1.
www.compliantfqhc.com
Deep Dive- Updates to the HRSA Site Visit Protocol
COMPLIATRIC WEBINAR SERIES
Presented by : Jennifer Genua-McDaniel
jgenua@genuaconsulting.com

2.
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
 This presentation is not endorsed by Health Resources Services
Administration (HRSA) or Bureau of Primary Health Care (BPHC)
 Not employed by MSCG or BPHC
 Independent Consultant who is contracted to do Operational Site
Visits (OSV)s and Technical Assistance (TA)
 Not intended to provide legal advice
 Please refer to your HRSA Project Officer (PO) for specific
questions

3.
 Updates to the SVP
◦ What has updated
◦ What has NOT updated
 Review requirements with updates
◦ Specific elements that have been clarified
 Maintaining continuous compliance
CHANGE TO HRSA COMPLIANCE MANUAL
NO

4.
 Thanks to feedback:
◦ Revisions to documents requested, methodologies,
questions asked and improved efficiencies
◦ Clarifications of overlapping sections
◦ “Related considerations” added to the SVP
 HRSA Compliance Manual and HRSA SVP
better aligned

5.
 Consolidated Documents
◦ Now one list
 No “documents prior” and “documents at the start”
https://bphc.hrsa.gov/programrequirements/site-visit-protocol/site-visit-resources

6.
 Performance Analysis
◦ Removed from the process February 2021
◦ Streamlined the site visit process to focus on compliance
◦ Request technical assistance through HRSA PO
 Health Centers WITH Sub-Recipients
◦ Methodology to assess compliance expanded to specific
requirements (board authority/composition and sliding
fee discount program)
 Eligibility for Look-Alike ID Applicants
◦ Aligned the criteria contained in the Look-Alike
applications

7.
NOT UPDATED CLARIFIED/UPDATED
 HRSA Compliance Manual
 How Virtual OSVs are
completed
 Following Program
Requirements:
◦ Quality
Improvement/Assurance
◦ Budget
◦ Program Monitoring/Data
Reporting Systems
◦ Board Authority
◦ Promising Practices
 Consolidated Checklist
 Performance Analysis no
longer completed
 Program Requirements
◦ Methodologies
◦ Questions to assess
compliance
◦ Clarification on assessing
compliance
https://bphc.hrsa.gov/programrequirements/site-visit-protocol/summary-updates

8.
 Review the Chapter and specific element that
is clarified
◦ Clarifications can be minor
◦ Clarifications provide additional information to
assess compliance

9.
 Element A
 Comparison of Form 5B zip code and most recent
UDS zip codes
◦ Where are your patients coming from?
◦ Does your Form 5B reflect updated zip codes?

10.
Clarification for reviewers on methodologies on
samples
Updated questions in Element A (Providing and
Documenting Services within Scope of Project)
Added a question on consistency of Form 5A (Scope
of Services) and whether any Changes in Scope (CIS)
were submitted

11.
 Updated questions in Element A (Providing
and Documenting Services within Scope of
Project)
◦ Column II

12.
 Updated questions in Element A (Providing
and Documenting Services within Scope of
Project)
◦ Column III

13.
 Clarification of Element C (Procedures for
Review of Credentials) and Element D
(Procedures for Review of Privileges) to
specify who constitute “clinical staff”

14.
 Element D (Procedures for Review of Privileges)
requires an explanation of HOW the health center
verifies fitness for duty
◦ Health Center makes the decision on how to verify
fitness for duty
◦ Needs to be documented

15.
 Element F (Credentialing and Privileging of
Contracted or Referral Providers) provides
examples of how a health center might
assess contracts and referral arrangements
for compliance with credentialing and
privileging requirements.

16.
 Element C (Accurate Documentation of Sites
within Scope) clarified the question on
whether Form 5B is correct

17.
 Clarifications on samples provided through
footnotes and documentation of after hour
follow up

18.
 Clarification of samples of hospital
admissions
 Documentation for hospital samples
◦ Need to document the health center’s entire hospitalization
tracking process, from admission and follow-up through
closure.

19.
 Clarification for reviewers on assessing
compliance
 Clarification on how to determine that the
nominal fee is nominal from the perspective
of the patient

20.
 Element I (Sliding Fee for Column II Services)
& Element J (Sliding Fee for Column III
Services)
◦ Clarification: for any service(s) delivered via
Columns II or III, HRSA expects health centers to
provide any other supporting documentation not
included in the written contracts/agreements,
showing how health centers ensure application of
the sliding fee discount program for these services.

21.
 Element E (HRSA Approval for Project
Director/CEO Changes)
◦ Updated the methodology when there is a new
Project Director/CEO since the start of the current
project

22.
 Clarification on which reviewer assesses
compliance
◦ If Sub-recipient, then Admin/Governance Reviewer
 Sub-Recipient Clarification (Elements G-J)
◦ Reviewers will focus on the health center’s
monitoring of subrecipient’s compliance with board
authority, board composition, and sliding fee
discount program requirements

23.
 Clarification procurement and contract samples
◦ What is required in contracts is the same
◦ Supporting documentation for procurement process is
the same
 Rationale, Selection, Contractor selection/rejection, basis for
price

24.
 Element F (Required Contract Provisions)
◦ Clarification of contract samples
◦ What is required in the contract is the same
 Specific activities/services performed
 Monitoring performance
 Data reporting expectations and intervals
 Provisions for record retention, access, audit and
property management

25.
 Administrative/Governance Reviews
 Clarification of Contract Samples

26.
 Element D (Adherence to Standards of
Conduct)
◦ Updated methodology to assess compliance

27.
 Updated methodology so the health center
can provide additional details of partnerships
and collaborations

28.
 Element C (Drawdown, Disbursement and
Expenditure Procedures)
◦ Added a footnote for information on annual
appropriations that limit the use of HRSA awards
https://www.hrsa.gov/grants/manage-your-grant/policies-regulations-guidance

29.
 Element F (Timely and Accurate Third-Party
Billing)
◦ Clarified billing samples
◦ All other elements the same:
 Submit claims within 14 business days from the date
of service
 Correct and resubmit claims that have been rejected
due to accuracy

30.
 Clarification:
◦ Provide Form 6A (Board Characteristics)
 Make sure it’s reflective of current practice
 Element A (Board Member Selection and
Removal Process)
◦ How bylaws/health center documentation
demonstrates board member selection or removal.

31.
 Element C (Current Board Composition)
◦ Clarifying information to address board evaluation
of patient representation using UDS and
descriptions of board member connections to the
community.

32.
 Not factored into compliance during the OSV
 Clarification of risk management
documentation required and an additional
question on claims related documentation

33.
HRSA Compliance Manual has not changed
Review the updated Protocol
Talk with your HRSA Project Officer with any clarifying questions
Review HRSA Resources
• https://bphc.hrsa.gov/programrequirements/site-visit-protocol
• https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html
• https://bphc.hrsa.gov/programrequirements/compliance-manual-faqs.html

34.
 Jennifer Genua-McDaniel, BA (Hons), CHCEF
◦ Genua Consulting, LLC
◦ jgenua@genuaconsulting.com