Health Center Program Site Visit Protocol: Onsite Interviews and Interactions Resource

NOTE: The Site Visit Protocol (SVP) is the tool for assessing compliance with Health Center Program requirements during Operational Site Visits (OSVs). Use this resource along with the SVP to prepare for OSVs.

Purpose
Project Director/Chief Executive Officer (PD/CEO), Key Management, and Administrative Staff
Chief Medical Officer (CMO) and Other Clinical Staff
Chief Financial Officer (CFO) and Other Financial Staff
Health Center Board Members

Purpose

This resource helps health centers prepare for the interviews and interactions that take place during site visits. HRSA encourages using this resource along with the Site Visit Protocol (SVP).

The table organizes each interview and interaction with the site visit team based on common health center staff titles. The health center selects the most appropriate staff to meet with the site visit team because staff roles, responsibilities, and titles may be different across health centers.

This resource does not address every methodology or interview and interaction used by the site visit team. Refer to the SVP for guidance on Operational Site Visits (OSVs) and the Health Center Program Compliance Manual for Health Center Program policy.

*Primary Reviewer: C = Clinical; F = Fiscal; G/A = Governance / Administrative

Project Director/CEO, Key Management, and Administrative Staff

SVP Section	Primary Reviewer*	Interviewees/Participants	Focus of Interviews and Interactions
Needs Assessment (Elements a and b)	G/A	Project Director/CEO and other key management staff	Service area analysis process and use of needs assessment
Required and Additional Health Services (Element a)	C	Project Director/CEO and other relevant staff	Accuracy of provided services (Form 5A)
Accessible Locations and Hours (Elements a – c)	G/A	Project Director/CEO and other key management staff	Considerations of patient access when selecting the location of either: One to two sites already in scope, or A site added to scope within the past 12 months How hours of operation are responsive to patient need Accuracy of service sites (Form 5B)
Sliding Fee Discount Program (SFDP) (Elements a -d, f-l)	F	Staff involved in implementing SFDP policies (for example, key management staff, eligibility and outreach staff, front desk staff, billing staff, office manager, case managers) Staff involved in administering contracts and referral arrangements for services	SFDP policies Implementation of SFDP procedures SFDP screening and enrollment process SFDS, including multiple SFDSs Assessment, re-assessment, and documentation of patient income and family size Mechanisms for informing patients of the SFDP Contracts and referral arrangements (Form 5A, Column II and III) Out-of-pocket costs for patients eligible for the SFDP and who have third-party coverage Any legal or contractual restrictions applicable to sliding fee discounts for patients with third-party coverage Process for evaluating the SFDP
Key Management Staff (Elements a, c, and d)	G/A	Project Director/CEO Key management staff Staff responsible for health center hiring/Human Resources (HR) functions and documentation	How key functions are distributed and carried out Status of key management vacancies and HR procedures for filling any current key management vacancies Project Director/CEO roles and responsibilities Reporting structures of Project Director/CEO and other key management staff to Board
Contracts and Subawards (Elements a, e, and i)	F (G/A for Element i)	Key management staff Staff involved in contract procurement and monitoring Staff who provide oversight of subrecipient activities	Procedures for purchasing and procurement Monitoring and oversight of contractual activities Monitoring and oversight of subrecipient activities (if applicable)
Conflict of Interest (Elements a and c)	F	Project Director/CEO Staff involved in HR and procurement	Standards of conduct and the process for disclosing any real or apparent conflicts of interest Mechanisms or procedures for informing employees, officers, board members, and agents of the health center’s standards of conduct
Collaborative Relationships (Elements a and b)	G/A	Project Director/CEO Key management staff	Collaboration activities with other providers and programs in the service area (including local hospitals, specialty providers, and social service organizations) that support: Reductions in non-urgent use of hospital emergency departments Continuity of care across providers Access to other health or community services that impact the patient population Coordination and integration of activities with other federally-funded, state, and local health services delivery projects and programs serving similar patient populations in the service area
Budget (Elements a and d)	F	Project Director/CEO	Budget formulation process Any variances or questions raised by the review of budget to actual comparison reports Other lines of business (if applicable)
Program Monitoring and Data Reporting Systems (Elements a and b)	F	Project Director/CEO Key management staff Health information technology or other staff tasked with data management, collection, or reporting	Data management, collection, and reporting EHR, practice management system, or other data collection systems or methods Receipt and relevance of health center data-based reports
Board Authority (Element c)	G/A	Project Director/CEO If a public agency health center: Relevant public agency staff (for example, leadership, and staff who work with the health center project)	Board roles and responsibilities (for example evaluating health center performance, approving applications, conducting long-range planning) Public agency roles and responsibilities (if applicable)
Eligibility Requirements for Look-Alike Initial Designation Applicants (if applicable)	G/A	Project Director/CEO Key management or other staff involved in procurement or contract oversight	Day-to-day oversight of health center activities Ownership and operation of the applicant organization

Chief Medical Officer (CMO) and Other Clinical Staff

SVP Section	Primary Reviewer*	Interviewees/Participants	Focus of Interviews and Interactions
Required and Additional Health Services (Elements a – c)	C	CMO, Clinical Director, or equivalent clinical leadership Other relevant clinical staff	Tour sites where a variety of services are provided directly by the health center (Column I). If the health center has more than one service site, tour at least two service sites Service delivery methods, including contracted or referred services, and accuracy of scope of project (Form 5A) Patient language needs and the role of cultural competency in the delivery of health center services
Clinical Staffing (Elements a – f)	C	CMO, Clinical Director, or equivalent clinical leadership Individuals who conduct or are responsible for credentialing Individuals or committee with approval authority for privileging	Tour sites where a variety of services are provided directly by the health center (Column I). If the health center has more than one service site, tour at least two service sites Scope of services Number and mix of clinical staff Recruitment and retention processes Credentialing and privileging procedures Credentialing and privileging files Methods for tracking timelines for re-credentialing staff Credentialing and privileging processes for contracted or referral providers
Coverage for Medical Emergencies During and After Hours (Elements a – d)	C	CMO, Clinical Director, or equivalent clinical leadership Outreach or front desk staff	Staff members trained and certified in basic life support present at each HRSA-approved service site Procedures for responding to on-site patient emergencies during regularly-scheduled hours of operation Methods for informing patients on how to access after-hours coverage Addressing barriers for patients with limited English proficiency (LEP) or literacy level challenges After-hours call documentation
Continuity of Care and Hospital Admitting (Elements a – c)	C	CMO, Clinical Director, or equivalent clinical leadership Other relevant clinical staff	Processes and procedures for ensuring continuity of care for patients that require inpatient hospitalization Patient medical information (for example discharge instructions, radiology results) related to hospital and ED visits Associated follow-up actions by health center staff
Quality Improvement/Assurance (Elements a – f)	C	CMO, Clinical Director, or equivalent clinical leadership Staff designated to oversee and who are responsible for the Quality Improvement/ Quality Assurance (QI/QA) program and related staff that support QI/QA Other relevant staff such as health information technology personnel, Compliance Officer, or Security Officer	Implementation of the QI/QA program, including related operating procedures and processes QI/QA program staff roles and responsibilities Provider adherence to clinical guidelines, standards of care, and standards of practice Patient safety and adverse events, including implementation of follow-up actions Patient satisfaction and grievances Systems or documentation of any related systems that support QI/QA QI/QA report generation and oversight Health center patient records Compliance with current federal and state requirements related to confidentiality, privacy and security of health information
FTCA Deeming Requirements (if applicable) (Elements a – e: Risk Management) (Elements a – d: Claims Management)	C	Staff who oversee and coordinate risk and claims management activities Other relevant clinical staff	Methods for identifying and mitigating areas and activities of highest patient safety risk Documentation of analysis and evidence that the health center addresses clinically-related complaints and “near misses” Implementation of risk management policies, procedures, training, assessment, reporting and follow-up actions, including: Quarterly risk management assessments Status of risk management activities and progress in meeting risk management goals Follow-up actions implemented based on risk management assessments Risk management reporting to board and key management staff and Training for relevant clinical staff on obstetrical procedures and infection control Training for all relevant staff on: Health Insurance Portability and Accountability Act (HIPAA) medical record confidentiality requirements Oversight and coordination of risk and claims management activities Claims management procedures Claims history and any mitigation of risk of such claims

Chief Financial Officer (CFO) and Other Financial Staff

SVP Section	Primary Reviewer*	Interviewees/Participants	Focus of Interviews and Interactions
Sliding Fee Discount Program (SFDP) (Elements a - d, f– l)	F	Key Management staff Staff involved in: Implementing SFDP (for example eligibility and outreach staff, front desk staff, billing staff, office manager, case managers) Administering contracts for services Administering referral arrangements for services Evaluating the SFDP	SFDP policies Implementation of SFDP procedures SFDP screening and enrollment process SFDS, including multiple SFDSs Assessment, re-assessment, and documentation of patient income and family size Mechanisms for informing patients of the SFDP Contracts and referral arrangements (Form 5A, Column II and III) Out-of-pocket costs for patients eligible for the SFDP and who have third-party coverage Any legal or contractual restrictions applicable to sliding fee discounts for patients with third-party coverage Process for evaluating the SFDP
Contracts and Subawards (Elements a, e and i)	F (G/A for Element i)	Staff involved in procedures for purchasing and procurement Staff who provide oversight of subrecipient activities	Procedures for purchasing and procurement Monitoring and oversight of contractual activities Monitoring and oversight of subrecipient activities (if applicable)
Financial Management and Accounting Systems (Elements a – e)	F	CFO, other relevant financial staff, and any contractors who have responsibility for the health center’s financial management system Any other staff authorized to draw down and expend federal award funds	Financial management, accounting and internal control systems Procedures for drawdown, disbursement and expenditure of federal award funds Financial management system and records from the last quarter Any findings, questioned costs, reportable conditions, material weaknesses, or significant deficiencies cited in audit Status of any corrective actions Any use of non-grant funds
Billing and Collections (Elements a – d, f, g, i, and j)	F	CFO and financial or billing staff Staff involved in billing and collections processes, including oversight of any contracts for billing and collections Staff involved in educating patients on insurance options	Fee schedules, including data and analysis used for setting fees Methods to develop and update fee schedule Health center participation in any public and private assistance or health insurance programs Educating patients on available insurance and related third-party coverage options Billing and collections systems and procedures Methods for notifying patients of any out-of-pocket costs for supplies and equipment related to but not included in the service Any contracts with outside organizations that conduct billing or collections on behalf of the health center Refusal to pay policy
Budget (Elements a and d)	F	CFO and financial staff	Budget formulation process Budget to actual comparison reports Other lines of business (if applicable)
Eligibility Requirements for Look-Alike Initial Designation Applicants (If applicable)	G/A	CFO and financial staff	Ownership and operation of the applicant organization

Health Center Board Members

SVP Section	Primary Reviewer*	Interviewees/Participants	Focus of Interviews and Interactions
Accessible Locations and Hours of Operation (Elements a and b)	G/A	Board members	Patient access considerations for either: One to two sites already in scope, or A site added to scope within the past 12 months How hours are responsive to patient need
Sliding Fee Discount Program (SFDP) (Elements b and l)	F	Board members	SFDP policies Setting nominal charges at a level that is nominal from the patient perspective (if applicable) Process for evaluating the SFDP
Conflict of Interest (Elements a and c)	G/A	Board members	Standard of conduct and the process for disclosing any real or apparent conflicts of interest Mechanisms or procedures for informing employees, officers, board members, and agents of the health center’s standards of conduct
Program Monitoring and Data Reporting Systems (Element b)	F	Board members	Receipt and relevance of health center data-based reports
Board Authority (Elements c – e)	G/A	Board members	How Project Director/CEO reports to the board Board roles and responsibilities (for example, evaluating health center performance, approving applications, conducting long-range planning) Board’s evaluation of and related updates to the health center’s SFDP, quality improvement/quality assurance program, and billing and collections policies Process for evaluating health center financial management and accounting systems and personnel policies
Board Composition (Elements c, d, and f)	G/A	Board members	Composition of the current board Process for verifying board membership eligibility For health centers with approved waivers, the use of special population input

Date Last Reviewed:

April 2023