- Purpose
- Contracts/Referral Arrangements
- Provider Files
- Patient Medical Records
- Reports
- Fiscal and Billing Records
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.
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):
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):
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:
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:
|
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 |
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:
The selected files should include:
|
Current |
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):
|
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):
|
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 |
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 |
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:
|
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:
|
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:
|
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 |
- 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.
- Only applicable for services that cannot be observed at various sites via the site tour(s) due to time/distance constraints.
- If the same patient has received more than one of these services, the same record can be used for assessing those services.
- If the same patient has received more than one of these services, the same record can be used for assessing those services.
- 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.
- 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.
- 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.
- The same sample of patient records utilized for reviewing other program requirement areas also may be used for this sample.
- 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.