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This Program Assistance Letter (PAL) supersedes
PAL 2007-02 for guidance on deeming requirements
for organizations funded under the Health Center
Program (section 330 of the Public Health Service
(PHS) Act) deemed under the Federally Supported
Health Centers Assistance Act (FSHCAA) of 1992
and the FSHCAA of 1995. This PAL contains the
instructions for health centers filing initial
and renewal deeming applications for calendar
year (CY) 2009.
The Federal Tort Claims Act (FTCA) coverage
for eligible Health Center Program grantees
was initially established through the FSHCAA
of 1992 (Public Law 102 501) by amending section
224 of the PHS Act. The eligible entities ("health
centers") are organizations receiving funding
under the Health Center Program (Migrant Health
Centers, Community Health Centers, Health Care
for the Homeless Centers, and Public Housing
Primary Care Centers). The FSHCAA of 1995, signed
into law on December 26, 1995, clarified the
1992 Act and eliminated its sunset provision,
making the program permanent. Effective October
1, 2002, Policy Information Notice (PIN) 2002-23
instructed all deemed health centers to reapply
for malpractice coverage under FSHCAA every
year.
It is the Health Resources and Services Administration’s
(HRSA) goal to incrementally improve and streamline
the deeming application process. For the CY
2009 deeming period (January 1 – December
31, 2009), improvements to the deeming process
include the identification of key contact persons,
the modification of the review criteria for
credentialing and risk management systems, and
the development of a formalized electronic submission
process.
HRSA recognizes that health centers may have
questions while we continue to refine our process,
and encourages the use of the free FTCA help
line to answer any questions.
The FSHCAA of 1995 requires all health centers
to apply for deemed status in order for FTCA
coverage to apply.
A. INITIAL APPLICATION
Health centers may submit an initial deeming
application at any time during the year. HRSA
will act upon a complete application submission
within 30 days.
B. RENEWAL APPLICATION
In order to be deemed for CY 2009, all currently
deemed health centers must file a renewal deeming
application no later than July 11, 2008.
To be considered complete, an initial or renewal
application for CY 2009 must contain the following
documentation:
- Application (signed by both the Executive
Director and Medical Director);
- A copy of the health center’s Quality
Improvement/Assurance Plan, with a notation
of the last governing Board approval date;
- A staff list which includes all LICENSED
or CERTIFIED health care practitioners and
the following:
- Name and Professional Designation (e.g.,
MD/DO, RN, CNM, DDS)
- Title/Position
- Specialty
- Employment Status (FTE/PTE/Contractor/Volunteer)
- Hire Date
- Initial Credentialing Date
- Most Recent Credentialing Date
- Next Expected Credentialing Date; and
- Review of professional liability history,
if necessary
- Explanation of “No” responses
To streamline FTCA deeming application submission
and processing, it is strongly recommended that
health centers electronically submit their deeming
application (initial or renewal) and supporting
documents within a .zip file folder to bphcftcaredeeming@hrsa.gov.(Instructions
on how to create a .zip file) 
To ensure timely review of applications, please
indicate in the email subject line whether the
health center is submitting an initial deeming
application or a renewal application; the health
center’s UDS number; the State; and whether
application pertains to a grantee health center,
sub-recipient or co-applicant (when applicable).
Health centers that are unable to submit electronically
may send their completed application to the
following address:
HRSA Health Center FTCA Program
Attn: Redeeming Application Office
Bureau of Primary Health Care, HRSA
5600 Fishers Lane, Mailstop 15C-26
Rockville, MD 20857
Telephone: 301-594-0818
Fax: 301-594-5224
For further information and/or questions on
the FTCA Program and the initial or renewal
deeming application process for CY 2009, please
contact:
Toll Free Telephone: 1-866-FTCA-HELP (866-382-2435)
– 9:00 AM to 8:00 PM (EST)
Email: Tritongp@optonline.net
Application for Health Center
Program Grantees for
Professional Liability Protection Under
the
Federal Tort Claims Act
| SECTION I - APPLICANT INFORMATION |
| GRANTEE NAME:
|
| DBA Name (if
appropriate): |
| UDS #: |
|
Community Health
Migrant Health
Health Care for the Homeless
Public Housing Primary Care
|
Sub-Recipient |
|
ADDRESS:
|
| EMAIL ADDRESS: |
| TELEPHONE #:
|
FAX #: |
| LIST OF SUB-RECIPIENTS
(if appropriate):
Grantees will indicate
the name(s) of their sub-recipient(s)
as documented on FORM 5B |
| 1. |
| 2. |
| 3. |
| EXECUTIVE DIRECTOR NAME: |
| Email: |
Telephone Number: |
| MEDICAL DIRECTOR
NAME: |
| Email: |
Telephone Number: |
| RISK MANAGER
NAME: |
| Email: |
Telephone Number: |
| DEEMING CONTACT
NAME:
(Individual
responsible for completing application) |
| Email: |
Telephone Number: |
| SECTION II – REVIEW OF RISK
MANAGEMENT SYSTEMS (Section 224(h)(1)) |
| Indicate Yes or NO to the following statements.
NO responses require explanation
on a separate sheet. |
YES |
NO |
| There are policies/procedures
on the appropriate supervision and back-up
of clinical staff. |
|
|
| A medical record is
maintained for every patient receiving
care at the health center. |
|
|
| There are policies/procedures
that address triage, walk-in patients,
and telephone triage. |
|
|
| There are clinical protocols
that define appropriate treatment and
diagnostic procedures for selected medical
conditions. |
|
|
| There is a tracking
system for patients who require follow-up
of specialty referrals, hospitalization,
x-ray, and lab results. |
|
|
| Medical records are
periodically reviewed to determine quality,
completeness, and legibility? |
|
|
| Quality assurance findings
are used to modify policies/procedures
in order to improve quality of care? |
|
|
| There is a written Quality
Assurance/Improvement Plan (QA Plan)
approved by the governing board. If yes, include the approval date and attach
a copy of the most recent QA Plan.
For deeming purposes,
the QA Plan must include or describe
the following requirements under Section
330(k)(3)(l) of the PHS Act and 42 CFR
51c.303(c)(1-2):
-
A focus of responsibility to support
the quality improvement/assurance program
and the provision of high quality patient
care;
-
Periodic assessment of the appropriateness
of the utilization of services, the
quality of services provided or proposed
to be provided to individuals served
by the applicant; and
-
Such assessments shall be: conducted
by physicians or by other licensed health
professionals under the supervision
of physicians; based on the systematic
collection and evaluation of patient
records; and identify and document the
necessity for change in the provision
of services by the applicant and result
in the institution of such change, where
indicated.
(NOTE: To ensure confidentiality,
please DO
NOT submit actual agendas or
minutes). |
|
|
|
Approval
Date:
____________ |
| SECTION III
– REVIEW OF CREDENTIALING SYSTEMS (Section
224(h)(2)) |
| Indicate YES or NO to the following statements.
NO responses require explanation
on a separate sheet. |
YES |
NO |
| All health care personnel
involved in direct patient care are
credentialed at least every two years,
as follows, for:
-
licensed independent practitioners;
-
licensed practitioners (i.e., social
workers, RNs, LPNs);
-
certified practitioners/technicians
(i.e., dental, lab, radiology) |
|
|
| The health center’s
credentialing verification procedures
include:
-
current licensure, professional certification,
and/or registration that is primary
source verified
-
professional educational background/postgraduate
training
·
primary source verified for licensed
independent practitioners
·
secondary source verified for licensed
and certified practitioners |
|
|
| As part of the health
center’s credentialing process, each
practitioner is required to submit evidence
of each of the following for review:
-
health fitness/fitness to perform duties
-
immunization status
-
professional references
-
certification in life support, as applicable
-
DEA registration, as applicable |
|
|
| A National Practitioner
Data Bank query is obtained and evaluated
for each licensed practitioner as part
of the health center’s credentialing
process. |
|
|
| A history of previous
malpractice liability claims and adverse
actions is reviewed for each practitioner |
|
|
| The health center utilizes
data from peer review and performance
improvement activities to support its
credentialing functions and these activities
are overseen by its governing board. |
|
|
| As part of the health
center’s privileging process, the following
occurs:
-
practitioners are granted privileges
by the health center, at least every
two years, specific to the services
being provided at each care delivery
site; and
-
clinical privileges and medical staff
membership at local hospitals and other
admitting facilities are verified |
|
|
| SECTION IV – REVIEW OF PROFESSIONAL LIABILITY
HISTORY (Section 224(h)(3)) |
|
Please note: Health centers are expected
to maintain their own records of medical
malpractice claims as part of their
risk management systems.
|
|
Initial
applicants only.
Please check one:
No professional liability suits were filed
against the health center and/or its
employees/contractors over the last
5 years.
Professional liability suits were filed against
the health center and/or its employees/contractors
over the last 5 years.
-
Initial applicants must provide a
list of all professional liability
suits filed against the health center
and/or its employees/contractors over
the last 5 years. Include the date of the complaint, the allegation,
current status, and amount of payment,
as applicable.
Renewal
applicants only.
Please check one:
No professional liability suits were filed
or settled against the health center
and/or its employees/contractors over
the last 5 years.
Professional liability suits were filed or
settled against the health center
and/or its employees/contractors over
the last 5 years.
-
Renewal applicants must provide a
list of the pending and settled FTCA
claims over the last five years with
a brief summary of the actions taken
by the health center to analyze the
claims and the corrective actions
taken or planned to prevent such claims
in the future.
Please document any systems
or clinical improvements, as applicable.
|
| SECTION V – SERVICES TO NON-HEALTH CENTER
PATIENTS
(Section 224(g)(1)(B), (C) and 42 CFR 6.6(d)) |
|
Are services provided
to non-health center patients? If yes, check all that apply based on the examples
listed in the Federal Register Notice
(Vol. 60, pages 49417-18) issued September
25, 1995.
COMMUNITY-WIDE INTERVENTIONS:
School-based clinics
School-linked clinics
Health Fairs
Immunization Campaign
Outreach
HOSPITAL-RELATED
ACTIVITIES:
Hospital call as required for privileges
Emergency Room coverage as required for privileges
COVERAGE-RELATED
ACTIVITIES:
Cross-coverage with community providers, as evidenced through the health center employees’
employment contracts
If the services do
not appear to fall under the examples
cited, then the health center should
submit a separate request to the Associate
Administrator for Primary Care, for
a determination of the applicability
of FTCA coverage. |
| SECTION VI - SIGNATURES |
| Requested
Effective Date of FTCA Coverage:
(FOR
INITIAL DEEMING ONLY) |
| EXECUTIVE DIRECTOR
NAME:
(Print or Type) |
| SIGNATURE: |
DATE: |
| MEDICAL DIRECTOR
NAME:
(Print or Type) |
| SIGNATURE: |
DATE: |
Attachment A - Copy of Health Center’s
Quality Assurance/Improvement Plan
Attachment B - List of Licensed
or Certified Health Care Practitioners
Attachment C - Review of
Professional Liability History, as necessary
Attachment D - Explanation
of “No” Responses, as necessary
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