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

2. 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

3. 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)

4. 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

5. Pre-Site Visit Activities
The health center will receive a site visit notification letter via .
The letter will provide the proposed dates of the site visit.
The health center should reply back via 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.

6. 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

7. 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)

8. 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

9. 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

10. 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.

11. 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

12. 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?

13. THANK YOU
QUESTIONS