Checklist for Deleting a Service Site from Scope

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Checklist for Deleting a Service Site from Scope
Background
Your change in scope (CIS) request will not become part of your health center’s HRSA-approved Health Center Program scope of project until all the following steps have been completed: 
    1. HRSA sends your health center the Notice of Award (NoA) or Notice of Look-Alike Designation (NLD) approving the CIS request.
    2. Next, your health center responds to a scope verification task that asks when this scope change will be implemented. HRSA will allow up to 120 days for your health center to respond to the scope verification task.  After 120 days, this scope change will be recorded by HRSA as implemented. 
    3. Finally, HRSA sends your health center an NoA or NLD documenting that this scope change is reflected in your health center’s scope of project. 
For more information, refer to the Scope of Project Resources. 


    1. Is this CIS request a scope correction in preparation for or resulting from one or more site visits?
    • Yes 
    • No 

        1.1 If YES: Identify the related site visits.
[textbox] 

        1.2 If YES: Explain. [textbox] 

    2. Within the last five years, has your health center received Health Center Program supplemental funding related to this site? 
For example, supplemental funding for site construction or renovation or funding for a New Access Point (NAP). 
    • Yes 
    • No 

    • If YES: 
        2.1 Which Health Center Program supplemental awards are related to this site? 
[textbox] 

        2.2 Explain how each supplemental award relates to this CIS request and how your health center will continue to satisfy the terms and conditions of each supplemental award.
[textbox] 
Description and Rationale
    3. Why are you requesting to delete this site from your health center’s scope of project? 
Select all reasons that apply:
    • The site is not financially sustainable. For example:
        ◦ Patient volume has substantially decreased to a point where the site cannot be sustained.
        ◦ There is insufficient staff to support the site.
Explain: [textbox] 
    • My health center is consolidating multiple sites. (Note: This CIS request serves to delete this one site, not multiple sites. If multiple sites need to be deleted, each site needs its own CIS request.) 
Explain: [textbox]
    • Other – explain: [textbox]

    4. How many patients annually does the site serve? 
Note: If the site is no longer serving patients, provide the last available patient count for the site. 
[textbox]

    5. ZIP Codes
        5.1 All Current Service Area ZIP Codes
These are all of the current service area ZIP Codes for all of your health center’s in-scope sites, based on your health center’s Form 5B: Sites. [textbox or electronic system auto-population]
        5.2 Service Area ZIP Codes of Site Proposed for Deletion
These are the service area ZIP Codes of the site proposed for deletion. [textbox or electronic system auto-population]
        5.3 ZIP Codes Removed From Your Health Center’s Service Area Due To Proposed Site Deletion
These are the service area ZIP Codes that are part of your health center’s current service area but that will no longer be in your health center’s service area once the site is deleted from your health center’s scope of project. [textbox or electronic system auto-population]

    6. Will any ZIP Codes be removed from your health center’s service area as a result of this proposed site deletion (refer to the “ZIP Codes Removed From Your Health Center’s Service Area Due To Proposed Site Deletion” field)?
    • Yes
    • No

        6.1 If YES: For EACH ZIP Code that is removed from your health center’s service area, how many patients are in that ZIP code? 
[textbox]
Note: A reduction in patients or ZIP Codes served as part of your health center’s scope of project may impact your health center’s eligibility for future Health Center Program Service Area Competition (SAC) applications. 

    7. What is the impact of deleting this site on your health center’s obligation to serve, in whole or in part, at least one MUA/MUP?  
Use the Health Center Program GeoCare Navigator to confirm that your health center will continue to serve, in whole or in part, at least one MUA/MUP after the proposed site deletion.
[textbox]

    8. What is the impact of deleting this site on the total number of patients served across ALL sites in your health center’s approved scope of project (sites reflected on your health center’s Form 5B: Sites), and will this impact your health center’s ability to meet its patient targets?
[textbox]

    9. Describe how your health center intends to maintain the level and quality of health services currently provided to the patient population who are currently served at the site proposed for deletion. Address all of the following:

    • The average travel time and distance to the closest service delivery site of your health center, another health center (health center award recipient or look-alike), or another safety net provider offering a sliding fee scale.
[textbox]
    • The impact of the site deletion on patient access to ALL health center services in your health center’s approved scope of project (required services and additional services reflected on your health center’s Form 5A: Services Provided). Include a description of what new or enhanced transportation services will be available. If new or enhanced transportation services will not be necessary, explain why.
[textbox]
    • How your health center will address any other barriers to care that the site deletion may present.
[textbox]

Note: Your health center is responsible for ensuring it has a plan for the transfer of:
    • Patient records; and
    • Equipment and other property purchased or improved with HRSA grant funding. Contact your health center’s Grants Management Specialist for questions related to Federal interest.
Outreach and Communication
    10. Describe how your health center will communicate with current health center patients and with the community at large (for example, other Health Center Program award recipients and look-alikes, rural health clinics, critical access hospitals, health departments) to raise awareness of the proposed site deletion. [textbox]

    11. Attach documents relevant to the proposed site deletion that demonstrate your health center’s outreach and communication plan and, if available, examples of implementing that plan (for example, sample patient notification documents, local media announcements about site closing, new MOUs). 
[attachments – multiple, with at least one required]



Reminder: If any information in this CIS request is incomplete, HRSA may disapprove this CIS request.


     
Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/2029. 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 1 hour 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.