Form 1 Checklist for Deleting Existing Service Delivery Site

The Health Center Program Application Forms

19. Checklist for Deleting Existing Service Delivery Site

Checklist for Deleting Existing Service Delivery Site

OMB: 0915-0285

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CIS Editable Checklist – Grantee Checklist – Delete Service Site


Change Checklist






DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

CHECKLIST FOR DELETING A SERVICE SITE (CHKLST004)

Grantee Name:

Grantee Number:

CIS Tracking Number:





Questions for Deletion of Service Site

Site Name


Site Address


Date Site Proposed for Deletion was Added to Scope:


Site Added/Used as Part of ARRA or ACA Grant?


1.

BACKGROUND AND JUSTIFICATION FOR DELETION

Provide brief background/justification for why your health center is proposing to remove this service site from your scope of project (e.g. major decrease in patient population, financial recovery plan, etc.). In providing background, specify whether the site will actually be closed or whether the site will remain open but the health center will no longer include it in its scope of project.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape1



2.

PROPOSED DATE OF SITE DELETION

When do you plan to close/leave and/or stop providing services at the site?




(mm/dd/yyyy): Shape2



Click "Save" button to save all information within this page.

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3.

MAINTENANCE OF LEVEL AND QUALITY OF HEALTH SERVICES

Clearly describe in a brief narrative format, the health center's plan for assuring that the deletion of this service site will in no way result in the diminution of the health center's total level or quality of health services currently provided to the patient/target population of the current site. In discussing this plan, provide the following information for each of the locations where patients will receive services following the deletion of the site:

  • Site/Provider Name

  • Site/Provider Address

  • Provider Type (e.g. existing site of your health center, site of another health center, other safety net provider - specify, any other provider type - specify, etc.).

  • Availability of a sliding fee discount programs and/or other programs at such locations that assure no health center patient will be denied health care services due to an individual's inability to pay for such services.

If the service site to be deleted was added to scope through a HRSA-funded application (e.g. New Access Point or Capital Grant), the health center MUST state this and must specifically address if and how the patient and visit projections included in the approved application for the site, will be maintained.


In addition, respond to ALL of the questions below (3a. – 3f.), which must align with and support this narrative.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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3a.

Describe if and how deletion of the site will impact access to any health center services (Required or Additional) in the current approved scope of project (as reflected on the health center’s Form 5A).




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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3b.

What is the number of patients that will be affected by the deletion of the service site? What proportion of the overall patient population (i.e. across all sites in scope) does this represent?




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape6



3c.

Average travel time for patients to service location(s) discussed in Question 3.












Currently:

Shape7 hrs Shape8 mins

(Format:99)


Following Deletion:

Shape9 hrs Shape10 mins

(Format:99)





3d.

Average miles traveled by patients to service location(s) discussed in Question 3.












Currently:

Shape11 miles

(Format: 9 or 9.99)

Following Deletion:

Shape12 miles

(Format: 9 or 9.99)





Click "Save" button to save all information within this page.

Shape13



3e.

Will enhanced and/or increased transportation services be available to assure access to all health center services for patients served by the site proposed for deletion?




Shape14 Yes

Shape15 No

Explain both Yes and No responses.
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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3f.

Describe how the health center will address any other barriers to care that the deletion of the service site may present.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape17
Optional: Upload any attachments relevant to the site deletion here that support the health center’s assurance that the total level or quality of health services currently provided will be maintained (e.g. maps, transportation plans etc.).








Maintenance of Quality & Level of Health Services Supporting Documentation (Maximum 6 attachments)

Select

Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

Shape18







4.

CONTINUITY OF CARE AND COLLABORATION

In 4a and 4b, describe your health center's plans for ensuring continuity of care for current patients affected by the site deletion as well as plans for maintaining existing and/or establishing new collaborative relationships within the service area.

For the purposes of this question:

Collaborative relationships are those that assist in contributing to one or both of the following goals relative to the patients served by the site that will be deleted:

(1) maximizing access to required and additional services within the scope of the health center project to the target population that is served at the site to be deleted; and/or
(2) promoting continuity of care to health care services for health center patients served at the site to be deleted beyond the scope of the project.


Collaboration Resources
Collaboration PAL:
http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html
UDS Mapper:
http://www.udsmapper.org



4a.

Describe outreach and communication plans for informing current health center patients and the community at large, of the site deletion including making them aware of any new or enhanced transportation or enabling services available to access services at other sites or locations.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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4b.

Describe plans for informing providers (e.g. section 330 grantees, Look-Alikes, rural health clinics, critical access hospitals, health departments, etc.) in or adjacent to the service area of the site that is proposed for deletion and for maintaining current or establishing new collaborative relationships with such organizations. If no other providers exist within or adjacent to the service area state this.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape20
Optional: Upload any attachments relevant to the site deletion here that support the health center’s continuity of care plan and/or collaborative relationships (e.g. sample patient notification documents, local media announcements about site deletion, new MOUs, etc.).




Continuity of Care Plan & Collaboration Supporting Documentation (Maximum 6 attachments)

Select

Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

Shape21







Click "Save" button to save all information within this page.

Shape22



5.

SITE OWNERSHIP AND OPERATION
If the site to be deleted is operated by a contractor or subrecipient, respond to the appropriate set of questions (5a. OR 5b.) below.

Health centers are reminded of their responsibilities to obtain any required prior approval from HRSA for aspects of the program conducted by subrecipients or contractors before a subrecipient or contractor can undertake an activity or make a budget change requiring that approval, e.g., delete a contractor or subrecipient operated site from scope, seek approval to extend the period of performance of a subaward to a subrecipient if it would extend beyond the end of the grant's project period.



IF SITE TO BE DELETED IS OPERATED BY A CONTRACTOR
5a. If the site is owned and/or operated by a third party on behalf of the health center through a written contractual agreement between the health center and the third party (i.e. the health center is purchasing a specific set of goods and services from the third party-such as the operation of a site) respond to all of the following questions:

Have (or will, based on site deletion date) all applicable records and documents of activities performed by the contractor on behalf of the health center in the operation of the site, been transferred to the health center PRIOR to the site's removal/closure? This should include at minimum:

  • Health center patient records

  • Billing records for the services provided to health center patients at the site






Shape23 Yes

Shape24 No





Has the health center followed their own board-approved procurement policies and procedures for terminating contractual agreements with third parties, including assuring access to all applicable financial, program and property management systems and records, as well as receiving (or ensuring provisions to receive) any final and complete financial and programmatic reports?






Shape25 Yes

Shape26 No


Optional: Attach any supporting documentation here.






Site Ownership and Operation Supporting Documentation A (Maximum 6 attachments)

Select

Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

Shape27







IF SITE TO BE DELETED IS OPERATED BY SUBRECIPIENT
5b. If the site is owned and/or operated by subrecipient on behalf of the health center through a written subrecipient agreement between the health center and the subrecipient organization to perform a substantive portion of the grant-supported program or project, respond to all of the following questions.

A subrecipient is an organization that "(ii)(I) is receiving funding from such a grant under a contract with the recipient of such a grant, and (II) meets the requirements to receive a grant under section 330 of such Act . . ." (1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act).

  • Subrecipients must be compliant with all of the requirements of section 330 to be eligible to receive FQHC reimbursement from both Medicare and Medicaid.

  • The subrecipient arrangement must be documented through a formal written agreement (Section 330(a)(1) of the PHS Act)

The health center (grantee of record) named on the NoA is the entity legally accountable to HRSA for performance of the project or program, the appropriate expenditure of funds by all parties including subrecipients, and other requirements placed on the health center (grantee of record), regardless of the involvement of others in conducting the project or program.

Has (or will, based on site deletion date) the subrecipient responded to all applicable final programmatic, administrative, financial, and reporting requirements of the grant, including those necessary to ensure compliance with all applicable Federal regulations and policies to the Grantee of Record?






Shape28 Yes

Shape29 No





Has (or will, based on site deletion date) the health center Grantee of Record reviewed all final documents related to providing funding to the subrecipient, including dollar ceiling, method and schedule of payment, type of supporting documentation required, and procedures for review and approval of expenditures of grant funds?






Shape30 Yes

Shape31 No

Optional: Attach any supporting documentation here.

Site Ownership and Operation Supporting Documentation B (Maximum 6 attachments)

Select

Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

Shape32







Click "Save" button to save all information within this page.

Shape33



6.

FINANCIAL IMPACT ANALYSIS






Template Name

Template Description

Action

Financial Impact Analysis

Template for Financial Impact Analysis

Instructions

Instructions for Financial Impact Analysis







Attach Financial Impact Analysis Document here.




Financial Impact Analysis (Maximum 6 attachments)

Select

Purpose

Document Name

Size

Uploaded By

Description

No attached document exists.

Shape34




Explain how
adequate revenue will continue to be generated to cover existing expenses across the overall scope of project incurred by the health center. If the overall scope and total budget of the health center will be reduced as a result of the site deletion, specify this. The Financial Impact Analysis must at a minimum show a break-even scenario or the potential for generating additional revenue.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape35



7.

HEALTH CENTER STATUS

Discuss any major changes in the health center’s staffing, financial position, governance, and/or other operational areas, as well as any unresolved areas of non-compliance with Program Requirements (e.g. active Progressive Action conditions) in the past 12 months that might impact the health center’s ability to implement the proposed change in scope.




Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape36



8.

SERVICES
Will this site deletion result in the deletion of any services currently included within the approved scope of project as documented on your health center’s
Form 5A?




Shape37 Yes, but a separate CIS request(s) to remove these service(s) from scope will be submitted.

Shape38 No





Click "Save" button to save all information within this page.

Shape39



Additional Considerations for Deleting a Site from Scope

While the following areas are not specific factors or criteria that will impact the CIS approval process, these are key elements that health centers should have considered or actively plan to address prior to deleting a service site from the scope of project.



A.

Medical Malpractice Coverage:

For grantees deemed under the Federal Tort Claims Act (FTCA), be aware that FTCA coverage is limited to the performance of medical, surgical, dental, or related functions within the scope of the approved Federal section 330 grant project, which includes sites, services, and other activities or locations, as defined in the covered entity's grant application and any subsequently approved change in scope requests.

Confirm that your health center is aware that if the request to delete this site is approved, FTCA coverage will no longer extend to any activities, services, providers, etc. at the deleted site as of the date of the approval to remove the site from scope.




Shape40 Yes, health center is aware that removing this site from scope will result in the loss of FTCA coverage for the deleted site.

Shape41 N/A, health center is not deemed or FTCA coverage does not apply.

For more information, the FTCA Health Center Policy Manual is available at:http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html For specific questions, contact the BPHC HelpLine at: 1-877-974-BPHC (2742) or Email: [email protected]. Available Monday to Friday (excluding Federal holidays), from 8:30 AM - 5:30 PM (ET), with extra hours available during high volume periods.

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape42



B.

Section 340B Drug Pricing Program Participation: Health centers that participate in the 340B Drug Pricing Program are reminded that sites added or deleted from the scope of project through the BPHC change in scope process do not automatically update within the 340B Program's Database. Health centers should contact the HRSA Office of Pharmacy Affairs to determine whether any updates to the 340B Database are necessary by contacting Apexus Answers at 888-340-2787, or [email protected] .

Will your health center complete all necessary 340B Program updates with the HRSA Office of Pharmacy Affairs?






Shape43 Yes

Shape44 N/A, health center does not participate in the 340B program

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape45



Click "Save" button to save all information within this page.

Shape46



C.

Reimbursement as a Federally Qualified Health Center (FQHC) under Medicare, Medicaid and CHIP:

Services provided at sites that are included under a health center's HRSA-approved "scope of projects" are generally eligible for reimbursement by Medicaid, Medicare, and CHIP under the FQHC payment systems. When a health center receives HRSA approval to delete a site from its scope of project, it must cease billing for services provided at this site under these FQHC payment systems as of the date that the site was removed from scope. The health center is also responsible for informing Medicare and Medicaid that the site has been removed from scope and is no longer eligible for reimbursement under the FQHC payment systems.

Will your health center stop billing Medicare, Medicaid and CHIP under the FQHC payment system for services provided at this site effective on the date that the site was approved to be removed from your scope of project?




Shape47 Yes

Shape48 N/A

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape49




Will your health center contact Medicare and Medicaid to inform them that the site is no longer within your scope of project and therefore no longer eligible for reimbursement under the FQHC reimbursement systems? For Medicare, health centers should contact the enrollment office at their Medicare Administrative Contractor; for Medicaid, health centers should contact the enrollment office at their State Medicaid Agency.




Shape50 Yes

Shape51 N/A

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
Shape52



D.

National Health Service Corps Program Participation:
Health centers that participate in the National Health Service Corps (NHSC) are reminded that all NHSC participants must continue to work ONLY at an approved site within the health center's scope of project. In addition, the NHSC must be kept aware of all changes in site addresses and NHSC participant site assignments.

NHSC sites and participants may contact the NHSC through the Customer Service Portal (https://programportal.hrsa.gov/extranet/landing.seam) or through the Customer Care Center by calling 1-800-221-9393.

In deleting this site from your scope of project, has your health center assessed the impact on any NHSC participants that might currently be working at the site and advised them that they will need to seek a site reassignment with the NHSC prior to beginning work at another site in scope?




Shape53 Yes

Shape54 N/A, health center does not have any NHSC participants at this site.

Briefly explain your response:
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
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AuthorEshita Shaheed
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