#10 HRSA Updates Site Visit Protocol: NPDB-Query Clarification

HRSA updated the HRSA Site Visit Protocol (SVP) on February 27, 2020. According to a newsletter sent to HRSA consultant reviewers on March 23, 2020, “For 2020, the focus of the SVP update has been on editorial and formatting improvements to the OSV report, such as more consistent use of acronyms.”

However, the one noted change was a clarification regarding National Practitioner Data Bank queries (HRSA SVP, Chapter 5: Clinical Staffing). Specifically, the change was made to question asked if the health center’s credentialing procedures require verification of, “Completion of a query through the NPDB for NPDB-reportable provider types?” The February 27, 2020 update removed the bolded text, “…for NPDB-reportable provider types”.

Though no further explanation was provided by HRSA, most would interpret this to clarify the question that was often asked: “Which employees are we required to perform NPDB queries for?”. This change seems to clarify this answer to be the clinical staff listed earlier in the question, “all clinical staff (LIPs, OLCPs, and other clinical staff) upon hire AND on a recurring basis.”

A common question we receive in regard to this topic is, “Do we have to query ‘Other Clinical Staff’ because the OCS are unlicensed and uncertified and I thought NPDB queries could only be done on licensed staff?”. The answer to that question is, “Yes, you do need to perform NPDB queries on all clinical staff, including the unlicensed and/or certified clinical staff (OCS).” The reality is that health centers are not required to report issues with OCS to NPDB, However, it is required for health centers to query all clinical staff - including unlicensed and/or uncertified clinical staff.

Make sure your team visits the HRSA Site Visit Protocol page to view the latest version. Additionally, HRSA encourages health centers to reference the NPDB Health Center page for more information.

Prior to your next HRSA Operational Site Visit, we recommend that your health center perform a mock site visit (either as an organization or through a trusted consultant like RegLantern) to ensure your HRSA Form 5A is correct and up-to-date. Continue to reference the HRSA Site Visit Protocol and HRSA Compliance Manual as you work to moved toward continuous HRSA compliance.

Revised to reflect current Site Visit Protocol version last updated May 26, 2022.