Supplement to the Health Center Program Site Visit Protocol: Guidelines and Logistics for Virtual Operational Site Visits

Introduction

The purpose of HRSA site visits is to support the effective oversight of the Health Center Program. Operational Site Visits provide an objective assessment and verification of the status of each Health Center Program awardee or look-alike’s compliance with the statutory and regulatory requirements of the Health Center Program. In order to continue the implementation of this important component of the Health Center Program monitoring and oversight process during the COVID-19 public health emergency, HRSA will conduct virtual OSVs. HRSA plans to utilize this virtual format to implement the OSV process until it is able to resume standard, onsite OSVs.

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

Resources

The following resources are available to assist health centers in preparing for their OSV:

Logistical Guidelines for the Conduct of Virtual Site Visits

Pre-Site Visit Preparation

  • Health centers will be contacted in advance by their Project Officer to confirm virtual site visit dates and provide an overview of the virtual site visit process.
    • Health centers are encouraged to review the Compliance Manual, the SVP, this Supplement to the Health Center Program SVP, and all resources on the SVP webpage.
    • Health Centers are also strongly encouraged to complete the Health Center Self-Assessment Worksheet for Form 5A: Services Provided (PDF - 1.2 MB), using their current Form 5A. This self-assessment will not only provide helpful context to the site visit team, but will also help the health center to self-assess the accuracy of their Form 5A. If the health center has any questions while completing the self-assessment, they may reach out to their Project Officer.
  • Once the dates of the site visit are confirmed, HRSA will send the health center a standard notification about the upcoming site visit, noting the dates of the site visit and the names of the HRSA representative and consultants who will be on the site visit.
  • The health center will also participate in a "Pre-Site Visit" conference call with the site visit team and HRSA representative at least 4 weeks prior to the scheduled OSV start date.
    • In advance of this call, HRSA’s technical assistance contractor, Management Solutions Consulting Group (MSCG), will provide the health center with file sharing and video/phone conference information to facilitate the virtual site visit.

Documentation 

  • The health center 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 OSV using the file sharing platform.
  • The file sharing platform is structured to align with the SVP sections. The health center should place documents in the appropriate folders, which are organized by each SVP section.
    • A Consolidated Documents Checklist (PDF - x KB) is available in the “SVP Tools” section of the SVP webpage to help health centers 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 “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 or documents with Personally Identifiable Information (PII) should be uploaded with the removal of PII, so long as enough information remains for the site visit team to assess compliance with health center program requirements.
  • HRSA will continue to provide the site visit team with the health center’s latest Service Area Competition (SAC)/Renewal of Designation (RD) application and other documents outlined in the Operational Site Visit Documents Provided by HRSA resource before the "Pre-Site Visit" conference call.

Note: If initial documents provided by the health center are insufficient for the site visit team to assess a program requirement, the site visit team may request additional documentation. The health center will need to provide this documentation by the end of the first day of the virtual visit.

Virtual Site Visit Schedule and Logistics 

  • The virtual OSV will be scheduled to occur over the standard three-day OSV period.
  • The site visit team and the health center 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, health center staff and board members must be available during the three-day site visit for the scheduled interviews and interactions required by the SVP.
    • Health centers are encouraged to review the Onsite Interviews and Interactions Resource (PDF - 662 KB) to prepare.
    • The site visit team will schedule necessary phone interviews and video conferences with health center staff and board members during or outside of business hours, as agreed upon by the health center and the site visit team.
    • Time zone differences between the site visit team and the health center 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 health center should have staff available to facilitate the use of technology and help to ensure sessions utilizing these systems are able to start on time.
  • No recordings are permitted of the virtual site visit, including site tours, interviews, entrance conferences, and exit conferences.

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 health center will conduct a live virtual tour for the site visit team of the service site (or, if the health center has multiple service sites, at least two service sites) utilizing video conferencing software and the health center’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 health center’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 three-day site visit and, if there are multiple sites, the site tour locations will be determined by the health center.
  • In the event the health center is unable to conduct the live virtual tour, in lieu of the virtual tour HRSA will utilize the OSV documentation submitted by the health center to assess compliance with related Health Center Program Requirements typically assessed through the tour.

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 SVP. This section outlines the supplemental documentation and additional interactions necessary to adapt to a virtual site visit format. Health centers must submit the supplemental 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): 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