As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level. This month’s webinar will focus on the following chapters: Chapter 7: Coverage for Medical Emergencies During and After Hours, and Chapter 8: Continuity of Care and Hospital Admitting Webinar attendee takeaways will include: · Understanding the requirements and why they are important · Methods to maintain continuous compliance (without addressing it last minute or only during an OSV) · How to use the requirement in everyday practice to improve your Community Health Center

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

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

3. ThankYou For Providing Care

4. 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 Site Visits (OSV), provide Technical 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.

5. Purpose of the Compliatric Series
 Virtual Operational Site Visits (VOSVs) are here to stay
◦ Time frames for notification can be short
 Compliance = HRSA funding
◦ Non-compliance can affect other Federal Programs (i.e.,
FTCA)
 Continuous Compliance = High performing health
center
◦ Eliminates the chaos of having to “prepare”

6. Agenda
 Requirements for Compliance
 Evaluation of Compliance
 Maintaining Continuous Compliance – Factors to
Consider
 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
 Health center must have clinical capacity for responding to
emergencies during the center’s regularly scheduled hours
 Must have at least one staff member trained and certified in
Basic Life Support (BLS) at each HRSA-approved site
◦ BLS is a minimum
◦ Can be a clinical or non-clinical person

10. Requirements for Compliance
 The health center must have procedures in place for
responding to emergencies during regular hours of operation
◦ Requires more than triage procedures
◦ Must reflect how an actual “emergency” at the health
center would be handled
 Chest pain
 Seizure
 The health center must follow the procedures in place for
responding to emergencies during regular hours of operation

11. Requirements for Compliance
 The health center must have operating procedures or
arrangements in place for after-hours coverage
 Arrangements may be with non-health center providers or
entities
 Operating procedures of arrangements must ensure:
◦ Coverage is provided via telephone or face-to-face
◦ Individual must have the qualifications and training necessary to
exercise professional judgement in assessing the patient’s need
for emergency medical care

12. Requirements for Compliance
 Operating procedures or arrangements must also ensure:
◦ The ability to refer patients to a Licensed Independent Practitioner
(LIP) for further consultation (on-call health center provider)
◦ The ability to refer patients to locations such as an emergency room
for further assessment
◦ Patients are informed of and able to access after-hours coverage
provided
 Includes Limited English Proficiency (LEP) patient population
 Information and instructions in language, literacy levels and
formats appropriate to the patient population

13. Requirements for Compliance
 To ensure continuity of care, the health center must:
◦ Maintain documentation of after-hours calls and any necessary
follow-up
◦ Maintain documentation of any necessary follow-up resulting from
after-hours calls
◦ Include the process used to address documentation and continuity of
care in the operating procedures for after-hours coverage

14. Evaluation of Compliance

15. 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
◦ Documentation of BLS certification for any employees for up to
five sites
◦ Sample patient records of after-hours calls requiring follow-up
◦ Methods for tracking and recording after-hours information

16. 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

17. Maintaining Continuous Compliance
Factors to Consider

18. Factors to Consider
 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

19. Factors to Consider
 Patient samples chosen 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
 Best practice – Industry standard call back time is 30 minutes
◦ Make sure the call back time is documented in the After-Hours
Policy and Procedure
 Best practice – Test the after-hours line on a regular basis

20. Chapter 8
Continuity of Care
and Hospital Admitting

21. Requirements for Compliance

22. Requirements for Compliance
 The health center must have documentation of:
◦ Health center provider hospital admitting privileges; and/or
◦ Formal written arrangements between the health center and one
or more hospitals for the purposes of hospital admission of health
center patients
 If providers have privileges:
◦ Must be admitting privileges and not courtesy privileges
◦ Must routinely admit and round on health center patients
◦ Frequently see admitting privileges for OB/GYN providers

23. 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
 Also any services listed on Form 5A that are provided by the hospital
◦ Must address the exchange of patient information and continuity
of care
◦ Must address appropriate credentialing and privileging of
providers

24. Requirements for Compliance
 The health center must have internal operating procedures and
provisions in any formal written arrangements that address:
◦ Receipt and recording of medical information related to the
hospital or ED visit
◦ Any follow-up actions taken by health center staff, when
appropriate
 The health center must follow procedures and formal
arrangements as documented by:
◦ Receipt and recording of medical information related to the
hospital or ED visit
◦ Evidence of follow-up actions taken by the health center based on
the information received

25. Evaluation of Compliance

26. 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 month (5-10)
 Staff Interviews
◦ Verification of process with Clinical Leadership

27. Maintaining Continuous Compliance
Factors to Consider

28. Factors to Consider
 Best Practice: Review hospital agreements on a regular
basis to mitigate risk and ensure compliance with frequently
changing HRSA requirements
 Best Practice: Review Hospital Tracking Policies and
Procedures routinely to ensure procedures are reflective of
current practice
 Best practice: Incorporate hospital tracking metrics into the
Quality Improvement Work Plan to monitor performance

29. 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

30. Resources

31. 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)

32. Questions & Answers

33. Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Direct: 214-766-0333