Although Operational Site Visits (OSV) are being conducted virtually, the clinical reviewer is still required to verify the arrangements the health center has in place for responding to medical emergencies after regularly scheduled hours. 

As outlined by “Chapter 7 – Coverage for Medical Emergencies during and After-Hours,” of the Health Resources and Services Administration (HRSA) Health Center Compliance Manual (Chapter 7 – Medical Emergencies) and the HRSA Site Visit Protocol, the clinical reviewer is required to place a test call after normal business hours.  To verify compliance, the reviewer must be able to answer “yes” to the following: 

1.       Was the reviewer connected to an individual with the qualification and training necessary to exercise professional judgment to address an after-hours call?

2.       Was the individual the reviewer was connected to able to refer patients to a covering Licensed Independent Practitioner (LIP) for further consultation, or to locations such as emergency rooms or urgent care facilities for further assessment or immediate care?

3.       Are provisions in place for calls received from Limited English Proficiency (LEP) patients?

The health center can expect the test call to occur anytime following the start of the vOSV.  It is important to note the test call should NOT occur prior to the Entrance Conference.  Additionally, the individual providing on-call coverage should be prepared to explain to the reviewer how the call would be handled for an LEP patient. 

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).