Handling Adverse Findings During an OSV

What is the best way to handle a situation where the health center does not agree with an area of non-compliance identified by the review team?

Operational Site Visits (OSVs) can be a stressful period of time for health centers.  When conducting an OSV, the review team considers all the documentation provided by the health center, patient samples and information collected during staff interviews.  The review team is responsible for utilizing the Health Resources and Services Administration (HRSA) Compliance Manual (Health Center Program Compliance Manual) to evaluate compliance and document any findings as directed by the HRSA Site Visit Protocol (Health Center Program Site Visit Protocol).  In the event the health center does not agree with a finding identified by the review team, the health center should consider the following:

  • Be respectful – Being confrontational is not beneficial to anyone.  The review team is strictly there to evaluate compliance and not to assign conditions. 
  • Ask questions – It is totally appropriate for a member of the health center team to ask the reviewer to identify the language in the Site Visit Protocol that generated the finding. 
  • Utilize the Federal Representative – The Federal Representative is a participant in the OSV and can act as the liaison between the health center, the review team and HRSA. 
  • Footnotes are your friend – There are a significant number of footnotes in the HRSA Health Center Compliance Manual and Site Visit Protocol that provide clarification.  If a footnote is referenced, be sure to read it. 
  • Supplemental Documents – Utilize supplemental documents, such as the Examples of Credentialing and Privileging Documentation (Credentialing and Privileging Examples), as these resources provide common examples that may demonstrate compliance. 

It is important to remember that findings identified by the review team and presented at the Exit Conference are strictly preliminary.  All findings are reviewed by HRSA, and HRSA is responsible for making final compliance determinations. 

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