Demonstrating Compliance with Chapter 7 – Coverage for Medical Emergencies During and After-Hours

As outlined by the guidance provided 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 is required to ensure continuity of the required primary health services offered by the center by maintaining the following:

• Provisions for promptly responding to patient medical emergencies during the health center’s regularly scheduled hours of operation; and
• Clearly defined arrangements for promptly responding to patient medical emergencies after the health center’s regularly scheduled hours of operation. 

Not only does this demonstrate compliance with HRSA Health Center Program Requirements, but also ensures access to medical advice 24 hours a day, seven days a week for medical emergencies that may be related to physical, oral, behavioral health and/or other emergent needs. The health center must warrant meaningful access to the programs, services and activities offered, including after-hours coverage, for the Limited English Proficiency (LEP) patient population, as well as patients with disabilities. 

The “Coverage for Medical Emergencies During and After-Hours” section of the HRSA Site Visit Protocol (SVP) contains a checklist of documentation the health center is required to provide (Site Visit Protocol Medical Emergencies). Below is the list of documents included in the SVP checklist, with some examples of specific documentation that will meet HRSA compliance standards.

• Operating procedures for addressing medical emergencies during the health center’s normal hours of operation – The document should reflect how an emergency (i.e., cardiac arrest, seizure, behavioral health emergency) would be managed if the situation were to occur at the health center.  Providing only a Triage Policy and Procedure will not meet the requirement.
• Operating procedures for responding to patient medical emergencies after business hours – This document must outline the process implemented for providing access to medical advice after hours for all services in scope.  Additionally, this document must address the following:
  • The manner in which information regarding after-hours is provided to patients.
  • The information regarding after-hours is provided in languages and literacy levels appropriate to the patient population.
  • By what means the health center ensures access to the Limited English Proficiency (LEP) patient population (i.e., translated documents, bilingual staff, translation service).
  • The process for managing an after-hours call for a LEP patient (bi-lingual staff, translation service).
  • Timeframes for documenting the after-hours call in the patient’s chart.
  • The manner in which after-hours calls are tracked.
• Staffing schedules for up to five delivery sites that identify at least one individual with current certification in basic life support at each site – In addition, a copy of the individual’s current certification must be provided.  The health center must continuously confirm that all clinical staff members’ life support training is current and remains as such.
• Health center provider on-call schedules – This is only required if the health center utilizes on-call providers for after-hours coverage.  If a health center utilizes a triage service, it is at the discretion of the health center as to whether to have on-call providers as a back-up. 
• Written arrangements for after-hours coverage.
• Information provided to patients for accessing after-hours coverage – This information should be provided in English, as well as any other primary languages identified in the patient population.  Typically, this information is provided via external/internal signage, patient pamphlets, and new patient packets.
• Three patient samples of after-hours clinical advice documentation – Samples should demonstrate the following:
  • Documentation of the after-hours call in the patient’s medical record
  • Necessary follow-up made by the health center

Documentation of calls made to the after-hours line for the purposes of medication refills, appointments and such, should not be utilized unless the health center has fewer than three after-hours calls requiring follow-up.

• Procedures for tracking, recording and storing of after-hours information – This can typically be demonstrated by providing a log of patient calls.

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 that is referenced above.