Presentation on theme: "How to Prepare for a FTCA Site Visit Office Hours"— Presentation transcript:
1 How to Prepare for a FTCA Site Visit Office Hours Christopher Gibbs, JD, MPHLCDR 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 ManagementQI/QA policies and proceduresCredentialingProfessional LiabilityAnd 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 applicationDocumentation submitted which indicates non-compliance with requirements during the review of the health center’s FTCA applicationThe 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 AwardHistory of medical malpractice claimsGrantee 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 yearApproximately 2.5 days in lengthEntrance conference with senior leadership and Board membersTour of facilityDocument reviewInterviews with leadership, Board, and interactions with staffExit 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 ProceduresPeer Review Policy and ProcedureCredentialing and Privileging files available for examinationHealth Center Credentialing and Privileging Excel SheetProvider Contracts/supervisory/collaborative agreements for PAs and NPs
7 Risk Management Review Medical Record Policies that address the following:HIPAA(Privacy)Completeness of documentationArchiving ProceduresRisk Management Training:Continuing education and annual medical malpractice/risk management training plan for all health center staff for the upcoming yearRisk Management Policies and ProceduresTriage PolicyWalk-in Patients PolicyTelephone Triage PolicyNo-Show Appointment PolicyReferral Tracking PolicyHospitalization Tracking PolicyDiagnostic Tracking (X-Ray, Labs)
8 Quality Improvement and Quality Assurance Review QI/QA PlanQI/QA Committee Meeting MinutesBoard MinutesHealth Center BylawsScope: May request to look at forms related to scope of serviceClinical Practice Protocols
9 Professional Liability Malpractice Liability Claims Policy and ProcedureProfessional Liability Claims for Last Five YearsDocumentation of internal analysis of claims or allegationsPeer reviewQI/QA Committee & Board minutesDocumentation of medical malpractice/risk management training for health center staff
10 Post-Site Visit Activities FTCA program will finalize reportSite visit findings will be shared with your Project OfficerHealth center will receive report with an Action Plan (if applicable) which outline specific actions to demonstrate complianceAll 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 managementFTCA will make efforts to connect grantees to additional resources to assist with identified concernsGrantees will receive detailed feedback prior to next deeming cycle
12 FTCA Site Visit FAQsWhat 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?