Form 6 Checklist for Deleting Existing Service Delivery Site -

Checklist for Deleting Existing Service Delivery Site

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 site linked to another recently submitted, in progress or planned CIS request (e.g., the health center is moving operations from this to a new site and will be submitting a CIS request to Add Site)?

Y/N – require text box explanation if Y

1. OVERVIEW: Provide brief background/justification for why the health center is proposing to delete this site from its scope of project (e.g., major decrease in patient population, public transportation changes).

Requires narrative response.

Proposed Date of Site 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., close the site). 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 at this site by discussing:

   1. the impact of deleting this site on the total number and percent of patients (i.e., across all sites in scope);

   2. the impact of deleting this site on access to health center services in the current approved scope of project (Required and Additional Services as reflected on the health center’s Form 5A) for current patients at the site

   3. the average travel time and distance to the closest service delivery location(s) of the health center or other safety net provider offering a sliding fee scale;

   4. if needed, what new or enhanced transportation services will be available to support access to all health center services for patients served by the site proposed for deletion; and

   5. how the health center will address any other barriers to care that the deletion of the site may present for current patients at the site.

Requires narrative response.

3. 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), to raise awareness of the site deletion, including any new or enhanced transportation or enabling services available to support access to services at other sites or locations. 

Requires narrative response.

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

Mandatory attachment

Note: the health center should ensure it has a plan related to the transfer of patient records and the transfer of equipment and/or other property purchased or improved with HRSA grant funding, as applicable. Please contact the health center’s Grants Management Specialist for questions related to Federal interest.

4. FUNDED SITE: Was the site to be deleted added to scope through a HRSA-funded application (e.g., New Access Point, Oral Health Service Expansion)? If yes, address how the health center plans to achieve/maintain the patient projections included in the original application for the site. 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 paperwork@hrsa.gov.