On May 27 2021, HRSA updated the Site Visit Protocol to further align with the Health Center Program Compliance Manual. While a high level overview of the changes was presented in a previous webinar on June 8th, this session will allow participants to further explore specific updates to assist with continuous compliance. Participants will learn about “Hot Spots” that can affect compliance within the fiscal, clinical and Admin/Governance sections. Best practices will be shared and presenters will allow additional time for questions. Please join us on September 8th for this exciting webinar hosted by Michelle Layton and Jennifer Genua-McDaniel.

1. Health Resources and
Services Administration
Operational SiteVisit Updates
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
Jennifer Genua-McDaniel, BA (Hons), CHCEF
Genua Consulting, LLC

2. ThankYou For AllYou Do!!!

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 and Genua 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.

4. Agenda
 Previous Webinars
 SiteVisit Protocol Updates with a focus on “Hot Spots”
 ReviewerTips
 Question and Answer Session
 QUESTIONS: marketing@fqhcwebinar.com

5. PreviousWebinars

6. PreviousWebinars
Continuous Compliance Series
 Webinars focus on strategies for maintaining
continuous compliance with each Chapter of the
HRSA Compliance Manual
Deep Dive into HRSA’s SiteVisit Protocol
Updates
 Webinar focuses on high-level updates to the HRSA
SiteVisit Protocol

7. HRSA andVirtual SiteVisits
 Virtual Operational SiteVisits (VOSVs)
◦ Will continue to be the mode to assess
compliance until the end of 2021
◦ Re-assessment in 2022 based on Covid-19
protocols
As of July 2021
Source: NACHC Conference, HRSA Presentation, August 2021

8. HRSA andVirtual SiteVisits

9. Chapter 3
Needs Assessment

10. Chapter 3- Needs Assessment
 Element A:
◦ Most recent UDS report (2021) compared to
Form 5B zip codes
◦ Does your Form 5B reflect updated zip
codes?

11. Chapter 3-Needs Assessment
 How does the update help Health Centers?
◦ 75% of current Health Center patients reside in
the service area identified on the most recent
UDS report
◦ Help to review the service area
◦ Review the UDS Mapper
 https://udsmapper.org/
◦ Update Form 5B with zip codes
 Requires a Change In Scope (CIS)
 Discuss with the Board of Directors and motion to
approve

12. Chapter 4
Required and Additional Health
Services

13. Required and Additional Health Services
 Column II formal written contracts:
◦ Compliance can be demonstrated through internal operating
procedures that address how the service will be documented in the
patient’s medical record.
*Column II contracts must still include how the health center will
pay for the service
 Column III formal written referral arrangements:
◦ Compliance can be demonstrated through internal referral tracking
procedures that address how referrals are made and managed, as
well as the process for tracking.

14. Required and Additional Health Services
 HRSA does not expect contracts/referral arrangements
for enabling services (i.e., transportation, translation,
outreach) to have all the language required for clinical
services.
 If changes are required to Form 5A, the reviewer must
answer a question stating whether a Change in Scope
(CIS) has been submitted.
 Fiscal reviewer is now officially the secondary reviewer.

15. Chapter 5
Clinical Staffing

16. Clinical Staffing
 Definitions of “Clinical Staff” have been added, which
include:
◦ Licensed Independent Practitioners (LIPs)
◦ Other Licensed and Certified Practitioners (OLCPs)
◦ Other Clinical Staff (OCS)
 The reviewer must provide a narrative explanation as to
how the health center ensures ALL clinical staff have the
physical and cognitive ability to safely perform their
duties (i.e., Fitness for Duty).

17. Chapter 9
Sliding Fee Discount Program

18. Sliding Fee Discount Program
 Element B
◦ Provides information on what needs to go in
the policy
◦ Question #4-Clarification on how to
determine that the nominal fee is nominal
from the perspective of the patient

19. Sliding Fee Discount Program
 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

20. Sliding Fee Discount Program
 Column II
 Reminder (Column II & III):
 Services on Form 5A that are not billed for in the
local health care market may be excluded from the
health center’s sliding fee program
 Ex.Transportation,Translation, Non-clinical services

21. Sliding Fee Discount Program
 Column III
◦ “The entity I refer to does not want to sign
anything”
◦ “The entity I refer to has a charity care that is
better than what we can offer”
 What to do?
 Talk with your Project Officer (PO)
 Can you put that in an addendum?
 Refer to it in the agreement
 Provide the entities’ documentation

22. Sliding Fee Discount Program
 Element L
◦ Evaluation of Sliding Fee Discount Program

23. Sliding Fee Discount Program
 An example of evaluation of the program
◦ Evaluation should include patient input from all pay classes
 Patient focus groups, patient satisfaction, etc.
 Generate a report indicating number of patients on each sliding
fee pay class
 Generate a report indicating the amount of outstanding patient
balance in each sliding fee pay class
 Generate a report indicating the number of patients with a
balance on a payment plan
 Present information for the board to discuss. Document any
changes if needed, or if due to the reports, any process that has
changed. If no changes are made, then also document that

24. Sliding Fee Discount Program
 Examples of Patient Satisfaction Questions
◦ “When you think about seeing your doctor
(dentist, etc.) is our $XX fee a reason why you
would not schedule a visit?”
◦ “Is what I pay for a visit considerate of my
financial status?”
◦ “Do you hesitate to make an appointment at
XXXX because you’re worried about not being
able to pay your bill?”
◦ “If we increase our fees by $5, would that be a
reason not to come here anymore?”

25. Chapter 21
Federal Tort Claims Act

26. FederalTort Claims Act
 The reviewer must now confirm or deny the
individual who oversees the health center’s risk
management activities completes annual risk
management training.
 Provided examples of claims related
information.

27. Performance Analysis

28. Performance Analysis
The Performance Analysis was
removed from theVOSV process
in 2/2021.
The health center can request
Technical Assistance (TA) through
their Project Officer.
TA does not have to be specific to
the Diabetes Performance
Measure and can be requested to
strengthen any clinical measure.

29. Reviewer Tips

30. ReviewerTips
Patient Samples and Credentialing/Privileging Files
 Patient Samples are required for:
◦ Chapter 4 – Required and Additional Health Services
◦ Chapter 7 – Coverage for Medical Emergencies During and After
Hours
◦ Chapter 8 – Continuity of Care and Hospital Admitting
◦ Chapter 10 – Quality Improvement/Assurance
 Credentialing and Privileging Files are required for:
◦ Chapter 5 – Clinical Staffing

31. ReviewerTips
Patient Samples and Credentialing/Privileging Files
 If patient samples and credentialing & privileging files are
loaded into ShareFile, all Personally Identifiable
Information (PII) must be redacted.
 If patient samples and credentialing & privileging files are
reviewed via GoToMeeting, PII is not required to be
redacted.
 The health center is allowed to choose patient samples
and the credentialing and privileging files.
 Confirm on Pre-OSV call how samples and files will be
reviewed.

32. ReviewerTips
Fitness for Duty
 Fitness for Duty must demonstrate ALL clinical staff
have the cognitive and physical ability to perform the
duties outlined in their job description.
 The health center should verify with their PO if the
current process being utilized for Fitness for Duty is in
compliance.
 HRSA has NOT provided guidance indicating that an
attestation cannot be used.

33. ReviewerTips
After-Hours Test Call
 Test the after-hours line to ensure functionality.
 Make answering/triage service and on-call providers
aware the reviewer will place a test call.
 The test call should NOT be placed before the official
start of theVOSV.
 The answering/triage service must be able to explain to
the reviewer how the call would be handled for a
Limited English Proficiency (LEP) Patient.

34. ReviewerTips
 If there is a discrepancy between the Health
center and HRSA ReviewTeam
◦ Ask for clarification where documentation can be
found
 Health Center Program Compliance Manual, SiteVisit
Protocol, Credentialing and Privileging File Resource Guide
◦ Work with HRSA Federal Representative
 ONLY HRSA determines compliance and gives grant conditions
 Consultants assess compliance based on documentation provided
◦ PLEASE FILL OUT EVALUATION FORM
 ANONYMOUS
 Provides honest feedback and helps to improve overall process

35. Additional Resources
Compliatric: Compliatric - HRSA
Compliance
HRSA Compliance Manual (8/2018):
Compliance Manual
HRSA SiteVisit Protocol (5/2021):
SiteVisit Protocol
HRSA Summary of Updates:
Summary of Updates
HRSA Sampling Review Resource
Guide: Sampling Resource Guide
NEW: Form 5B Scope Accuracy
Worksheet: Form 5B Worksheet

36. Questions & Answers

37. Have Additional Questions?
Marketing@fqhcwebinar.com