Overview
In April 2023, the Health Resources and Services Administration (HRSA) released an updated version of the Health Center Program Site Visit Protocol. This key 21-chapter document serves as a guide for HRSA reviewers to assess compliance and performance during Operational Site Visits for Look-Alikes and full H80 grantee Federally Qualified Health Centers (FQHCs). During these visits, a team of HRSA representatives and designated reviewers undertake a thorough examination of the health center by gathering information and evidence through a series of interviews, document reviews, and observations.
The latest version of the Site Visit Protocol features plain language-related edits across all chapters. These amendments aim to make the document clearer and more accessible to both health centers and reviewers. Among the key changes in the protocol are updates to Chapter 21, which pertains to Federal Tort Claims Act (FTCA) Deeming Requirements. Amendments focus on enhanced compliance requirements for health center risk management programs and training requirements for obstetrics. These changes are in line with HRSA’s February 2023 Program Assistance Letter 2023-01, issued to provide critical updates to the FTCA application and compliance expectations for calendar year 2024 applicants.
Core Updates
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The previous version’s language indicated that the FTCA Program will issue Corrective Action Plans (CAP) for findings. This language has been changed to may issue a CAP.
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Addition of new requirements:
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Documentation of the last two quarterly risk management assessments
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Board meeting minutes that discuss the status of risk management activities
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Reports on risk management activities presented to the board and management staff
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Steps implemented to mitigate future claims for health centers with closed claims under FTCA in the past 5 years
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Documentation of the health center informing patients of FTCA deemed status via website, promotional materials and statements posted within lobbies or checkout counters
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Must provide obstetrical training as part of the risk management training plan regardless of whether labor and delivery services are offered through FTCA-deemed providers (applies to both health center employees or individual contractors)
View the updated Site Visit Protocol here: https://bphc.hrsa.gov/compliance/site-visits/site-visit-protocol
If you are preparing for an upcoming site visit and need assistance, please reach out to Elizabeth (elizabeth@burrowsconsulting.net) or Jonathan (jonathan@burrowsconsulting.net) to learn how we can help.
