Form 5 Checklist for Deleting Existing Service -Clean

Checklist for Deleting Existing Service

Assurances:

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

• I certify that the following statements related to the preparation of this Change in Scope (CIS) request are true, complete and accurate:

• This CIS request is complete and responsive to all applicable criteria relating to the CIS checklist. Refer to http://www.bphc.hrsa.gov/programrequirements/scope.html for all applicable policies and guidance.

• The health center consulted with its Project Officer prior to submitting this CIS request.

• The proposed CIS implementation date is at least 60 days from the submission date to HRSA. Note: HRSA recognizes that there may be circumstances where submitting a CIS request at least 60 days in advance of the desired implementation date may not be possible; however, the goal is to minimize these occurrences through careful planning.

• The health center’s governing board approved this CIS request prior to submission to HRSA, as documented in board minutes (must be made available upon request).

• The health center has examined the potential impact of this CIS under the requirements of other programs as applicable (e.g., 340B Program, FTCA). Refer to: https://www.bphc.hrsa.gov/programrequirements/pdf/potentialimpactofcisactions.pdf

• The health center understands that HRSA will consider its current compliance with Health Center Program requirements and regulations (i.e., the status and number of any progressive action conditions) when making a decision on this CIS request. See Health Center Program Compliance Manual, Chapter 2: Health Center Program Oversight for more information on progressive action. Refer to: https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html

• I will ensure the health center complies with the following statements related to the implementation of this Change in Scope (CIS) request, if approved:

• All Health Center Program requirements (http://www.bphc.hrsa.gov/programrequirements/index.html) will apply to this CIS. Note: Compliance with Health Center Program requirements across sites and services will be assessed through all appropriate means, including site visits and application reviews.

• This CIS will be undertaken directly by or on behalf of the health center for the benefit of the current or proposed health center patient population, and the health center’s governing board will retain oversight over the provision of any services and/or sites.

• This CIS will be accomplished without additional Health Center Program Federal award funding (for awardees only) and will not shift resources away from carrying out the current HRSA-approved scope of project.

• The impact of this CIS will be reflected in the total budget submitted with the health center’s next annual competing or non-competing or designation application.

• This CIS will be implemented and verified within 120 days of receiving the NoA or HRSA notification approving the change.

• This CIS will not diminish the patient population’s access to and quality of services currently provided by the health center.

• The health center will take all applicable steps related to the requirements of other programs impacted by this change in scope request. Refer to https://www.bphc.hrsa.gov/programrequirements/pdf/potentialimpactofcisactions.pdf

Change in Scope Questions:

Is this request to delete a service linked to another recently submitted, in progress or planned CIS request (e.g., the health center will be deleting a site at which this service is provided)?

Y/N – require text box explanation if Y

1. OVERVIEW:

FOR ADDITIONAL/SPECIALTY DELETION ONLY: Provide a brief background/justification for why the health center is proposing to delete the service from its scope of project (e.g., major decrease in demand for service based on shifting target population health needs, improve capacity by providing service via formal referral vs. directly).

FOR REQUIRED SERVICES TO COLUMN III ONLY: Provide brief background/justification for why the health center is proposing to provide this service only through a Formal Written Referral Arrangement(s) (Form 5A, Column III) where the actual service is provided and paid/billed for by another entity (e.g., major decrease in demand for service based on shifting target population health needs, improve capacity by providing service via formal referral vs. directly).

Requires narrative response.

Proposed Date of Service Deletion: mm/dd/yyyy

Note: Please review Program Assistance Letter 2014-10: Updated Process for Change in Scope Submission, Review and Approval Timelines and Policy Information Notice 2008-01: Defining Scope of Project and Policy for Requesting Changes. In cases where a health center is not able to determine the exact date by which a CIS will be fully accomplished, BPHC will allow up to 120 days following the date of the CIS approval Notice of Award (NoA) or look-alike Notice of Look-Alike Designation (NLD) for the health center to implement the change (e.g., stop providing the service). Review Program Assistance Letter 2009-11: New Scope Verification Process for more information.

2. MAINTENANCE OF LEVEL AND QUALITY OF HEALTH SERVICES: Describe how the health center intends to maintain, to the extent possible, the level and quality of health services currently provided to the patient population by discussing:

1. The impact of deleting the services on the total number and percent of patients across service types (medical, dental, etc.);

2. how deletion of the service may impact access to and/or level of demand for health center services in the current approved scope of project (Required and Additional Services as reflected on the health center’s Form 5A) (e.g., if the health center is proposing to stop providing additional dental services, if and how will this impact the demand for preventive dental services);

3. the average travel time and distance for patients to closest other location(s) to receive the service if this service is deleted from scope;

4. any new or enhanced transportation or enabling services to support access the service at referral or other provider sites or locations; and

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

6. FOR REQUIRED SERVICE ONLY: how data will be obtained from referral provider(s) for UDS reporting purposes

Requires narrative response.

3. FOR ADDITIONAL/SPECIALTY DELETION ONLY: Outreach AND COMMUNICATION:

1. Describe how the health center will communicate with current health center patients and the community at large (e.g., other Health Center Program grantees and Look-alikes, rural health clinics, critical access hospitals, health departments, etc.), to raise awareness that the service will no longer be provided by the health center.

2. If the service will be removed from scope entirely (i.e., the health center will not provide a formal referral for the service), discuss how (1) the health center will make patients aware of other community providers or organizations that offer the service; and (2) the health center's policies and procedures ensure continuity of care for current patients that may seek this service through other community providers.

3. If the service will be removed from scope but provided via a formal written referral arrangement, discuss how the health center will make patients aware that the service available via referral.

Requires narrative response.

4. Attach any documents relevant to the service deletion that demonstrate the health center’s outreach and communications (e.g. sample patient notification documents, local media announcements about site deletion, new MOUs, etc.).

Mandatory attachment that supports response

4. FOR REQUIRED SERVICES TO COLUMN III ONLY: REFERRAL ARRANGEMENT DETAILS:

The proposed service will be provided via a Formal Written Referral Arrangement (where the actual service is provided and paid/billed for by another entity (the referral provider) and thus the service itself is NOT included in the health center's scope of project (Note: The establishment of the actual referral arrangement and any follow-up care provided by the health center subsequent to the referral are included in scope). Therefore, describe:

1. How the referral arrangement is documented (i.e., via an MOU, MOA, or other formal agreement);

2. How the referral arrangement addresses the manner by which the referral will be made and managed; and

3. How the referral arrangement addresses the tracking and referral of patients back to the health center for appropriate follow-up care.

Requires narrative response

No attachment requested/required

5. FUNDED SERVICE: Was the service to be deleted added to scope through a HRSA-funded application (e.g., New Access Point, Service Expansion)? If yes, address how the health center plans to achieve/maintain the patient projections included in the original application for the service. Note: health centers are expected to comply with terms and conditions of all awards, including serving the number of patients that have been served in the service area plus those the health center has committed to serve through recently-awarded HRSA funding.

Yes/No radio button; require narrative if Yes

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].