Site Visit Coming Up? We Will Help You Prepare!

Have a site visit coming up? Let us help you get organized with a simulated site visit. We offer flexible, cost-effective options, both on-site and off-site review, tailored to meet your needs. We will run the same protocol as HRSA site visitors, produce findings, issue a plan of corrective action, and help you revise policies and procedures, organize your files for ease of access to HRSA site reviewers, and ensure you are fully prepared for your official HRSA site visit.

Contact us today via email, phone, or chat, to schedule site visit preparation.

HRSA Issues New Site Visit Protocol

In December of 2017, HRSA published the latest and greatest collection of documents detailing site visit protocol for calendar year 2018 onward. Site visits provide an objective assessment and verification of the status of each Health Center Program awardee or look-alike’s compliance with the statutory and regulatory requirements of the Health Center Program. In addition, HRSA conducts site visits to assess and verify look-alike initial designation applicants for compliance with Health Center Program requirements to inform initial designation determinations.

When is My Site Visit?

Typically, the site visit will occur in the middle of your project period. HRSA will notify you, via multiple emails, of the upcoming visit and how to prepare. HRSA will send out a small team of individuals to your clinics to assess the center’s operations and activities in three areas of focus: administration, fiscal, and clinical. HRSA reviewers will ask the health center to produce several documents prior to the site visit and during, many of which are your operating policies and procedures as well as various forms and attachments produced in the most recent Service Area Competition (SAC) application or initial deeming/re-designation application for Look-Alikes.

It is important that all health centers review requirements of the site visit protocol and health center compliance manual prior to the official visit. You may find one of your policies is not in compliance with HRSA's requirements, that you'll be required to amend the policy and get board approval prior to it being considered adequate. This will save you a lot of time and grief. Remember, there are 19 program requirements and with each comes a list of details HRSA expects you to deliver. Wouldn't you rather address one finding of non-compliance as opposed to 19 or more? Hire CLC today and be prepared.

What Comes Out of a Site Visit?

Areas of non-compliance will be addressed by site reviewers and produced in a formal report. Within the EHB, tasks will be populated specific to areas of noncompliance, and the center will be allowed to upload documentation demonstrating resolution and compliance. For example, if your Sliding Fee Discount Program policy is out of compliance, HRSA will provide detail in how to correct the policy and will ask you to upload the revised policy along with board minutes that demonstrate the board’s review and approval of the revised policy.  Keep in mind that an issue with one requirement may produce several associated findings. Also remember that regardless the number of findings you produce, all will carry the same deadline: therefore, the less findings, the better.

What Happens If We Don't Address the Findings?

Being that all on-site findings will carry the same deadline, it is important that you effectively and efficiently manage your time. Should you not submit your findings on time, HRSA may initiate the Progressive Action process (see pg. 15), giving you a brief window of time to process corrections before the hammer comes down. We highly advise you avoid this process as it doesn't put you in considerable light with the agency. Consequences, should you exceed the allotted amount of time include:

  • Temporarily withhold cash payments (from the Federal award) pending further action;
  • Disallow all or part of the cost of the activity or action not in compliance;
  • Wholly or partly suspend award activities or terminate the Federal award;
  • Initiate suspension or debarment proceedings;
  • Withhold further Federal awards for the project or program; or
  • Take other remedies that may be legally available.