HRSA Site Visit Protocol (SVP) Updates - 2023

On April 13, 2023, the Health Resources and Services Administration (HRSA) released its updated version on the Health Center Program Site Visit Protocol (SVP).

RegLantern’s team of health center experts immediately reviewed the SVP and we have summarized the changes below. Additionally, RegLantern’s platform has been updated as of today to the new SVP version. Largely, small wording, grammatical, and formatting changes were made and there were few significant changes at all. Some of these changes were noted in a “SVP 2023 Summary of Changes” document shared with OSV Consultant Reviewers. However, not all changes we found were noted in this document. We have noted those areas below with an asterisk (“*”). Additionally, there are a few changes that are significant changes that the health center should note (these have been bolded and underlined).

General Changes

• Introduction - Added that “If the HRSA site visit team is unable to assess a Health Center Program requirement using the health center’s sample, the team may complete additional sampling in coordination with the health center.”

• Introduction - Added list of commonly used abbreviations related to scope of project (and eliminated use of those longer terms throughout rest of SVP)

• Retitled “Document Checklist for Health Center Staff” section as “Documents that the Health Center Provides”

• Under the “Documents that the Health Center Provides” sections, rearranged items to put similar items together and align with each section’s element order

• Retitled the “Demonstrating Compliance” section as “Compliance Assessment”

• Retitled “Elements” as “Demonstrating Compliance Elements”

• Aligned terminology across Documents that the Health Center Provides, Methodology, and Questions

• Clarified staff types and topics for interviews

• Removed duplicative information from methodology or questions if information was already included in Documents that the Health Center Provides. For example, instructions to health center on selecting a sample are not repeated in the related Methodology.

• Clarified that any patient records samples can be reviewed by using “live navigation of the EHR, screenshots from the EHR, or other patient record formats”

• Multiple plain language type edits, including but not limited to:

  • Removed optional plural parentheses and updated to be singular or plural depending on context. For example, changed policy(ies) to policies.

  • Made “if applicable” occurrences clearer by explaining when or why something is applicable. For example, “If the health center has a co-applicant…” or “Any contracts or agreements with…”

  • Removed occurrences of “and/or” to clarify “and” or “or”

• *“Project/Designation Period” is now being referred to as a health center’s “Period of Performance”

Needs Assessment

• DCE a: Added item to Methodology that was previously missing but was already in Documents the Health Center Provides: “Review the service area reports or analysis documentation.”

• DCE b: Moved item from question Note to methodology: “If the health center is part of a larger organization (for example, a health department, mental health or social service agency), review whether the needs assessment provides data that are relevant and specific enough to inform the delivery of health center services.”

Required and Additional Health Services

• Documents that the Health Center Provides: added details on how to select certain documents (information was previously only in Methodology); clarified total number of patient records to provide in samples

• DCE a: rearranged Methodology to group items together by service delivery method; corrected occurrence of “contract” to be “referral agreement” under Column III review; added item to Methodology that was previously missing but was already in Documents that the Health Center Provides: “Review the health center’s operating procedures for tracking and managing referred services.”

Clinical Staffing

• No significant changes were noted in the Clinical Staffing section of the SVP.

Accessible Locations and Hours of Operation

• No significant changes were noted in the Accessible Locations and Hours of Operation section of the SVP.

Coverage for Medical Emergencies During and After Hours

• Documents that the Health Center Provides:

  • Combined staffing schedule and list of sites with BLS certified staff (up to 5) into one document

  • *Added a request to “include a copy of each site’s BLS-certified staff’s copy of their current BLS certifications”

• DCE c: added item to Methodology that was previously missing but was already in Documents that the Health Center Provides: “Review any after-hours written arrangements with non-health center providers/entities (for example, formal agreements with other community providers, nurse call lines).

Continuity of Care and Hospital Admitting

• No significant changes were noted in the Continuity of Care and Hospital Admitting section of the SVP.

Sliding Fee Discount Program

• Documents that the Health Center Provides: Added item that was previously missing but was already in Methodology: “For health centers that choose to have a nominal charge for patients with incomes at or below 100 percent of the FPG…” with detailed sub-bullets on documentation needed

• DCE c: added note to clarify how to answer Question 5 if a health center has multiple SFDSs

• DCE i: added note to clarify how to answer Question 18 if a health center has multiple SFDSs

Quality Improvement/Assurance

• DCE d: Separated Question 7 into two questions to be able to individually answer each component (who conducts assessment and if assessment is conducted at least quarterly)

Key Management Staff

• Documents that the Health Center Provides: Removed item (“Bios or resumes for key management staff”) that was previously requested but is not used as part of site visit methodology; this documentation is reviewed as part of the SAC or RD review.

Contracts and Subawards

• Documents that the Health Center Provides:

  • Added subtitles and reordered list to clarify which documents are needed for the Contracts elements and which documents are needed for Subawards elements

  • Removed the need to provide “related supporting procurement documentation” as part of “Sample of five contracts that do NOT use federal award funds” (those five contracts are still reviewed, but supporting documentation is not reviewed as part of the site visit)

  • Added detailed information on selecting subrecipient documentation (information was previously only in Methodology)

• DCE b: added item to Methodology that was previously missing but was already in Documents that the Health Center Provides: “Review the complete list of contracts.”

• DCEs G – J: Clarified these elements only apply to awardees with at least one subrecipient

• DCE i: Separated Question 21.4 into two questions to be able to individually answer each component (approval of services and approval of locations and hours of operation)

Conflict of Interest

• Documents that the Health Center Provides:

  • Removed “Procedures for purchasing and procurement, including, if applicable or separate, procedures for contracting and contract management” from the list. These procedures are not specifically reviewed within this section of the SVP, and any relevant policies and procedures will be provided as part of the required “Documents containing the health center’s standards of conduct.”

• DCE a: integrated the review of the disclosure process into the interview of staff within this methodology.

Collaborative Relationships

• Documents that the Health Center Provides: 

  • Reordered list and notes to clarify types of documentation and relevant examples 

• DCE b:

  • Clarified documentation and examples in methodology

  • Clarified additional explanation of efforts to establish coordination with health centers is not required if documentation of those efforts is provided

Financial Management and Accounting Systems

• No significant changes were noted in the Financial Management and Accounting Systems section of the SVP.

Billing and Collections

• Documents that the Health Center Provides:

  • Added item that was previously missing but was already in Methodology: “Sliding fee discount schedule (SFDS), including any SFDSs that differ by service or service delivery method.”

  • Clarified that “the average filing time for the last 6 months of claims” should be included as part of the claims report

• DCEs f and g: added item to Methodology that was previously missing but was already in Documents that the Health Center Provides: “Review the current data on the revenue cycle management metrics”

• DCE f: Clarified that Question 12 is asking about an average of 14 days

• DCE f: Clarified that Question 13 is asking about both rejected and denied claims

• DCE h: Clarified that for Question 17, an explanation is required if the health center has no billing records where patient fees or payments were waived or reduced

Budget

• No significant changes were noted in the Budget section of the SVP.

Program Monitoring and Data Reporting Systems

• No significant changes were noted in the Program Monitoring and Data Reporting Systems section of the SVP.

Board Authority

• Documents that the Health Center Provides:

  • Added item that was previously missing but was already in Methodologies: “Any additional corporate or governing documents.”

  • Added Note that was missing but was already in Methodology for health centers with less than 12 months of board agendas and minutes

• DCE b: Separated Question 4.4 into two questions to be able to individually answer each component (approval of services and approval of locations and hours of operation)

• DCE d: Clarified when Not Applicable should be selected for Question 10

Board Composition

• Documents that the Health Center Provides:

  • Added item that was previously missing but was already in Methodologies: “Any additional corporate or governing documents.”

• DCE c: Clarified Question 8 by adding Note that “At least one unique individual needs to represent each special population.”

• DCE d: Removed methodology item that was not used as part of this element’s review (“Review documentation regarding board member representation”)

Federal Tort Claims Act (FTCA) Deeming Requirements

• Documents that the Health Center Provides:

  • Clarified that board meeting minutes and board reports from the last 12 months are required (already clear in Methodology)

• *Significant Change (New note added explaining when OB Procedure risk management training):

  • A FTCA-deemed health center that provides obstetrical services through FTCA-deemed providers (health center employees or individual contractor providers) is required to include obstetrical training as part of the health center risk management training plan to demonstrate compliance.

  • A FTCA-deemed health center that provides prenatal and postpartum care through FTCA-deemed providers (health center employees or individual contractor providers) is required to include obstetrical training as part of the health center risk management training plan to demonstrate compliance. This applies regardless of whether the health center provides labor and delivery services through FTCA-deemed providers (health center employees or individual contractor providers).

  • For FTCA-deemed health centers that only provide obstetrical services through contracts with provider organizations or formal written referral agreements, the health center is required to ensure that the risk management training plans, credentialing, and privileging of each of the provider organizations and referral providers include obstetrics. (THIS IS A SIGNIFICANT CHANGE all should be aware of!)

  • In addition, regardless of the provision of obstetrical services, if a FTCA-deemed health center has contact with reproductive age patients for other clinical services through FTCA-deemed providers (health center employees or individual contractor providers), the health center is required to include obstetrical training as part of the health center risk management training plan to demonstrate compliance. (THIS IS A SIGNIFICANT CHANGE all should be aware of!)

  • Select “Not Applicable” if the health center provides all obstetrical services, including prenatal and postpartum care, to patients only through contracts with provider organizations or formal written referral agreements AND if the health center does not have contact with reproductive age patients for other clinical services through FTCA-deemed providers (health center employees or individual contractor providers).

Promising Practices

• Removed duplicative instructions that were in both the Methodology and the Findings sections