2022 HRSA Site Visit Protocol Updates

If you are a LAL or FTCA-deemed, read on!

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If you are a LAL or FTCA-deemed, read on! 〰️

On May 26, 2022, HRSA posted the updated Site Visit Protocol (SVP). Changes are extremely minor including changes to numbering, formatting, grammar, and added several additional documentation examples. The most significant changes apply to health centers that are look-alikes and those that are FTCA-deemed. If either of these categories apply to you read-on below!

The most significant changes (which are not very significant) for those who are LALs are as follows:

• A new prompt was added to Chapter 13-Conflict of Interest. The prompt applies to look-alikes who have a “parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe”. If this applies to you, you will want to navigate to the Chapter 13 section of RegLantern’s Site Visit Protocol Checklist and upload the required documents.

• A small clarifying note was added in Chapter 19-Board Authority. To question number 5 (page 139), a clarifying note was added: “For look-alike initial designation applicants and newly-funded health centers that did not have 12 months of board agendas and minutes, determine whether the board met monthly based on the board minutes provided.” This does not really change anything for the health center but is a clarifying note.

The most significant changes (which are not very significant) for those who are FTCA-deemed are as follows:

• Question 9 in Chapter 21-FTCA was changed from a narrative question to a yes/no question. The OSV preparation resource called “Reference – FTCA OSV Narrative Questions Worksheet” was revised to reflect this change. RegLantern recommends that each health center preemptively fill-out this document in preparation for the FTCA section of the OSV.

• HRSA added a “question 13” that asks, “Does the health center’s training plan also require risk management training in areas that the health center has identified as high-risk services?” Most health centers are probably already doing this but each organization should be prepared to show documentation that they are identifying which areas could be considered “high-risk services” (usually documented in Quarterly Risk Management Assessments), and ensuring that risk management training in these areas is included in the health center’s Risk Management Training Plan.

According to HRSA, these updates will not impact the way that site visits are conducted and no changes were made to the Health Center Program Compliance Manual. See a summary of key changes. If you have questions, you can contact one of our RegLantern HRSA compliance experts or use the BPHC Contact Form (Policy > Site Visit Protocol General Inquiry).