedules and answering service contract (if applicable; for health centers whose own providers cover after-hours calls).
  • Written arrangements with non-health center providers/entities (for example, formal agreements with other community providers, “nurse call” lines) for after-hours coverage (if applicable; for health centers that utilize non-health center providers).
  • List of service delivery sites with names of at least one individual (clinical or non-clinical staff member) at each site trained and certified in basic life support, including a copy of that individual’s current certification (for example, credentialing file for licensed independent practitioner or other licensed or certified practitioner, certification of training if non-clinical staff).
  • Instructions or information provided to patients for accessing after-hours coverage.
  • Three samples of after-hours clinical advice documentation in the patient record1 (for example, screenshots selected by the health center), including associated documentation of follow-up.

    Note: The samples will be based on after-hours calls that necessitated follow-up by the health center. If the health center has fewer than three after-hours calls that required follow-up, the health center will make up the difference with after-hours call documentation that did not require follow-up.

  • Documentation demonstrating systems/methods of tracking, recording, and storing of after-hours coverage interactions (for example, log of patient calls) and, if applicable, related follow-up.

Demonstrating Compliance

Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.

The health center has at least one staff member trained and certified in basic life support present at each HRSA-approved service site (as documented on Form 5B: Service Sites) to ensure the health center has the clinical capacity to respond to patient medical emergencies2 during the health center’s regularly-scheduled hours of operation.3

Site Visit Team Methodology

  • Interview health center clinical leadership.
  • Review operating procedures for provisions that ensure that all service delivery sites have at least one individual per site present during the health center’s regularly-scheduled hours of operation to respond to patient medical emergencies.
  • Using staffing schedules for up to five service delivery sites, request that clinical leadership identify the individual(s) with current certification in basic life support present at each site during the health center’s regularly-scheduled hours of operation.

Site Visit Findings

  1. Was there documentation that the health center ensures at least one staff member (clinical or non-clinical) trained and certified in basic life support is present at each HRSA-approved service delivery site to respond to patient medical emergencies during the health center’s regularly-scheduled hours of operation?

    Response is either: Yes or No

    If No, an explanation is required, including stating what, if any, provisions the health center has in place to respond to patient medical emergencies during regularly-scheduled hours of operation at its site(s).

The health center has and follows its applicable operating procedures when responding to patient medical emergencies during regularly-scheduled hours of operation.

Site Visit Team Methodology

  • Review health center’s operating procedures for responding to medical emergencies.
  • Interview CMO, Clinical Director, and/or equivalent leadership regarding how the health center HAS or WOULD follow its operating procedure when responding to a patient emergency.

Site Visit Findings

  1. Were you able to confirm that the health center has operating procedures for responding to patient medical emergencies during the health center’s regularly-scheduled hours of operation?

    Response is either: Yes or No

    If No, an explanation is required.

  2. Was the health center able to describe how it either has responded to or is prepared to respond to (for example, staff training or drills on use of procedures) patient medical emergencies during regularly-scheduled hours of operation?

    Response is either: Yes or No

    If No, an explanation is required.

The health center has after-hours coverage operating procedures, which may include formal arrangements4 with non-health center providers/entities, that ensure:

  • Coverage is provided via telephone or face-to-face by an individual with the qualification and training necessary to exercise professional judgment in assessing a health center patient's need for emergency medical care;
  • Coverage includes the ability to refer patients either to a licensed independent practitioner for further consultation or to locations such as emergency rooms or urgent care facilities for further assessment or immediate care as needed; and
  • Patients, including those with limited English proficiency (LEP),5 are informed of and are able to access after-hours coverage, based on receiving after-hours coverage information and instructions in the language(s), literacy levels, and formats appropriate to the health center’s patient population needs.

Site Visit Team Methodology

  • Review the health center’s operating procedures or, if applicable, other documentation of arrangements for responding to patient medical emergencies after hours.
  • Review provider on-call schedules and answering service contract (if applicable).
  • Review instructions or information provided to patients for accessing after-hours coverage.
  • Using contact information for after-hours coverage (for example, phone number provided by front desk staff, on signage, in brochures, on health center’s website), call the health center once the health center is closed.
  • Interview CMO, Clinical Director, and/or equivalent health center leadership and, if applicable, outreach or front desk staff regarding methods of informing patients of after-hours coverage.

Site Visit Findings

  1. Does the health center have written operating procedures or other documented arrangements for responding to patient medical emergencies after hours?

    Response is either: Yes or No

    If No, an explanation is required.

  2. Based on the interview with clinical leadership and/or front desk staff, is information provided to patients at all health center service sites (as listed on Form 5B) on how to access after-hours coverage?

    Response is either: Yes or No

    If No, an explanation is required.

  3. Has the health center addressed barriers that patients might face in attempting to utilize the health center’s after-hours coverage? This would include barriers due to LEP or literacy levels.

    Response is either: Yes or No

    If No, an explanation is required.

  4. Did the results from the call made to the health center after hours confirm the following:
    • You were connected to an individual with the qualification and training necessary to exercise professional judgment to address an after-hours call?

      Response is either: Yes or No

    • This individual can refer patients to a covering licensed independent practitioner for further consultation or to locations such as emergency rooms or urgent care facilities for further assessment or immediate care?

      Response is either: Yes or No

    • Provisions are in place for calls received from patients with LEP?

      Response is either: Yes or No

    If No was selected for any of the above, an explanation is required.

    The health center has documentation of after-hours calls and any necessary follow-up resulting from such calls for the purposes of continuity of care.6

    Site Visit Team Methodology

    • Interview CMO, Clinical Director, and/or equivalent health center leadership.
    • Review the health center’s operating procedures or, if applicable, other documentation of arrangements (for example, contract with nurse call line) for responding to patient medical emergencies after hours.
    • Review three samples of after-hours documentation within the patient record (a screenshot of the record is also acceptable) provided by the health center, including associated documentation of follow-up. The samples will be based on after-hours calls that necessitated follow-up by the health center.

      Note: If the health center has fewer than three after-hours calls that required follow-up, the health center will make up the difference with after-hours call documentation that did not require follow-up.

    • Review documentation or systems/methods for tracking, recording, and storing after-hours call coverage interactions and, if applicable, related follow-up.

    Site Visit Findings

    1. Does the health center document after-hours calls or, if no such calls have been received, does the health center have the capacity to document such calls?

      Response is either: Yes or No

      If No, an explanation is required.

    2. Does the health center (based on review of systems or the sample of records) provide the necessary follow-up, based on the nature of after-hours calls (for example, health center contacts the patient within a prescribed number of days to check in on the patient’s condition, schedule an appointment)?

      Note: For health centers that had no after-hours calls that required follow-up (for example, a newly-funded health center that has just started its operations), a review of operating procedures and results of the interview(s) with health center staff can be used when responding to this question.

      Response is either: Yes or No

      If No, an explanation is required.

     

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