HRSA Operational Site Visits – what are they, what you can expect, and how you can prepare as a health center.

HRSA-Operational-Site-VisitsYou just received a call from your Health Resources and Services Administration (HRSA) Project Officer (PO) telling you of your upcoming Operational Site Visit (OSV). Before panic sets in, take a moment to review this information. Take a deep breath and relax, your Primary Care Association (PCA) is here to provide you with technical assistance to make your HRSA OSV a total success.

So what is the point of the HRSA OSV anyways?

These visits are designed to perform a full organizational assessment in all operational areas (fiscal, clinical, administration/ governance). Every health center will have an operational assessment at least once per project period (read every 3 years). Operational assessments are usually 3 days on site and are attended by Consultant Reviewers contracted by HRSA and a HRSA Representative.

The key to remember here is that the entire focus of the OSV is to ensure that your health center is meeting all the elements detailed in the Program Compliance Manual. This link provides a breakdown of each of the components and how to comply with each.

The compliance elements are divided into 18 categories:

  • Needs Assessment
  • Required and Additional health Services
  • Clinical Staffing
  • Accessible Locations and Hours of Operation
  • Coverage for medical Emergencies During and After Hours
  • Continuity of Care and Hospital Admitting
  • Sliding Fee Discount Program
  • Quality Improvement/Assurance
  • Key management Staff
  • Contracts and Sub awards
  • Conflict of Interest
  • Collaborative Relationships
  • Financial management and Accounting Systems
  • Billing and Collections
  • Budget
  • Program Monitoring and Data Reporting Systems
  • Board Authority
  • Board Composition

NOTE: Portions of program compliance elements indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (section 330(h)) and/or the Public Housing Primary Care (section 330(i)) Programs.

So what can you expect?

Pre Site Visit Conference Call:

The purpose of this call is to introduce the site visit team, made up of and Administrative/Governance Consultant; Financial Management/Information Management Consultant; and the Clinical Consultant. It will also include a HRSA Representative, who will not be the health center’s designated Project Officer.

The health center’s PO will arrange a pre-site visit call with the health center, the site visit consultant team, and the individual who will serve as the on-site HRSA Representative; however, a health center’s designated PO will not attend the site visit, nor will they have a role in the determination of compliance.

The call will describe the purpose of the site visit (Program Requirement compliance/technical assistance where possible); the on-site process (entrance and exit conferences, agenda, management staff availability, document list (hard copy/digital); the Board member interview/meeting; site tour; and onsite logistics including work area. You will confirm the site visit location and they will answer any questions.

CHC’s Pre Site Visit Preparation:

OK, now you know when the site visit is happening – how do you prepare?

  • Ensure all staff are aware of the site visit date and their roles in a successful visit
  • Review the Health Center Program Compliance Manual with Board and staff
  • Review the Health Center Site Visit Protocol to help with preparation or required documentation
  • Ensure management team/board member(s) are available for first and last day of site visit
  • Ensure CMO/Providers allocate time to meet with the Clinical Consultant
  • Prepare documents and send to site visit team as requested prior to their visit

What to expect – a sample agenda:


DAY 1:

  • 9:00 AM – 10:00 AM – Entrance Conference: (the on-site HRSA Representative leads if present); Introduce Consultant Team/Purpose of the site visit; Health Center Overview- Senior Management Team/ Executive Director
  • 10:00 AM – 12:00 PM – Meet with Members of Senior Management Team on individual basis (CFO, Medical Director, Exec. Director, Board Representative, etc.)
  • 12:15 PM – 1:30 PM – Lunch with Board Members (at least members of the Executive Committee) CHC’s may be asked to arrange this lunch.
  • 2:00 PM – 3:00 PM – Tour Facility
  • 3:00 PM – 5:00 PM Continue Meeting with Senior Management Team and Center Staff

DAY 2:

  • 9:00 AM – 4:00 PM – Continue Meeting with Senior Management Team and Center Staff, Information Gathering/ Document Review

DAY 3:

  • 9:00 AM – 11:00 AM – Continue Meeting with Senior Management Team and Center Staff, Information Gathering/Document Review
  • 11:00 AM-12:00 PM – Finalize Technical Assistance recommendations
  • 12:00 PM –1:00 PM – Exit Interview (on-site HRSA Representative leads if present); Consultants summarize findings
  • 1:00 PM – Team departs

What to expect – Visit Entrance Conference:

  • Lead by the Consultant team
  • Describes onsite process and outcome
  • Lasts about an hour
  • Team/staff introductions
  • Set onsite expectations
  • Reviewers are expecting CHC Leadership/Board to describe successes, challenges and opportunities for improvement, organizational priorities, and potential technical assistance needs. (Can be done in Powerpoint or Prezi).
  • Reviewers are also looking for promising practices – an activity, procedure, approach or policy that leads to or is likely to lead to improved outcomes or increased efficiency for health centers. This is the time to share these practices.

What to expect – Interviews & Document Review:

  • The Consultant team’s approach may vary where one member may read first and talk later – others may not
  • Management & staff Interviews:
    • Consultant team will seek clarification of policies and procedures
    • What do you do
    • Who reports to whom
    • Verifies practices are consistent with policy
    • Assesses job tasks, duties and responsibilities are consistent with observed practices
    • Who’s running the organization
  • Consultant team obtains an overall impression of grantee financial and operational performance and status based on expertise and available documentation
  • Consultant team determines compliance with the Health Center Program Compliance Manual and identifies areas for performance improvement
  • Identifies best practices

Health Center Board’s Role during HRSA OSV:

  • Board members are requested to attend the entrance and exit conferences
  • Usually there is an additional, separate meeting with Board
  • Board members could be asked about the following:
    • Assessment of Center financial, operational and clinical performance
    • Program Requirements
    • Strategic Plan
    • Financial Reporting and Status
    • Quality Assurance Plan
    • Information systems/informatics
    • Performance reporting
    • Overall management performance
    • Board performance and self-evaluation

The on-site HRSA Representative Role during HRSA OSV:

  • The on-site HRSA Representative does not manage the visit, work flow, process and or product
  • Opens & closes the site visit (entrance & exit conference) & explains post-onsite process
  • Observes (shadows) consultants’ work process (interviews) but is not a participant except in cases of specific findings set forth in the Notice of Award (NOA)
  • The on-site HRSA Representative’s presence at interviews can change the dynamic and sometimes puts a brake on health center staff openness. If this occurs the Consultant may do a follow up interview
  • If team performance issues arise on-site, consults with the Team Leader for resolution
  • Consults with Team about the application/interpretation of HRSA policy, but ultimately it is the Consultant’s decision as what goes in the initial report

Consultant Team’s Roles during HRSA OSV:

  • The Consultant Team Leader:
    • Manages the site visit
    • Ensures the agenda is followed and that all Program Requirements are addressed
    • Facilitates effective communication among the Consultant Team regarding findings and recommendations
    • Resolves onsite performance issues
    • Leads/facilitates entrance and exit conferences
    • Consultant Team introductions
    • Establishes order of presentation of preliminary findings and recommendations at exit conference
  • Other Consultant Team Members:
    • Completes document review and interviews (board, management and other staff – consultant choice) within their disciplines
    • Prepares preliminary report addressing demonstrated Program Compliance Elements; performance improvement recommendations and Technical Assistance (TA) recommendations

Oregon Primary Care Association’s (OPCA) role during HRSA OSV:

  • OPCA is available over the phone to answer questions as well as provide data, available to OPCA, that may offer some context during the OSV
  • We can have data available that compares your CHC to state and national quality metric averages
  • Listen and learn! Site visits are a great forum for us to learn and share our learning with other sites that are preparing for site visits
  • During the exit interview there is a review of suggested/required opportunities for improvement. OPCA can support you as needed around areas of noncompliance.       if needed or desired. We have a network of clinics that are able and willing to share policies, procedures, workflows so that you may not need to re-create the wheel
  • If OPCA’s presence on the phone during the exit conference is in any way uncomfortable to the organization, we do not need to attend – it’s completely up to the health center. It’s OPCA’s intention to be invited in and be value added, as needed

What to expect – Exit Conference:

  • Identifies post-onsite process including report preparation and distribution
  • Consultants report preliminary summary:
    • program requirement compliance
    • findings and recommendations
  • The on-site HRSA Representative describes post onsite process

Demonstrating Compliance Elements

The demonstrating compliance elements within the Compliance Manual include a list of items that must be addressed in order to demonstrate compliance. Nearly all of the elements within the Health Center Program Compliance Manual are assessed during an OSV.

Each of the 18 Program Compliance Elements will be designated as either ‘Yes’, ‘No’ or ‘NA’ based on the consultant’s review and judgment of the grantee’s operational/implementation response to the Health Center Program Compliance Manual.

If a compliance element receives a ‘No’, the consultants will provide information on the grantee operations that shows why the element was not compliant.

Although a compliance element may be designated as “Yes”, there still may be a recommendation that provides performance improvement guidance to the grantee on a way to further improve some aspect of the grantee’s operation.

If the designation of the element is “No”, there will be a finding that specifically addresses what part of the program element is non-compliant (some of the requirements have multiple parts) and a recommendation that specifically provides guidance to the grantee on what action(s) need to be taken to bring that portion of the operation back into compliance.

What is in the report?

HRSA will develop and present a site visit report to the health center within 45 days after the site visit. The report will convey the site visit findings and final compliance determinations.

  • Basic information-grantee name, and address, consultant(s) and their review areas
  • Overview of the grantee- some history, population and target area demographics, information relevant to the grantees current operations
  • Participants and if they were interviewed and attended entrance and exit conferences
  • List of documents reviewed
  • List of documents left with the grantee
  • Primary Compliance Issues, Concerns, and/or Performance Improvement Opportunities Addressed During Visit
  • Sections that follow the elements of the Health Center Program Site Visit Protocol
    • Each section is populated with the applicable Program Requirements and Performance Improvement recommendations

Compliance Resolution Opportunity:

The HRSA Compliance Resolution Opportunity, or CRO, supports the timely resolution of areas of non-compliance found on-site during an OSV. CRO provides health centers an opportunity to address non-compliance findings prior to HRSA issuing the site visit report and placing conditions on the award/designation due to a failure to demonstrate compliance.

Specifically, CRO provides a 14 calendar day window for health centers to address OSV findings by submitting evidence of compliance via the HRSA Electronic Handbook (EHBs). CRO submission(s) will be reviewed and assessed before the final site visit report is issued.

Following the OSV process, health centers will be able to take advantage of the new CRO process and submit documentation via an Urgent Site Visit Report Request task in EHBs to demonstrate compliance. This new feature is designed to be a uniform and efficient way to help health centers demonstrate compliance while maintaining the objectivity and integrity of the OSV on-site review process. Learn more about the CRO process.

OSV Follow Up Visit:

If HRSA determines that a health center has not demonstrated compliance with one or more of the elements reviewed via the OSV, as indicated in the final site visit report, a corresponding condition will be placed on the award/designation. Get more information and a full list of conditions.

If a health center submits a response before the 14 calendar day timeframe has expired and compliance is still not demonstrated for all or some of the findings, the Urgent Site Visit Report Request task will be returned to the health center for additional information/clarification on the remaining non-compliance findings. No deadline extension will be provided beyond 14 calendar days. Information shared via methods other than the EHBs Urgent Site Visit Report Request task submission (e.g., phone calls, e-mails) will NOT be considered in HRSA’s final compliance assessment.

Following the release of the site visit report, the health center will work with the designated Project Officer. The designated Project Officer will discuss with the on-site HRSA Representative the findings from the OSV, including any findings that were not addressed/resolved through the CRO process and resulted in conditions.

The designated Project Officer will call the health center about conditions within 15 days of the release of the Notice of Award/Notice of Look-alike Designation communicating any conditions.

Bottom Line for the Health Center:

  • Cooperate with the on-site HRSA Representative and Consultant Team
  • Be transparent! Communicate! Prepare!
  • If you receive a ‘No’ on any Compliance Elements, then work aggressively and expeditiously to resolve. OPCA can help!
  • Show yourself off – Brag a little!

Further questions? Contact OPCA’s Sonya Howk.