How to Prepare for a FTCA Site Visit Office Hours Christopher Gibbs, JD, MPH LCDR Shayna Wilborn, BSN, CNOR

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: Risk Management QI/QA policies and procedures Credentialing Professional Liability And other related FTCA requirements

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)

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

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.

Credentialing & Privileging Review Credentialing and Privileging Policies and Procedures 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

Risk Management 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)

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

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

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.

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

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?

THANK YOU QUESTIONS