1.
www.compliantfqhc.com
Continuous Compliance Series- It’s not JUST an
OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Michelle Layton BSN, MBA
marketing@fqhcwebinar.com

2.
Chapter 7
Coverage for Medical Emergencies During
and After Hours
Chapter 8
Continuity of Care

3.
Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
 This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
 Not employed by MSCG or BPHC
 Independent Consultant who is contracted to conduct Operational
SiteVisits (OSV), provideTechnical Assistance and assist health
centers with preparation for their OSV
 This information should not be considered legal advice
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned
party.

4.
Purpose of the Compliatric Series
 HRSA’s evaluation of compliance during COVID-19 continues via
Virtual Operational SiteVisits (vOSV)
 Provides an overview of the health center program requirements
 Provides updates to the SiteVisit Protocol and vOSV Process
 Provides tips on “What to Expect”
 Provides tips on “How to Prepare”
 Provides a reviewer perspective

5.
Purpose of the Compliatric Series
 Compliance maintains HRSA funding
◦ Non-compliance can impact other Federal Programs (i.e., FTCA)
 Continuous Compliance supports high performing health centers
◦ Eliminates the chaos of having to “prepare”
◦ Develops practices for operational excellence for the health
center

6.
Agenda
 Requirements for Compliance
 Evaluation of Compliance
 Maintaining Continuous Compliance
 Clinical Reviewer Insight
 Question and Answer Session

7.
Chapter 7
Coverage for Medical Emergencies
During and After Hours

8.
Requirements for Compliance

9.
Requirements for Compliance
To assure continuity of care, the health center must have
the following:
 Provisions for promptly responding to medical
emergencies during normal business hours; and
 Clearly defined arrangements for promptly responding
to medical emergencies outside of normal business
hours.

10.
Requirements for Compliance
Element a: Clinical Capacity for Responding to
Emergencies During Hours of Operation
The health center has at least one staff member trained
and certified in Basic Life Support (BLS) at each HRSA-
approved site on Form 5B to ensure the health center has
the clinical capacity to respond to medical emergencies
during normal business hours

11.
Requirements for Compliance
Element b: Procedures for Responding to
Emergencies During Hours of Operation
The health center has and follows its operating
procedures for responding to medical emergencies during
normal hours of operation
 Conduct staff training
 Conduct mock drills

12.
Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
The health center has after-hours coverage procedures,
which may include formal arrangements with non-health
center providers or entities that ensure the following:

13.
Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Coverage is provided via telephone or through face-to-
face contact by an individual with the qualifications and
training necessary to exercise professional judgement in
determining a patient’s need for emergency medical care

14.
Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Coverage includes the ability to refer patients either to a
Licensed Independent Practitioner (LIP) for additional
consultation or to locations such as emergency rooms or
urgent care centers for further assessment/care as needed

15.
Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Patients, including those with Limited English Proficiency
(LEP) are informed of and able to access after-hours
coverage, including being provided with information and
instructions on how to access after hours coverage in
languages, literacy levels and formats appropriate to the
patient population

16.
Requirements for Compliance
Element d: After Hours Call Documentation
The health center has documentation of after-hours calls
and any associated follow-up resulting from such calls for
the purposes of continuity of care

17.
Requirements for Compliance
 BLS is a minimum requirement
 Individual with BLS at each site can be a clinical or non-
clinical person
 To ensure continuity of care, the health center must:
◦ Maintain documentation of after-hours calls and any
necessary follow-up
◦ Include the process used to address documentation
and continuity of care in the operating procedures for
after-hours coverage

18.
Evaluation of Compliance

19.
Evaluation of Compliance
 Review of Documentation
◦ Procedures to address emergencies during business hours and
after-hours
◦ Mock drills with staff
◦ Agreements with answering service/triage service
◦ Provider on-call schedules

20.
Evaluation of Compliance
 Review of Documentation (cont.)
◦ Documentation of BLS certification for any employees for up to
five sites
◦ Sample patient records of after-hours calls requiring follow-up
(3)
◦ Instructions/information provided to patients
◦ Methods for tracking and recording after-hours information (i.e.,
log)

21.
Evaluation of Compliance
 Staff Interviews
◦ Verification of process with Clinical Leadership
 Placement of after-hours test call
◦ Can be completed at any time during the vOSV
◦ Reviewer will ask the point of contact how the call would be
handled if they were a non-English speaking patient

22.
Maintaining Continuous Compliance

23.
Maintaining Continuous Compliance
 Review the following on a regular basis to ensure paper meets
practice:
◦ Operating procedures for handling medical emergencies during
normal business hours – Should not just be triage procedures
◦ Operating procedures for handling medical emergencies after
normal business hours
 Conduct mock drills on a regular basis
◦ Chest pain, seizure, etc.
 Test the after-hours line on a regular basis
 Conduct routine chart audits to ensure appropriate documentation
of follow-up

24.
Chapter 8
Continuity of Care
and Hospital Admitting

25.
Requirements for Compliance

26.
Requirements for Compliance
Element a: Documentation of Hospital Admitting
Privileges or Arrangements
The health center has documentation of the following:
 Health center provider hospital admitting privileges; and/or
 Formal written arrangements between the health center and
one or more hospitals/entities in the service area for the
admission of health center patients

27.
Requirements for Compliance
Element b: Procedures for Hospitalized Patients
The health center has internal operating procedures and
provisions in any formal arrangements with non-health center
providers/entities that address the following:
 Receipt and recording of medical information related to the
hospital or ED visit
 Follow-up actions by the health center, when appropriate

28.
Requirements for Compliance
Element c: Post-HospitalizationTracking and
Follow-Up
The health center follows its operating procedures and formal
arrangements as documented by the following:
 Receipt and recording of medical information related to the hospital
or ED visit
 Evidence of follow-up actions by the health center, when appropriate

29.
Requirements for Compliance
 If providers have hospital privileges:
◦ Must be admitting privileges and not courtesy privileges
◦ Must routinely admit and round on health center patients
◦ Must be documentation of admitting privileges
◦ Frequently see admitting privileges for OB/GYN providers

30.
Requirements for Compliance
 If formal written arrangement(s) with hospital:
◦ One or more hospitals in the service area
◦ Must address patients across all lifecycles
◦ Must address emergency room and inpatient services
◦ Must address the exchange of patient information and continuity
of care
◦ Must address appropriate credentialing and privileging of
providers

31.
Evaluation of Compliance

32.
Evaluation of Compliance
 Review of Documentation
◦ Hospital privileges; and/or
◦ Hospital agreements with one or more referral hospitals
◦ Procedures to address tracking of ER visits and inpatient
hospitalizations, including patient follow-up
◦ Methods for tracking and recording ER visits and inpatient stays
◦ Samples of patient records for patients who have been hospitalized or
have had ER visits in the past 12 months (5-10)
 Staff Interviews
◦ Verification of process with Clinical Leadership

33.
Maintaining Continuous Compliance

34.
Maintaining Continuous Compliance
 Review hospital agreements on a regular basis to mitigate risk and
ensure compliance with frequently changing HRSA requirements
 Review HospitalTracking Policies and Procedures routinely to
ensure paper meets practice
 Review credentialing and privileging files routinely to ensure
appropriate documentation of admitting privileges
 Incorporate hospital tracking metrics into the Quality
ImprovementWork Plan to monitor performance

35.
Clinical Reviewer Insight

36.
Clinical Reviewer Insight
 Ensure all points of contact for the after-hours process are aware a
test call will be placed
 The after-hours process must address all services in scope and
ensure access to the Limited English Proficiency (LEP) population
◦ The reviewer will verify translation capability during the test call
 The test call should NOT be placed prior to the start of the vOSV
 The reviewer does NOT have to identify themselves as a site visit
reviewer when placing a call to the after-hours line

37.
Clinical Reviewer Insight
 Patient samples for after-hours coverage must be those that
require follow-up by the health center
 Patient samples:
◦ Can be loaded into ShareFile with information redacted
◦ Screenshots can be viewed via GoToMeeting during the review
 Industry standard call back time is 30 minutes
◦ Make sure the call back time is documented in the After-Hours
Policy and Procedure

38.
Factors to Consider
 Choose patient samples that clearly demonstrate follow up:
◦ Notification of patient hospitalization
◦ Receipt of discharge summary or hospital records
◦ Follow-up with patient (i.e., scheduling hospital follow-up visit)
 Patient samples:
◦ Can be loaded into ShareFile with information redacted
◦ Screenshots can be viewed via GoToMeeting during the review
◦ Confirm the process during the pre-OSV call with the review
team

39.
Resources

40.
Additional Resources
Compliatric
https://www.compliatric.com/
HRSA Health Center Compliance Manual
Health Center Program Compliance Manual | Bureau of Primary Health
Care (hrsa.gov)
HRSA SiteVisit Protocol
Health Center Program SiteVisit Protocol | Bureau of Primary Health
Care (hrsa.gov)
HRSA Sampling Review Resource Guide
Health Center Program SiteVisit Protocol: Sampling Review Resource
Guide | Bureau of Primary Health Care (hrsa.gov)

41.
Questions & Answers

42.
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
marketing@fqhcwebinar.com