1 christopher gibbs, jd, mph lcdr shayna wilborn, bsn, cnor how to prepare for a ftca site visit...
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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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