Gibbs JD MPH LCDR Shayna Wilborn BSN CNOR How to Prepare for a FTCA Site Visit Office 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 pr ID: 258228
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Christopher Gibbs, JD, MPHLCDR Shayna Wilborn, BSN, CNOR
How to Prepare for a FTCA Site Visit
Office
HoursSlide2
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 Liability And other related FTCA requirements
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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 claims Grantee request site visit (limited and subject to approval)
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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 staff4Slide5
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.5Slide6
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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 ReviewSlide7
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 ProceduresTriage 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 ReviewSlide8
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 8Slide9
Professional Liability
Malpractice Liability Claims Policy and ProcedureProfessional Liability Claims for Last Five Years Documentation of internal analysis of claims or allegations Peer reviewQI/QA Committee & Board minutesDocumentation of medical malpractice/risk management training for health center staff
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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.
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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 cycle11Slide12
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?12Slide13
THANK YOU
QUESTIONS13