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Operational Site Visits-Overview and Q&A Panel
Discussion
COMPLIATRIC WEBINAR SERIES
Michelle Layton
Infidium Healthcare
Solutions
Jennifer Genua-McDaniel
Genua Consulting, LLC
Tonya Harris
Tonya Harris Consulting
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 Consultants who are contracted to conduct
Operational SiteVisits (OSV) and provideTechnical Assistance.
 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, Genua Consulting and Tonya Harris Consulting. 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 parties.
Agenda
Overview of the
Operational SiteVisit
(OSV) Process
Panel Q&A Discussion
with Three Consultants
Admin/Governance
Clinical
Fiscal
OPERATIONAL SITE
VISIT (OSV) PROCESS
Operational SiteVisit (OSV) Process
Source: HRSA OSV TA Webinar; November 1, 2023
Operational SiteVisit (OSV) Process
Health Centers should have
already been contacted regarding
OSVs for 2024 visits
If unsure, reach out to the HRSA
Point of Contact
OSVs will be onsite
Once confirmed, the Point of
Contact in the EHB will receive an
email notification on logistics of
the OSV
Ensure that Point of Contact is
updated
Consultant Team will be onsite
HRSA Federal Representative may
attend virtually
Operational SiteVisit (OSV) Process
 At least 4-6 weeks prior to the
site visit, a pre-OSV call will be
completed
◦ HC, Consultants, HRSA
Federal Representatives
◦ Agenda will consist of:
 Purpose of the visit
 Logistics
 Draft agenda review
 Interview with the board
 Patient samples
Operational SiteVisit (OSV) Process
The process of completing the site visit has NOT
changed:
• 3-day visit which starts with an Entrance Conference
• 3 consultants (Admin/Gov, Fiscal and Clinical) along with a HRSA
Federal Representative
• Completion of a tour of Health Center sites
• Chapter 21 (FTCA) is no longer reviewed during the OSV
HRSA utilizes:
• GoToMeeting platform
• Citrix Share File platform to upload documents
• Standard agenda for the OSV
Operational SiteVisit (OSV) Process
Documents
All documents must be submitted at
least 2 weeks prior to the OSV
No new documents uploaded to
Citrix Share File after “end of
business” for Day 1
Documents may be
needed in multiple
chapters
Upload them in various chapters
• Ex.Audit, needs assessment,
contracts
Determine whether
samples will be uploaded
or live navigation
Health Center chooses the method
If uploaded, remove any identifiers
Operational SiteVisit (OSV) Process
• If multiple sites, at least 2 tours are required
• 1site must be a site where the majority of services are
completed
Health Center tours:
• Start on the outside
• Review signage
• Services provided:
• When compared to Form 5A (Column 1)
• Overall impression of the Health Center
From the perspective of the patient:
Health Center Compliance &
Engagement SiteVisit (CE-OSV)
CE-OSV:
• Started as a pilot in 2022/2023
• From 2024 onward, another OSV method of assessing
compliance
• One-day OSV
Focus is the same:
• Comprehensive assessment based on the Compliance
Manual (CM) and SiteVisit Protocol (SVP)
• Pre-OSV call will include a presentation by the Health
Center to provide an overview
Health Center Compliance &
Engagement SiteVisit (CE-OSV)
• One on one time to assist and engage the health center staff to discuss
the SVP
• Link the elements and operational process to the documentation
• Form 5A self-assessment work session with clinical and fiscal
consultants
Cultivation session by each consultant:
• Supplemental narratives for the Health Center staff to respond in
writing versus interviews
Desktop review of 14 chapters
ALL documents must be uploaded to Citrix Share File
Health Center Compliance &
Engagement SiteVisit (CE-OSV)
Health Center Compliance &
Engagement SiteVisit (CE-OSV)
Operational SiteVisit (OSV) Process
Compliance
Resolution
Opportunity (CRO)
• Within 45 days of
completion of OSV, a
draft OSV report will
be provided through
the EHB
• Request will be an
“Urgent SiteVisit
Report Request”Task
• 14 CALENDAR
DAYS to submit a
response to non-
compliance findings
Work with HRSA
Federal Representative
to submit documents
• HRSA will review
documentation
submitted to
demonstrate
compliance and if
compliance is met, a
final report will be
issued
• If documentation
does not meet
compliance, a grant
condition will be
placed
PANEL Q&A
DISCUSSION
Panel Q&A Discussion
Clinical
Consultant
Fiscal
Consultant
What questions can we
answer?
Resources
HRSA Health Center Program
Compliance Manual
HRSA Compliance Manual
Health Center Program Site
Visit Protocol
HRSA SiteVisit Protocol
Health Center Program:
Sampling Review Resource
Guide
HRSA Sample Resource Guide
Health Center Program:
Examples of Credentialing and
Privileging
HRSA Credentialing and Privileging
Documentation
Have Additional Questions?
Marketing@fqhcwebinar.com

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2024 Compliatric Webinar Series - OSV Overview and Panel Discussion April 2024.pdf

  • 1. www.compliantfqhc.com Operational Site Visits-Overview and Q&A Panel Discussion COMPLIATRIC WEBINAR SERIES Michelle Layton Infidium Healthcare Solutions Jennifer Genua-McDaniel Genua Consulting, LLC Tonya Harris Tonya Harris Consulting
  • 2. 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 Consultants who are contracted to conduct Operational SiteVisits (OSV) and provideTechnical Assistance.  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, Genua Consulting and Tonya Harris Consulting. 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 parties.
  • 3. Agenda Overview of the Operational SiteVisit (OSV) Process Panel Q&A Discussion with Three Consultants Admin/Governance Clinical Fiscal
  • 5. Operational SiteVisit (OSV) Process Source: HRSA OSV TA Webinar; November 1, 2023
  • 6. Operational SiteVisit (OSV) Process Health Centers should have already been contacted regarding OSVs for 2024 visits If unsure, reach out to the HRSA Point of Contact OSVs will be onsite Once confirmed, the Point of Contact in the EHB will receive an email notification on logistics of the OSV Ensure that Point of Contact is updated Consultant Team will be onsite HRSA Federal Representative may attend virtually
  • 7. Operational SiteVisit (OSV) Process  At least 4-6 weeks prior to the site visit, a pre-OSV call will be completed ◦ HC, Consultants, HRSA Federal Representatives ◦ Agenda will consist of:  Purpose of the visit  Logistics  Draft agenda review  Interview with the board  Patient samples
  • 8. Operational SiteVisit (OSV) Process The process of completing the site visit has NOT changed: • 3-day visit which starts with an Entrance Conference • 3 consultants (Admin/Gov, Fiscal and Clinical) along with a HRSA Federal Representative • Completion of a tour of Health Center sites • Chapter 21 (FTCA) is no longer reviewed during the OSV HRSA utilizes: • GoToMeeting platform • Citrix Share File platform to upload documents • Standard agenda for the OSV
  • 9. Operational SiteVisit (OSV) Process Documents All documents must be submitted at least 2 weeks prior to the OSV No new documents uploaded to Citrix Share File after “end of business” for Day 1 Documents may be needed in multiple chapters Upload them in various chapters • Ex.Audit, needs assessment, contracts Determine whether samples will be uploaded or live navigation Health Center chooses the method If uploaded, remove any identifiers
  • 10. Operational SiteVisit (OSV) Process • If multiple sites, at least 2 tours are required • 1site must be a site where the majority of services are completed Health Center tours: • Start on the outside • Review signage • Services provided: • When compared to Form 5A (Column 1) • Overall impression of the Health Center From the perspective of the patient:
  • 11. Health Center Compliance & Engagement SiteVisit (CE-OSV) CE-OSV: • Started as a pilot in 2022/2023 • From 2024 onward, another OSV method of assessing compliance • One-day OSV Focus is the same: • Comprehensive assessment based on the Compliance Manual (CM) and SiteVisit Protocol (SVP) • Pre-OSV call will include a presentation by the Health Center to provide an overview
  • 12. Health Center Compliance & Engagement SiteVisit (CE-OSV) • One on one time to assist and engage the health center staff to discuss the SVP • Link the elements and operational process to the documentation • Form 5A self-assessment work session with clinical and fiscal consultants Cultivation session by each consultant: • Supplemental narratives for the Health Center staff to respond in writing versus interviews Desktop review of 14 chapters ALL documents must be uploaded to Citrix Share File
  • 13. Health Center Compliance & Engagement SiteVisit (CE-OSV)
  • 14. Health Center Compliance & Engagement SiteVisit (CE-OSV)
  • 15. Operational SiteVisit (OSV) Process Compliance Resolution Opportunity (CRO) • Within 45 days of completion of OSV, a draft OSV report will be provided through the EHB • Request will be an “Urgent SiteVisit Report Request”Task • 14 CALENDAR DAYS to submit a response to non- compliance findings Work with HRSA Federal Representative to submit documents • HRSA will review documentation submitted to demonstrate compliance and if compliance is met, a final report will be issued • If documentation does not meet compliance, a grant condition will be placed
  • 18. Resources HRSA Health Center Program Compliance Manual HRSA Compliance Manual Health Center Program Site Visit Protocol HRSA SiteVisit Protocol Health Center Program: Sampling Review Resource Guide HRSA Sample Resource Guide Health Center Program: Examples of Credentialing and Privileging HRSA Credentialing and Privileging Documentation