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We are having an Operational Site Visit and are in the process of revising our policies. Can you please tell us what is required to be included the After-Hours Policy and Procedure?
In accordance with the guidance outlined in “Chapter 7 – Coverage for Medical Emergencies during and After-Hours” of the Health Resources and Services Administration (HRSA) Health Center Compliance Manual (Compliance Manual Chapter 7), the health center must have operating procedures in place for managing medical emergencies during and after hours. Medical emergencies include emergent health needs related to physical, oral and behavioral health. It is at the discretion of the health center to determine the process used to manage after-hours coverage, which may include formal arrangements with entities outside of health center providers. To ensure compliance, the health center must develop, document and implement procedures that ensure the following:
“Coverage for Medical Emergencies During and After Hours”; Element C – Procedures or Arrangements for After-Hours Coverage; question four of the HRSA Site Visit Protocol (Site Visit Protocol Medical Emergencies) asks the clinical reviewer to verify whether or not the health center has written operating procedures or other documented arrangements for responding to patient medical emergencies after hours. To ensure compliance and meet industry standard best practices, the health center should ensure the After-Hours Policy and associated procedures address the following:
Health Centers can view other requirements for this chapter and evaluate compliance by answering the questions in the “Coverage for Medical Emergencies During and After-Hours” section of the HRSA Site Visit Protocol (Site Visit Protocol Medical Emergencies).