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DECEMBER 2015

ALERT: What to Expect During an FTCA Site Visit

The Health Resources and Services Administration (“HRSA”) announced last year that it intends to increase the number of Federal Tort Claims Act (“FTCA”) site visits it will conduct each year.  Most site visits occur between June and August, although they can occur any time during the year.  The site visit typically lasts about two and one-half days.  During the site visit, the HRSA representatives will review four areas:  

  • Credentialing and Privileging: During the visits, the health center’s credentialing/privileging and peer review policies and procedures will be reviewed.  The credentialing/privileging policies and procedures must include the elements contained in Policy Information Notice (“PIN”) 2002-22, such as credentialing requirements for licensed providers and licensed independent practitioners and the process for granting initial, revision and renewal of privileges.  HRSA reviewers also will evaluate compliance with those policies and procedures by randomly selecting provider credentialing files for review.  They also will review collaborative or supervisory agreements for nurse practitioners and physicians’ assistants for compliance with state law.  Health centers should review their credentialing files of providers and the training files of non-licensed or certified staff regularly to ensure that all required documentation for providing patient care services is current.
  • Risk Management: The risk management review includes a review of the medical record policies of the health center, including HIPAA privacy policies, policies addressing documentation and archiving procedures and a review of risk management policies and procedures, including walk-in and telephone triage, no-show appointments, referral and hospitalization tracking and diagnostic tracking policies.  The HRSA reviewers then will assess the health center’s compliance with these policies.  Further, the HRSA reviewers will evaluate the health center’s continuing education and board approved annual medical malpractice/risk management training plan for the health center staff.  Health Centers should ensure that the board of directors meeting minutes approving the risk management plan and documentation of risk management training are readily available for review.
  • Quality Improvement/Quality Assurance (“QI/QA”): The QI/QA review will include a review of the board-approved QI/QA plan, QI/QA committee meeting minutes, board minutes evidencing oversight of QI/QA activities, health center bylaws, clinical practice protocols and, possibly, forms related to scope of service and sites (specifically Forms 5A and 5B).  Typically, the HRSA reviewers will review six sets of minutes for QI/QA committee and board meetings that occurred within one year prior to the date of submission of the FTCA application. The HRSA reviewers, however, can request minutes from an earlier time period.  Health centers should ensure that all such minutes are readily available for review.
  • Professional Liability: The professional liability review evaluates how the health center responds to claims or potential claims (the “Claims”).  HRSA reviewers will review the health center’s malpractice liability claims policy and procedures and professional liability claims for the last five years.  The review also includes documentation of internal analyses of the Claims, including peer review conducted on the Claims, as well as QI/QA committee and board minutes that discuss the Claims and the corrective action taken.  HRSA also will review documentation of medical malpractice/risk management training for health center staff.  Health centers should be prepared to provide evidence of such training (attendance sheets and/or post-training evaluations).  HRSA reviewers also may request documentation of the health center’s last Joint Commission or patient centered medical home reviews.

A recent FTCA site visit of a Connecticut Federally Qualified Health Center (FQHC) confirmed that HRSA is focused on whether the health center has the appropriate policies and procedures in place and is in compliance with them.  It is recommended, therefore, that health centers review their policies and procedures and update and revise as necessary, ensure that health center operations are in compliance with such policies and procedures and maintain clear documentation of such compliance.


Karen A. Daley is an attorney with Pullman & Comley LLC, is corporate counsel for one of the largest FQHCs in Connecticut and a registered nurse and former director of risk management for two Connecticut hospitals.  Copyright 2015 Pullman & Comley, LLC. All Rights Reserved.

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