Checklist for Replacing a Service Site in Scope

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Checklist for Replacing a Service Site in Scope
Replace Service Site Criteria 
If your health center does not meet all of these criteria, you cannot submit a Replace Site CIS request.  You will need to submit separate CIS requests to add a site to scope and to delete a site from scope.  Contact your project officer for further guidance.
    • One new site is proposed to be added to your health center’s scope of project (“replacement site”) to replace one site currently in your health center’s scope of project (“current site”). The replacement site will be added to your health center’s scope of project, and the current site will be removed from your health center’s scope of project. 
    • The replacement site must be directly operated by your health center and cannot be a site that is (i) operated by a contractor or a subrecipient; or (ii) co-located with another organization.
Note: The current site can be operated by a contractor or by a subrecipient, but the replacement site must be directly operated by your health center. 
    • Within 120 days of the NoA or NLD issue date approving this CIS request, your health center will verify that the replacement site is open and operational and verify that the current site is closed.
    • For the replacement site:
        ◦ The ZIP Code of the physical address of the replacement site must be WITHIN the list of service area ZIP Codes for the current site on your health center’s Form 5B: Sites; and
        ◦ The service area ZIP Codes for the replacement site must be the SAME as those for the current site on your health center’s Form 5B: Sites.
Note: The replacement site cannot add or remove service area ZIP Codes. 
    • The same or a greater number of patients will be seen at the replacement site as at the current site.
    • The replacement site will provide the same or a greater set of in-scope services as the current site (for example, the current site and the replacement site both offer primary care and dental services).
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 submits a scope verification task that confirms your health center has implemented the change. HRSA will allow up to 120 days for your health center to submit the scope verification task; and 
    3. Finally, HRSA sends your health center an NoA or NLD documenting that the change is included 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 the current site or to the replacement 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.
[textbox]
Description and Rationale
    3. Why are you requesting to replace the current site in your health center’s scope of project? 
Select all reasons that apply:
    • Your health center is exceeding capacity at the current site. Explain. [textbox]
    • Other – Explain. [textbox]

    4. Number of Patients			
Notes:
    • All patient numbers must be specific only to the replacement site and to the current site. Do not provide data at the organizational level (across all of your health center sites).
    • For the replacement site, the patient projection should be based on the first 12-month period that the site will be open and operational.
    • For the current site, the patient number should be based on data for the most recent 12-month period. 
        4.1 Replacement Site (projection): [textbox]
        4.2 Current Site: [textbox]
        4.3 Explain how the replacement site will serve the same or a greater number of patients as the current site.
[textbox]

    5. ZIP Codes
        5.1 Current Site’s Service Area ZIP Codes
These are the service area ZIP Codes for your health center’s current site. [textbox or electronic system auto-population]
        5.2 Replacement Site’s Service Area ZIP Codes
These are the service area ZIP Codes for the replacement site. [textbox or electronic system auto-population]
        5.3 Replacement Site’s Physical Address ZIP Code
This is the ZIP Code in the physical address of the replacement site. [textbox or electronic system auto-population]
        5.4 Confirm that the service area ZIP Codes for the replacement site are the SAME as those for the current site.
    • Yes
    • No
        5.5 Confirm that the ZIP Code in the physical address of the replacement site is WITHIN the list of service area ZIP Codes for the current site.
    • Yes
    • No

    6. Explain how the replacement site will provide the same or a greater set of services as the current site (for example, the current site and the replacement site both offer primary care and dental services).
[textbox]
    7. Attach any additional documentation that supports the decision to replace the current site (for example, floor plans of the current site and replacement site, needs assessment data, or health center reports).

[attachments – multiple, with all optional]
    8. Provide a description of how your health center plans to ensure continuity of care for current patients and address any patient access issues, including those related to transportation.
[textbox]
Outreach and Communication
    9. Describe outreach and communication plans for informing current health center patients of the site replacement (for example, mailers, phone calls, signage, social media, and health center website information).
[textbox]
    10. Describe what actions your health center will take to ensure that:
    • The replacement site will be operational within 120 days after notification approving this CIS request; and
    • The current site will be closed within the same 120 days.
[textbox]

    11. Describe any impacts to existing collaborative relationships and any new collaborative relationships due to this site replacement.
[textbox]
Residents of Public Housing under Section 330(i)
For the purposes of health centers receiving a Health Center Program award or designation under section 330(i) of the Public Health Service Act, public housing includes public housing agency-developed, owned or assisted low-income housing, including mixed finance projects, but excludes housing units with no public housing agency support other than Section 8 housing vouchers.

(Section 330(i) of the PHS Act).

    12. Does your health center receive funding to serve residents of public housing under Section 330(i)?
    • Yes
    • No

        12.1 If YES: Does the current site predominantly serve residents of public housing?
    • Yes
    • No

            12.1.1 If YES: Is the replacement site:
    • Located in public housing
    • Immediately accessible to public housing
Note: The term “Immediately accessible” means that the service site is within or adjacent to the public housing and that no physical barriers (for example, a highway or river) exist that prevent this medically underserved population from accessing the proposed service site.
    • None of the above – Document the specific public housing units or areas immediately accessible to public housing where patients live who will be seen at the proposed site. [textbox]

12.1.2  How did your health center consult with the residents of public housing who will be served by the replacement site? [textbox]

12.1.3  How will residents of public housing be involved in the planning and ongoing administration of the replacement site? [textbox]


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 0.75 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 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.