HRSA Compliance: Appropriate Clinical Staffing Makeup

The RegLantern team commonly receives questions in regard to HRSA Site Visit Protocol, Chapter 5: Clinical Staffing, Element a., Question 1 (“Does the health center’s current clinical staffing makeup (e.g., employees, volunteers, contracted and referral providers) enable it to carry out the approved scope of project (i.e., the list of Required and Additional services on Form 5A)?”

Health centers often ask: “How do we show our staff makeup enables us to carry out our scope of project?”

Though many of the HRSA Site Visit Protocol questions have been revised to be more objective, this one could be classified as a rather subjective judgement call. So, the onus lies on the health center to make very clear why the reviewer should have no choice but to mark, “Yes” to this question.

When ensuring your health center is continuously compliant and has the documentation to prove it, we recommend you do three things:

Assign an accountable leader to every service on Form 5A (Column I)
On your health center’s Form 5A, the Column I services are services that you are telling HRSA you’re providing directly and paying for out of health center funds. This means that your health center must show that you have the staff (employees, individual contractors, and volunteers) to handle administering and managing these services. If you are using the RegLantern web-based tools, this is easy – fill-in the staff member title beside every Column I service. If you are not using our platform tools, at least make sure you create a document that lists the Column I services together with the staff member role accountable to the oversight of that service (i.e. “General Primary Medical Services-Chief Medical Officer”, “Pharmaceutical Services-Pharmacy Director”, etc.).

Provide supporting documentation
Besides staff numbers and FTEs (full-time equivalents) that may be captured on your HRSA Form 2 (Staffing Profile), a health center may document other outcomes that may be indicative of a healthy clinical staff makeup. These may include Third Next Available Appointment tracking (to demonstrate there is plenty of access to your clinical providers) or maybe it is a list of staff vacancies. Another metric might be provider productivity rates (number of patients seen per hour) or patient panel size (per FTE). Together, these data points will paint a picture for the reviewer of how well your staff is covering your in-scope services.

Discuss with the Board
After compiling your staffing and supporting documentation, take the report to your Board. Present your findings and state any recommendations you may have in areas where you need to shore-up your staff. Make sure the person taking the minutes captures that a robust discussion was had and that this question was fully taken into consideration.

When you have done these three things, compile the documentation and Board meeting minutes into a document and provide the packet to the reviewers when the time comes for your Operational Site Visit.

Health center leaders should always review the current HRSA Compliance Manual and the HRSA Site Visit Protocol as references to guide their work. When reviewing your credentialing and privileging systems, review the HRSA Program Requirements and consider having an FQHC mock site visit. As HRSA continues to work to align their key guidance documents, staying on top of the changes will keep you heading away from episodic compliance and toward HRSA Continual Compliance.