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Christopher Gibbs, JD, MPHLCDR Shayna Wilborn, BSN, CNOR

How to Prepare for a FTCA Site VisitOffice Hours

What is a FTCA Site Visit?

The FTCA Health Center Program may conduct a site visit at any point during the FTCA Deeming Cycle. The site visit may be initiated from the application review process and/or as part of its oversight responsibilities to ensure implementation of:

1. Risk Management

2. QI/QA policies and procedures

3. Credentialing

4. Professional Liability

5. And other related FTCA requirements2

Criteria for FTCA Site Visit

Factors that may prompt a site visit include, but are not limited to:

• Submission of an initial FTCA deeming application

• Documentation submitted which indicates non-compliance with requirements during the review of the health center’s FTCA application

• The need for follow-up based on prior site visit findings or other identified issues; History of repeated pertinent conditions, or current conditions, placed by HRSA on the health center’s Health Center Program grant, as documented on the health center’s associated Notice of Award

• History of medical malpractice claims

• Grantee request site visit (limited and subject to approval)3

FTCA Site Visit Overview

• Majority of FTCA site visits occur between June and August, however visits may take place at any time during the year

• Approximately 2.5 days in length

• Entrance conference with senior leadership and Board members

• Tour of facility

• Document review

• Interviews with leadership, Board, and interactions with staff

• Exit Conference, inclusive of findings recommendations for improving quality of care and safety for patients and staff

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Pre-Site Visit Activities

• The health center will receive a site visit notification letter via email.

• The letter will provide the proposed dates of the site visit.

• The health center should reply back via email to the P.O.C. provided to set up a pre- site visit conference call.

• A call will be arranged to assist in you in preparing for the visit.

• A sample agenda and list of documents to have available on site will be provided at this time.

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• Peer Review Policy and Procedure

• Credentialing and Privileging files available for examination • Health Center Credentialing and Privileging Excel Sheet

• Provider Contracts/supervisory/collaborative agreements for PAs and NPs

• Credentialing and Privileging Policies and Procedures

Credentialing & Privileging Review

Medical Record Policies that address the following: • HIPAA(Privacy)

• Completeness of documentation

• Archiving Procedures

Risk Management Training: • Continuing education and

annual medical malpractice/risk management training plan for all health center staff for the upcoming year

Risk Management Policies and Procedures• Triage Policy

• Walk-in Patients Policy

• Telephone Triage Policy

• No-Show Appointment Policy

• Referral Tracking Policy

• Hospitalization Tracking Policy

• Diagnostic Tracking (X-Ray, Labs)

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Risk Management Review

Quality Improvement and Quality Assurance

Review

• QI/QA Plan

• QI/QA Committee Meeting Minutes

• Board Minutes

• Health Center Bylaws

• Scope: May request to look at forms related to scope of service

• Clinical Practice Protocols

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Professional Liability

• Malpractice Liability Claims Policy and Procedure

• Professional Liability Claims for Last Five Years

• Documentation of internal analysis of claims or allegations

– Peer review

– QI/QA Committee & Board minutes

• Documentation of medical malpractice/risk management training for health center staff

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Post-Site Visit Activities

• FTCA program will finalize report

• Site visit findings will be shared with your Project Officer

• Health center will receive report with an Action Plan (if applicable) which outline specific actions to demonstrate compliance

• All health centers who respond to the FTCA Action Plan by the specified due date will receive one on one technical assistance.

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Benefits of Participating in a FTCA Site Visit

• Identifies areas of improvement to support patient safety and risk management

• FTCA will make efforts to connect grantees to additional resources to assist with identified concerns

• Grantees will receive detailed feedback prior to next deeming cycle

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FTCA Site Visit FAQs

• What impact will this site visit have on our deeming?

• Our health center contracts with a CVO, will FTCA select provider credentialing files to review prior to the site visit?

• Our entire governing board is not available for the entire length of the site visit, will this be a problem?

• Will the health center have an opportunity to rectify any findings of non-compliance prior to the processing of the report?

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THANK YOU

QUESTIONS

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