Health Center Program Site Visit Protocol: Sampling Review Resource Guide

Purpose

The purpose of this resource is to guide health centers in understanding the sampling process for an Operational Site Visit (OSV). This resource only pertains to cases where the health center has flexibility in deciding which subset of documents (samples) to provide to the site visit team; sampling is a process of selecting a subset of documents from a topic of interest. The health center will provide these samples along with other specific documents outlined in the Site Visit Protocol (SVP). This resource is designed for use in conjunction with the SVP. 

Note the following when using this guide:

  • The health center is expected to provide (or "pull") the sample and have it ready when the site visit team arrives onsite in cases where a sample (for example, sample of patient records) is referenced in the list of documents to be provided by the health center.
  • For the following sample size methodology requirements:
    • At least one but no more than three: For example, “at least one but no more than three written contracts/agreements” means the health center determines whether to provide one, two, or three contracts.
    • Up to: For example, “staffing schedules for up to five service delivery sites” means the health center may provide anywhere between one and five staffing schedule(s).
    • Half or five (whichever is less): For example, “half or five (whichever is less) contracts” means a health center that has six total contracts would provide three, while a health center that has 20 contracts would provide five. 
  • The health center should pull samples that are applicable to its organization or health center project. Therefore:
    • The health center should consider its size and complexity when determining sample sizes within the stated methodologies.
    • The health center would not pull a sample that does not apply to its organization or health center project.  For example, a health center would not have written contracts/agreements for services if the health center doesn’t deliver required and additional health services via contracts/agreements (Column II).
    • The HRSA site visit team (consultants and HRSA staff) may complete additional sampling in coordination with the health center if the sample provided by the health center is not sufficient to allow the team to assess compliance with program requirements.

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Contracts/Referral Arrangements

SVP Section Focus of Review Required Sample Time Period (most recent)
Required and Additional Health Services Validate the actual provision of the various required and additional services via Contracts/Agreements (Column II). For services delivered via Column II of the health center’s current Form 5A (whether or not the service is also delivered via Column I and/or Column III):
  • At least one but no more than three written contracts/agreements for EACH Required and EACH Additional Service.
  • To assist in the review, the health center should flag all relevant provisions within contracts/ agreements related to:
    • How the service will be documented in the patient’s health center record; and
    • How the health center will pay for the service.

Note: The same sample of contracts/agreements is to be utilized for the review of both Required and Additional Health Services (PDF - 1.4 MB) and Sliding Fee Discount Program (SFDP) (PDF - 517 KB)

Current
Required and Additional Health Services Validate the actual provision of the various required and additional services via Formal Referral Arrangements (Column III).

Note: When preparing the sample of referral arrangement(s), ensure any supporting systems or procedures related to making, tracking and managing referrals are also available for review.

For services delivered via Column III of the health center’s current Form 5A (whether or not the service is also delivered via Column I and/or Column II):
  • At least one but no more than three written referral arrangements for EACH Required and EACH Additional Service.
  • To assist in the review, the health center should flag all relevant provisions within referral arrangements related to:
    • The manner by which referrals will be made and managed; and
    • The process for tracking and referring patients back to the health center for appropriate follow-up care (for example, exchange of patient record information, receipt of lab results).

Note: The same sample of contracts/agreements is to be utilized for the review of both Required and Additional Health Services (PDF - 1.4 MB) and Sliding Fee Discount Program (PDF - 517 KB).

Current
Clinical Staffing Ensure the credentialing and privileging of contracted providers (Column II). No more than three contracts with contracted provider organizations drawn from the sample that was pulled for the review of Required and Additional Health Services (PDF - 517 KB). Prioritize the review of any services that are offered only via Column II. Current
Clinical Staffing Ensure the credentialing and privileging of referral providers (Column III). No more than three written referral arrangements drawn from the sample that was pulled for the review of Required and Additional Health Services (PDF - 517 KB). Prioritize the review of any services that are offered only via Column III. Current
Sliding Fee Discount Program Ensure sliding fee discount provision for in-scope services provided via contracts (Column II). Same sample of contracts as Required and Additional Health Services (PDF - 517 KB). Current
Sliding Fee Discount Program Ensure sliding fee discount provision for in-scope services provided via formal referral arrangements (Column III). Same sample of referral arrangements as Required and Additional Health Services (PDF - 517 KB). Current
Contracts and Subawards *Not applicable for Look-Alikes

Confirm the health center has records for procurement actions paid for in whole or in part under the federal award.

Confirm the health center retains final contracts and related procurement records for procurement actions paid for in whole or in part under the federal award.

Based on the list of contracts provided prior to the site visit that support the HRSA-approved scope of project:
  • Sample of half or five (whichever is less) contracts AND related supporting procurement documentation for actions of $25,000 or more that utilize federal award funds.

Note: The same sample of contracts/agreements is to be utilized for the review of both Contracts and Subawards (PDF - 1.4 MB) and Conflict of Interest (PDF - 1.4 MB).

Current or ended less than 3 years ago
Contracts and Subawards *Not applicable for Look-Alikes

Confirm the health center’s contracts that support the HRSA-approved scope of project include required provisions.

Based on the list of contracts provided prior to the site visit that support the HRSA-approved scope of project:
  • Sample of half or five (whichever is less) contracts AND related supporting procurement documentation for actions of $25,000 or more that utilize federal award funds.
  • Sample of half or five (whichever is less) contracts AND related supporting procurement documentation for actions of $25,000 or more that do NOT utilize federal award funds.
Current or ended less than 3 years ago
Conflict of Interest *Not applicable for Look-Alikes EXCEPT those look-alikes that have a parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe as identified in the assessment of element “b.”

Confirm the health center’s procurement records document adherence to its standards of conduct.

Same sample of related supporting procurement documentation as Contracts and Subawards (PDF - 1.4 MB). Current or ended less than 3 years ago

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Provider Files

SVP Section Focus of Review Required Sample Time Period
(most recent)
Clinical Staffing Verify providers are properly credentialed and privileged. Sample of files that contain credentialing and privileging information:
  • Four to five licensed independent practitioners (LIPs) files
  • Four to five other licensed or certified practitioners (OLCPs) files
  • Two to three files for other clinical staff (if applicable)

The selected files should include:

  • Representation from different disciplines and sites
  • Directly employed and contracted providers in addition to volunteers (if applicable)
  • Providers who do procedures beyond core privileges for their discipline(s)
  • Newest provider (to assess timeliness of process and whether clinician was credentialed and privileged prior to delivering patient care)
  • Re-credentialed/re-privileged provider
Current

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Patient Medical Records1

SVP Section Focus of Review Required Sample Time Period
(most recent)
Required and Additional Health Services Confirm the health center is directly delivering required and additional health services (Form 5A Column I). At least one patient record for any service not directly observed during the site tour(s).2 Current
Required and Additional Health Services Confirm patients receive required and additional health services offered via contractual/formal agreements (Form 5A Column II). For any service delivered via Column II (whether or not the service is also delivered via Column I and/or Column III):
  • Based on three Required Services and two Additional Services: three to five patient records for patients who have received services from a contracted provider(s)/organization(s).3
24 months
Required and Additional Health Services Confirm patients receive required and additional health services offered via formal referral arrangements (Form 5A Column III). For any service delivered via Column III (whether or not the service is also delivered via Column I and/or Column II):
  • Based on three Required Services and two Additional Services: three to five patient records for patients who have received service(s) from a referral provider(s)/organization(s).4
24 months
Coverage for Medical Emergencies During and After Hours Validate the health center is documenting after-hours calls and any follow-up as necessary.

Three patient records that document after-hours clinical advice including associated documentation of follow-up.5

Note: The samples will be based on after-hours calls that necessitated follow-up by the health center.6

Current
Continuity of Care and Hospital Admitting Confirm the health center conducts post-hospitalization tracking and follow-up for its patients. Five to ten patient records for patients who have been hospitalized or had Emergency Department (ED) visits.7 12 months
Quality Improvement/Assurance Confirm the health center maintains a retrievable health record for each patient, which is consistent with federal and state laws and requirements. Five to ten patient records that include clinic visit note(s) and/or summary of care.8 Current
Eligibility Requirements for Look-Alike Initial Designation Applicants Confirm the applicant is delivering primary health care services. Three to five patient records. Current

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Reports

SVP Section Focus of Review Required Sample Time Period
(most recent)
Quality Improvement/Assurance Confirm the health center produces and shares patient satisfaction data that support decision-making and oversight. Sample of patient satisfaction results. Current
Quality Improvement/Assurance Confirm the health center produces and shares Quality Improvement/Quality Assurance (QI/QA) reports that support decision-making and oversight. Two QI/QA assessments and/or the related reports resulting from these assessments. 1 year
Contracts and Subawards Confirm the health center has access to contractor records and reports related to health center activities in order to ensure that all activities and reporting requirements are being carried out. Two to three reports or records (for example, monthly invoices or billing reports, data run of patients served, visits provided) drawn from the sample of contractors selected from the list provided prior to the site visit. Current or ended less than 3 years ago
Contracts and Subawards *Not applicable for Look-Alikes

Confirm oversight and monitoring of the subrecipient by the awardee.

One or more financial and performance reports from the subrecipient. Current project period
Financial Management and Accounting Systems Confirm the health center produces reports for the board and key management staff to monitor financial status. Two or more periodic financial reports provided to the board and key management staff. 6 months
Program Monitoring and Data Reporting Systems Confirm the health center produces data-based reports to inform and support internal decision-making and oversight by the health center’s key management staff and by the governing board.9 One to two internal health center data reports (for example, monthly board reports, dashboards, presentations). Current project period
Board Authority Confirm the board receives necessary information for decision-making and to carry out its required authorities. At least two board packets from different board meetings. 12 months

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Fiscal and Billing Records

SVP Section Focus of Review Required Sample Time Period
(most recent)
Sliding Fee Discount Program Verify the health center is consistently assessing and re-assessing patient income and family size. Sample of 5–10 records, files, or other forms of documentation of patient income and family size. Specifically provide a sample that includes records for:
  • Uninsured and insured patients
  • Initial assessments for income and family size
  • Re-assessments for income and family size
Current
Financial Management and Accounting Systems *Not applicable for Look-Alikes

Verify the health center's appropriate use and expenditure of federal award funds.

Sample of source documentation (for example, financial records, receipts, invoices) that support expenditures made under the federal Health Center Program award. Last quarter
Billing and Collections Confirm health center billing claims are submitted in a timely and accurate manner to third-party payors. Sample of claims submission data to compare initial billing dates to service dates:
  • Choose 5 patient records for patient visits reflective of the health center’s major third-party payors from across at least 3 unique services (for example, routine primary care, preventive dental, behavioral health, obstetrics) for a total of at least 15 patient records.
Current
Billing and Collections Confirm the health center accurately bills self-pay patients and attempts to collect amounts owed. Sample of billing and payment records for charges requested from patients:
  • Randomly choose 5 patient records for patient visits from across at least 3 unique services (for example, routine primary care, preventive dental, behavioral health, obstetrics) for a total of at least 15 patient records.
  • Ensure billing records include:
    • Patients that are eligible for the sliding fee discount program (SFDP) (incomes at or below 200 percent of the Federal Poverty Guidelines (FPG))
    • If applicable, patients that are not eligible for the SFDP (incomes above 200 percent FPG)
Current
Billing and Collections Confirm the health center waives or reduces fees or payments due to inability to pay, consistent with its policies and procedures. Sample of two to three billing records where patient fees were waived or reduced. Current
  1. Health Center may present records either using live navigation of the Electronic Health Record (EHR), screenshots from EHR, or actual records if the records are not electronic.
  2.  Only applicable for services that cannot be observed at various sites via the site tour(s) due to time/distance constraints.
  3.  If the same patient has received more than one of these services, the same record can be used for assessing those services.
  4.  If the same patient has received more than one of these services, the same record can be used for assessing those services.
  5.  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.
  6. 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.
  7.  For a health center that has had no patients who have been hospitalized in the past 12 months (for example, a newly-funded health center that has just started its operations), a review of operating procedures and results of the interview with health center staff can be used to respond to these questions.
  8.  The same sample of patient records utilized for reviewing other program requirement areas also may be used for this sample.
  9. Examples of data health centers may analyze as part of such reports may include patient access to and satisfaction with health center services, patient demographics, quality of care indicators, and health outcomes.

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Date Last Reviewed:  July 2020