Health Center Program Site Visit Protocol
Health Resources and Services Administration (HRSA) site visits support the effective oversight of the Health Center Program. Operational Site Visits (OSVs) 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 addition, HRSA conducts site visits to assess and verify look-alike initial designation applicants for compliance with Health Center Program requirements to inform initial designation determinations.
The Health Center Program Site Visit Protocol (SVP) is the tool for assessing compliance with Health Center Program requirements during OSVs. The SVP is designed to provide HRSA the information necessary to perform its oversight responsibilities using a standard and transparent methodology that aligns with the Compliance Manual. Learn more about the SVP:
- Introduction (PDF – 468 KB)
- Needs Assessment (PDF – 716 KB)
- Required and Additional Health Services (PDF – 297 KB)
- Clinical Staffing (PDF – 684 KB)
- Accessible Locations and Hours of Operation (PDF – 689 KB)
- Coverage for Medical Emergencies During and After Hours (PDF – 280 KB)
- Continuity of Care and Hospital Admitting (PDF – 773 KB)
- Sliding Fee Discount Program (PDF – 450 KB)
- Quality Improvement/Assurance (PDF – 638 KB)
- Key Management Staff (PDF –771 KB)
- Contracts and Subawards (PDF – 816 KB)
- Conflict of Interest (PDF – 732 KB)
- Collaborative Relationships (PDF – 838 KB)
- Financial Management and Accounting Systems (PDF – 754 KB)
- Billing and Collections (PDF – 806 KB)
- Budget (PDF – 691 KB)
- Program Monitoring and Data Reporting Systems (PDF – 796 KB)
- Board Authority (PDF – 824 KB)
- Board Composition (PDF – 847 KB)
- Federal Tort Claims Act (FTCA) Risk Management Deeming Requirements (PDF – 775 KB)
- Performance Analysis (PDF – 796 KB)
- Promising Practices (PDF – 514 KB)
- Eligibility Requirements for Look-Alike Initial Designation Applicants (PDF – 712 KB)
Site Visit Resources
The following tools are available to assist health centers in preparing for their site visit:
- Credentialing and Privileging File Review Resource (PDF – 572 KB)
- HRSA OSV Support Documents (PDF – 353 KB)
- Health Center Staff Documents Checklist (PDF - 522 KB )
- Operational Site Visit (OSV) Expert Recommendation Tracking Resource (PDF - 1 MB)
- More Coming Soon!
Frequently Asked Questions
Review some of the most common questions about the Health Center Program Site Visit Protocol and their associated answers.
- When will HRSA begin using the SVP for its Operational Site Visits (OSVs)?
HRSA will begin using the SVP for all OSVs in CY 2018 currently scheduled to begin in late January.
- How does the SVP differ from the previous Site Visit Guide?
The SVP is specifically designed to be a standardized tool to assess a health center’s compliance with Health Center Program requirements through site visits. The SVP is fully aligned with the Health Center Program Compliance Manual (the “Compliance Manual”), which was issued in August 2017 and serves as a consolidated resource to assist health centers in understanding and demonstrating compliance with Health Center Program requirements and with Health Center Federal Tort Claims Act (FTCA) Deeming requirements. The goals of the SVP are to provide clarity, transparency, and consistency in the site visit process, while ensuring that HRSA staff have the information necessary to perform their oversight roles and responsibilities.
- What documentation must a health center provide to support an OSV or look-alike Initial Designation site visit?
The SVP lists the documents that a health center must provide within the relevant sections. In addition, the SVP specifically identifies which documents the health center is expected to provide to the site visit team in advance of the site visit and which documents need to be available when the site visit team arrives onsite. Note, HRSA also will provide the site visit team with relevant documents prior to the visit (see tools above).
- Can consultants provide technical assistance during OSVs?
The primary purpose of an OSV is to assess whether a health center demonstrates compliance with the statutory and regulatory requirements of the Health Center Program. However, during the OSV, a health center may also request or consultants may choose to share, recommendations or technical assistance on various areas of optimizing health center operations that fall outside the scope of the compliance review. Recommendations and/or technical assistance information offered by site visit team members will not be recorded as a part of the site visit report.
- How will reviewers assess whether a health center is following operating procedures?
As appropriate, the “demonstrating compliance” elements within the Compliance Manual include a list of items that must be addressed in operating procedures in order to demonstrate compliance. The SVP also specifically notes instances where a site visit reviewer must review documentation that demonstrates that such procedures are being implemented and/or utilized. Implementation or utilization of operating procedures generally would be assessed through the review of records, files, etc., as noted in the SVP.
Progressive Action Conditions Library
When HRSA determines that a health center is not demonstrating compliance with one or more of the Health Center Program requirements, a condition(s) is placed on its Notice of Award/Look-alike Designation. The Health Center Program uses a library of standard conditions that follow its Progressive Action policy and process, which fully aligns with the Health Center Program Compliance Manual. View the Progressive Action Conditions Library.
Date Last Reviewed: March 2018