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Why I need to be prepared for a HRSA Site Visit?

Updated: Apr 3, 2019

The purpose of Health Resources and Services Administration (HRSA) site visits is to support the effective oversight of the Health Center Program.


Operational Site Visits (OSVs) provide an objective assessment and verification of the status of each Health Center Program awardee or look-alike’s compliance with the statutory and regulatory requirements of the Health Center Program.


HRSA conducts site visits to assess and verify look-alike initial designation

applicants for eligibility and compliance with Health Center Program requirements to inform

initial designation determinations. CFOPerfect can help you during this SVP process.


Just imagine if you are not prepare during a visit, what could be the consequences of not being compliant with one or more requirements ?.

HRSA uses the Health Center Program Compliance Manual (“Compliance Manual”) as the

basis for determining whether health centers have demonstrated compliance with the statutory and regulatory requirements of the Health Center Program.

 

Each Health Center Program requirement has a section in the Site Visit Protocol (SVP) and each section contains the:

  1. Statute and Regulations: The supporting statute and regulations for the associated program requirements.

  2. Primary and Secondary Reviewers: The member of the site visit team who serves as the primary reviewer for that section, based on expertise (governance/administrative,fiscal, or clinical), and an optional or suggested secondary reviewer who may add expertise and assistance as needed. The site visit team confers and works together on compliance assessments.

  3. Documents Checklist for Health Center Staff: The list of documents a health center provides to the site visit team prior to the site visit or onsite.

  • Documents provided prior to the site visit are to be sent at least two weeks prior to the start of the site visit.

  • Documents provided by the start of the site visit are to be ready when the site visit team arrives onsite.

  • In cases where a sample (e.g., sample of patient records) is referenced in the list of documents to be provided by the health center, the health center is expected to provide (or "pull") the sample and have it ready when the site visit team arrives onsite.

Documents not provided by the close of the first day of the site visit will not be considered in the compliance assessment by the site visit team.

4. Demonstrating Compliance Elements: The elements from the Compliance Manual that describe how health centers would demonstrate their compliance with the Health Center Program requirements.

5. Site Visit Team Methodology: The methods a site visit team uses to assess compliance with the corresponding demonstrating compliance elements. Methods include but are not limited to reviews of policies and procedures, samples of files and records, site tours, and interviews.

6. Site Visit Findings: The site visit team’s responses to the series of questions based on the related methodologies. These findings are included in the health center’s site visit report and form the basis for determining whether a health center has demonstrated compliance with Health Center Program requirements.


 

You can download the latest 2019 updated version clicking this link.

The updated 2019 SVP will go into effect for site visits after April 18, 2019.


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