Frequent Clinical Areas of Non-Compliance

The purpose of a Health Resources and Services Administration (HRSA) Operational Site Visit (OSV) is to provide oversight of the HRSA Health Center Program and utilize an objective assessment to verify compliance with the HRSA Health Center Program statutory and regulatory requirements. 

During an Operational Site Visit (OSV), compliance is evaluated in the areas of Administrative/Governance, Fiscal and Clinical.  As outlined by the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual (HRSA Compliance Manual) and HRSA Health Center Program Site Visit Protocol (HRSA Site Visit Protocol), the clinical expert is the primary reviewer for the following chapters:

• Chapter 4 – Required and Additional Health Services
• Chapter 5 – Clinical Staffing
• Chapter 7 – Coverage for Medical Emergencies During and After Hours
• Chapter 8 – Continuity of Care
• Chapter 10 – Quality Improvement/Assurance
• Chapter 21 – Federal Tort Claims Act (if applicable)

Some of the most frequent areas of non-compliance during the clinical review are identified in the following chapters:

• Chapter 4 – Required and Additional Health Services:  This chapter includes a review of Form 5A (Scope of Services), which frequently identifies discrepancies in the manner and mode of service delivery.  Health Centers should utilize the Services Descriptors for Form 5A:  Services Provided (Form 5A Service Descriptors) and Form 5A: Service Delivery Method Descriptors (Form 5A Column Descriptors) to assist with the completion of Form 5A.  
• Chapter 5 – Clinical Staffing:  This chapter includes a review of the health center’s Credentialing and Privileging Policy, as well as credentialing and privileging files.  Oftentimes, the Credentialing and Privileging Policy does not address all of the HRSA requirements, including the credentialing and privileging/verification of competency for Other Clinical Staff (OCS), is not reflective of current practice, and does not accurately reflect the requirements for credentialing versus the requirements for privileging. Additionally, the review of credentialing and privileging files is not inclusive of the required sample composition and results in missing or expired documentation.  Health centers should utilize the Health Center Program Site Visit Protocol:  Examples of Credentialing and Privileging Documentation (Examples of Credentialing and Privileging) to ensure compliance with credentialing and privileging requirements of all clinical staff.  
• Chapter 10 – Quality Improvement/Assurance:  This chapter includes a comprehensive review of the health center’s Quality Improvement/Assurance Program. Frequently, the Quality Improvement/Assurance Plan is not reflective of all services in scope and does not address the evaluation of both clinical services and clinical management metrics.  Additionally, Quality Improvement/Assurance policies and procedures are not provided, Quality Improvement/Assurance assessments are not completed on a quarterly basis, and Quality Improvement/Assurance Committee Meeting Minutes do not reflect active discussion regarding quality initiatives, as well as the ability to facilitate decision making by key management staff and the board of directors. 

The most effective way to have a successful OSV is to always maintain continuous compliance.  Although the Site Visit Protocol is the tool employed by the reviewers to evaluate compliance during an OSV, health centers also have access to this tool and should utilize this as a guide to evaluate compliance on an ongoing basis.