Form 1 Checklist for replacing existing service delivery site

CIS Editable Checklist – Grantee Checklist – Replace Service Site

Change Checklist

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration CHECKLIST FOR REPLACING A SITE (CHKLST005)	Grantee Name:
	Grantee Number:
	CIS Tracking Number:

When do you plan to start providing services at the replacement site?

Questions for Replacement of Service Site

Site to be Replaced
Replacement Site

1. BACKGROUND AND JUSTIFICATION FOR REPLACEMENT
Provide brief background/justification for why your health center is proposing to replace the current site with this new site.

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

2. MAINTENANCE OF SITE CAPACITY AND SERVICE LEVEL
Clearly describe how the replacement site is comparable to the current site and 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, by responding to ALL of the following questions(2a.-2d.)
The following information comparing the key characteristics of the current site (site to be closed/deleted from scope) to those of the replacement site, should be based on projections through the first year of the replacement site’s operations. All data must be specific to only the current and replacement sites. Do NOT provide data at the organizational level (i.e. across all health center sites).

2a. Number of patients served

Current Service Site: (Format: 9)

Replacement Site: (Format: 9)

2b. Types of services offered (e.g. general primary care, OB/GYN, etc.)

Current Service Site:

Replacement Site:

2c.Comparison of Comparable Service Space : Square footage/Number of exam rooms

Current Service Site:

Replacement Site:

2d. Total expenses

Current Service Site: (Format: $9 or $9.99)

Replacement Site: (Format: $9 or $9.99)

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

3. MAINTENANCE OF ACCESS AND QUALITY OF CARE
Demonstrate that the site replacement will continue to address the needs of the patient and/or target population served by the current site by maintaining access and quality of care for this current patient/target population.

3a. Based on UDS patient origin data, will the majority of patients seen at the current site have to travel further to access care at the replacement site?

Yes

No

IF NO, MOVE TO QUESTION 3b.
IF YES RESPOND TO THE FOLLOWING TWO QUESTIONS

What is the additional distance that patients will have to travel to the site, on average?

Distance: Miles

Travel Time: hrs. mins.

Will transportation services be available?

Yes

No

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

3b. Describe how any other potential new access barriers that may result from the site replacement will be addressed.

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

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 replacement as well as plans for maintaining existing and/or establishing new collaborative relationships as appropriate 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 proposed site:
(1) maximizing access to required and additional services within the scope of the health center project to the target population that will be served at the proposed replacement site; and/or
(2) promoting continuity of care to health care services for health center patients served at the proposed replacement site 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 of the site replacement, including making them aware of any new or enhanced transportation or enabling services available to access the replacement site.

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

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

4b. Describe plans for informing existing health centers (section 330 grantee and Look-Alikes) and other safety net providers (rural health clinics, critical access hospitals, health departments, etc.) in or adjacent to the service area of the proposed replacement site and for maintaining current or establishing new collaborative relationships with such organizations. If no other health centers and/or safety net providers exist within or adjacent to the service area state this.

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

Optional: Upload any attachments relevant to the site replacement 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 replacement, new MOUs, etc.).

CONTINUITY OF CARE AND COLLABORATION SUPPORTING DOCUMENTATION (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

5. SLIDING FEE DISCOUNT PROGRAM
Will the health center continue implement its current sliding fee discount program (sliding fee discount schedule, including any nominal fees and related implementing policies and procedures) at the proposed replacement site to patients with incomes at or below 200 percent of the Federal Poverty Guidelines, and ensure that no patients will be denied access to the service due to inability to pay?

Yes

No

If No, explain.

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

6. STAFFING
Discuss any potential impact resulting from the site replacement, on the overall organization’s staffing plan(reference the Financial Impact Analysis as applicable) and specifically discuss any CHANGES in key management staff that will supervise/oversee site operations at the replacement site and who they will report to within the larger health center organizational structure (e.g. CMO, COO, etc.).The discussion of “staffing” should include non-health center employees if the site will be operated via contract or subrecipient arrangement.

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

7. SITE OWNERSHIP AND OPERATION

For replacement sites that will be operated through a contractual or subrecipient arrangement (i.e. not directly by the health center):

Will services at the contracted or subrecipient operated site be provided on behalf of the health center to health center patients?

Yes

No

Will the health center’s governing board retain control and authority over the provision of the services to health center patients at the contracted or subrecipient operated site?

Yes

No

Briefly justify why the health center has chosen to operate the site through such third party arrangements.
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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., 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).

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

If the replacement site will be operated by a contractor or subrecipient, respond to the appropriate set of questions (7a. OR 7b.) below.

ONLY APPLICABLE FOR REPLACMENT SITES OPERATED BY A CONTRACTOR
7a. If the proposed 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), does the contract state, address or include:

The activities to be performed by the contractor in the operation of the site, specifically including?

• How the services provided at the site will be documented in the health center patient record?

• How the health center will bill and/or pay for the services provided to health center patients at the site?

Yes

No

List Page #(s):

The time schedule for such activities (e.g. hours of site operation)?

Yes

No

List Page #(s):

The policies and requirements that apply to the contractor, including those required by 45 CFR 74.48 or 92.36(i) and other terms and conditions of the grant? These may be incorporated by reference where feasible – See the HHS Grants Policy Statement for more information on public policy requirements applicable to contractors at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf pages II-2 to II-6

Yes

No

List Page #(s):

The maximum amount of money for which the health center may become liable to the third party under the agreement?

Yes

No

List Page #(s):

Provisions consistent with the health center’s board approved procurement policies and procedures in accordance with 45CFR Part 74.41-48?

Yes

No

List Page #(s):

Assurances that no provisions that will affect the health center’s overall responsibility for the direction of the site and services to be provided there and accountability to the Federal government by reserving sufficient rights and control to the health center to enable it to fulfill its responsibilities?

Yes

No

List Page #(s):

Requirements that the contractor maintain appropriate financial, program and property management systems and records and provides the health center, HHS and the U.S. Comptroller General with access to such records, including the submission of financial and programmatic reports to the health center if applicable and comply with any other applicable Federal procurement standards set forth in 45CFR Part 74 (including conflict of interest standards)?

Yes

No

List Page #(s):

Provision that such agreement is subject to termination (with administrative, contractual and legal remedies) in the event of breach by the contractor?

Yes

No

List Page #(s):

It is the responsibility of the health center to ensure that the contract does NOT inappropriately imply the conference of the benefits and/or privileges of Health Center Program grantees or FQHC Look-Alikes such as 340B Drug Pricing or reimbursement, on the other party.

Attach the contract for the site (draft agreements are acceptable) here.

Contract for Replacement Site (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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

ONLY APPLICABLE FOR REPLACEMENT SITES OPERATED BY SUBRECIPIENTS
7b. If the proposed 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 the health center’s key management staff confirmed that the subrecipient meets all applicable section 330 requirements and does the health center’s key management staff and its governing board have a plan in place to monitor the subrecipient’s compliance over time?

Yes

No

Does the board-approved subrecipient agreement state, address or include the following elements necessary for meeting the programmatic, administrative, financial, and reporting requirements of the grant, including those necessary to ensure compliance with all applicable Federal regulations and policies:

Identification of the PI/PD and individuals responsible for the programmatic activity at the subrecipient organization along with their roles and responsibilities?

Yes

No

List Page #(s):

Procedures for directing and monitoring the programmatic effort?

Yes

No

List Page #(s):

Procedures to be followed in 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?

Yes

No

List Page #(s):

If different from those of the recipient, a determination of policies to be followed in such areas as travel reimbursement and salaries and fringe benefits (the policies of the subrecipient may be used as long as they meet HHS requirements)?

Yes

No

List Page #(s):

Incorporation of applicable public policy requirements and provisions indicating the intent of the subrecipient to comply, including submission of applicable assurances and certifications? See the HHS Grants Policy Statement for more information on public policy requirements applicable to subrecipients at: http://www.hrsa.gov/grants/hhsgrantspolicy.pdf pages II-2 to II-6

Yes

No

List Page #(s):

Attach the subrecipient agreement documentation (draft documents are acceptable) here.

Subrecipient Agreement for Replacement Site (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

Subrecipients are eligible to receive FQHC reimbursement as well as many of the other benefits and privileges of Health Center Program grantees and Look-Alikes such as 340B Drug Pricing, FTCA coverage (section 330 grantees only). However, the health center AND subrecipient organization are reminded that such benefits are not automatically conferred and may require additional steps and updates (e.g. updating the FTCA deeming folder to ensure that the subrecipient is deemed via the grantee of record’s FTCA coverage).

8. FINANCIAL IMPACT ANALYSIS

Download Template
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.

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

8a. Explain how the replacement of the proposed site will be accomplished and sustained without additional section 330 Health Center Program funds. Specifically (referencing the attached Financial Impact Analysis, as necessary) describe how adequate revenue will be generated to cover any additional expenses as well as an appropriate share of any additional overhead costs incurred by the health center in replacing the current site.

The Financial Impact Analysis must at a minimum show a break-even scenario or the potential for generating additional revenue.

Additional revenue (program income) obtained through the addition of a new site must be invested in activities that further the objectives of the approved health center project, consistent with and not specifically prohibited by statute or regulations.

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

8b. Is this change in scope dependent on any special grant, foundation or other funding that is time-limited, e.g., will only be available for 1 or 2 years?

Yes

No

If Yes, how will the replacement site be supported and sustained when these funds are no longer available? Describe a clear plan for sustaining the site.

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


All time-limited or special one-time funds should be clearly identified as such in the Financial Impact Analysis.

9. 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)

10. CREDENTIALING AND PRIVILEGING
How has the health center planned for the appropriate credentialing and privileging of all provider(s) that will staff the replacement site in accordance with PIN 2002-22? If there will be no change in provider staffing, state this.

In responding, consider the following:

• It is the responsibility of the health center to ensure that all credentialing and privileging of providers has been completed BEFORE providing services at the replacement site as part of their Federal scope of project. This includes services provided either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement (e.g. contract). For services provided via a Formal Written Referral Arrangement (Column III), the referral provider should be able to assure to the health center that all their providers are appropriately credentialed and privileged individually.

• The health center’s current board-approved policy must cover the required verification of credentials and establishment of privileges to perform any new activities and procedures expected of providers by the health center or be updated to do so (for services provided at the replacement site either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement.

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

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

11. QUALITY IMPROVEMENT/ASSURANCE PLAN
How will the replacement site be integrated into and assessed via the health center’s quality improvement/assurance and risk management plans? In responding, address the following:

• Will it be integrated into the current QI/QA plan?

• Are board-approved peer and chart review policies in place by which all provider(s) at the proposed site will be assessed?

• Are risk management plans in place to assure the new site has appropriate liability coverage (e.g. non-medical/dental professional liability coverage, general liability coverage, automobile and collision coverage, fire coverage, theft coverage, etc.).

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

Additional Considerations for Replacing a Site in 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 planned to address prior to replacing a current site in scope with a new site.

A. Medical Malpractice Coverage: Your health center must develop plans for any providers that will provide services on behalf of the health center at the replacement site (e.g., extension of FTCA coverage, private malpractice coverage). Respond to the following as applicable:

For grantees deemed under the FTCA, have you reviewed the FTCA Health Center Policy Manual or if appropriate, consulted with BPHC to assure the applicability of FTCA coverage for the replacement site?

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: bphchelpline@hrsa.gov. Available Monday to Friday (excluding Federal holidays), from 8:30 AM – 5:30 PM (ET), with extra hours available during high volume periods.

Yes	Not Applicable, health center is not deemed or FTCA coverage does not apply.

If you selected “Not Applicable” respond to the question below.

For health centers not deemed under the FTCA or if FTCA coverage is not applicable to the site, have you developed a plan for medical malpractice coverage?

Yes

No

Briefly explain your response:

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

B. Section 340B Drug Pricing Program Participation: Health centers that participate in the 340B Drug Pricing Program are reminded that changes to the scope of project approved by BPHC 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 ApexusAnswers@340bpvp.com.

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

Yes	Not Applicable, health center does not participate in the 340B program

Briefly explain your response:

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

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

C. Facility Requirements: Has your health center assured that any/all Federal, State and local standards/accreditation requirements of the facility where the proposed replacement site will be established have been fully met (including those associated with CMS FQHC certification)?

Yes	Not Applicable

Briefly explain your response:

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

D. 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 project” are generally eligible for reimbursement by Medicaid, Medicare, and CHIP under the FQHC payment systems. When a health center receives HRSA approval to remove 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 the current site that will be replaced effective on the date that the site was approved to be removed from your scope of project?

Yes	Not Applicable

Briefly explain your response:

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

Will your health center contact Medicare and Medicaid to inform them that the current 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).

Yes	Not Applicable

Briefly explain your response:

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

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

Health centers are required to submit a separate Medicare enrollment application for each “permanent unit” at which they provide services. This includes units considered both “permanent sites” and “seasonal sites” under their HRSA scope of project, but not mobile vans. Health centers are also required to bill each service to Medicare using the unique Medicare Billing Number assigned to the site at which it was provided. Specifically, health centers must inform Medicare of any change of address for a permanent or seasonal site within 90 days of the change. This is done by submitting an updated Medicare Enrollment Application, Form 855A, for the replacement site that has been added to scope, to their Medicare Administrative Contractor. Form 855A is available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads//cms855a.pdf. For further information on the Medicare enrollment application process, review Program Assistance Letter 2011-04: Process for Becoming Eligible for Medicare Reimbursement under the FQHC Benefit available at: http://www.bphc.hrsa.gov/policiesregulations/policies/pal201104.html.

In addition, many state Medicaid programs also require all permanent and seasonal sites to enroll individually and bill using a site-specific billing number. For further information about the requirements in a state, health centers should contact their Primary Care Association or State Medicaid Agency.

Will your health center submit an updated Medicare enrollment application for the replacement site to the appropriate Medicare Administrative Contractor as soon as possible after HRSA’s approval of the Change in Scope, and bill for services provided at this site using that site’s unique Medicare Billing Number?

Yes	Not Applicable

Briefly explain your response:

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

Will your health center determine if a separate Medicaid enrollment application is required for your replacement site, and if so, submit it as soon as possible?

Yes	Not Applicable

Briefly explain your response:

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

E. National Health Service Corps Program Participation:
Health centers that participate in the National Health Service Corps (NHSC) are reminded that all NHSC providers must continue to work ONLY at an approved site within the health center's scope of project. Note that there may be some sites within a health center’s scope of project that are not NHSC-eligible (see the Eligibility Requirements and Qualification Factors section of the NHSC Site Reference Guide at http://nhsc.hrsa.gov/downloads/sitereference.pdf for information on eligible and non-eligible NHSC sites) and that the NHSC must be kept aware of all changes in site addresses.
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 replacing this site and changing your scope of project, has your health center assessed the impact on any NHSC participants that are working at the current site or will be asked to work at this the replacement site and advised them that they will need to contact the NHSC and seek a site reassignment prior to beginning work at this new site?

Yes	Not Applicable, health center does not have any NHSC Participants at the current site and/or will not place any NHSC Participants at the replacement site.

Briefly explain your response:

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

Page 25 of 25