CurrentBaylor Scott & White Health PlanPolicy SWHP PNO.O14.P

Site Visit Performance Standards

Defines office site visit standards and procedures used by Scott and White Health Plan/Insurance Company of Scott & White to assess quality, safety, accessibility, and recordkeeping at practitioner/provider office sites; applies to all lines of business and affects Provider Network Operations and providers being credentialed or monitored.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicySite Visit Performance Standards

Policy CodePolicy SWHP PNO.O14.P

Change TypeNo material changes

Effective Date04/14/2021

Next Review Date

Key ActionConduct site visits by trained Provider Relations staff, document deficiencies, and require corrections within specified timeframes with follow-up evaluations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%Checklist item thresholds (many)

90%Overall compliance threshold

60 daysSite visit scheduling after complaint

6 monthsTime to correct deficiencies

30 daysTime to correct some deficiencies (credentialing)

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Site Visit Coverage and Checklist Criteria

Site visit coverage criteria

Site visits evaluate physical accessibility, appearance, adequacy of waiting/exam room space, appointment availability, and treatment record keeping. Covered when ALL of the following are met:

Trigger: Member complaint or ongoing monitoring by Credentialing Coordinator initiates site visit (scheduled within 60 days of receipt of complaint).

Performer: Trained SWHP/ICSW Provider Relations staff conduct the site visit; delegated entities may conduct visits if specified in the delegation agreement.

Assessment components: physical accessibility (e.g., ramps or single low step, wheelchair access to exam rooms, lavatory with safety bars), exterior and interior appearance, adequacy of waiting and exam room space and seating, adequacy of supplies and exam equipment, and medical record security and organization.

Appointment availability standards assessed: urgent/acute access, routine within 5 days, behavioral health within 10 days, preventive care within 6 weeks (next available appointment recorded).

Documentation: Completed Site Visit Form (SWHP PNO.O14.A1 or SWHPPNO.014.A2) is filed in the provider credentialing file; deficiencies are documented and a copy left with the provider.

Thresholds and scoring: Individual checklist items generally have a 100% threshold; overall assessment score of 90% compliance is required for the office site to be considered compliant. Failure to meet 90% = considered deficient.

Deficiency follow-up and tracking: Deficiencies must be corrected within six months with a follow-up evaluation or second site visit; if improvements are unsatisfactory a second site visit may be scheduled and persistent failure is reported to the Credentials Committee for review and possible action. When major construction is involved, CMO/Medical Director designee may consider an extension.

Accreditation alternative: Acceptable passing inspection letter from CMS or Texas DADS may be used in lieu of a site visit for accredited facilities.

Site visit checklist criteria

Site visit checklist items and expected YES/NO/NIA responses for facility/provider compliance.

Medical records available during office hours (expected response: YES/NO/NIA).

Medical records individualized by patient name or ID and orderly with legible file markers (expected response: YES/NO/NIA).

Consults, labs, X-rays and ancillary studies included in the medical record (expected response: YES/NO/NIA).

Medical records secured and released only in accordance with federal/state laws (expected response: YES/NO/NIA).

Electronic medical records (secure system used) where applicable (expected response: YES/NO/NIA).

Facility accessible to persons with disabilities (ramps, single low step, door widths, lavatory safety bars) (expected response: YES/NO/NIA).

Thresholds and Key Metrics

Checklist item thresholds

Checklist items with 100% thresholdMultiple checklist items (e.g., lavatory safety bars, entrance ramp/single low step, exam room space, waiting room adequacy, exam room adequacy, treatment record keeping) are expected to meet a 100% threshold on the Site Visit form.

Overall compliance vs. item-level thresholdsAlthough many individual checklist items require 100%, overall assessment compliance threshold for site visit is 90% (scores below 90% are considered deficient).

Examples of 100% itemsExam rooms have adequate space; waiting room provides adequate seating; medical records secure and confidential; record availability organized for easy retrieval — each listed with Threshold: 100% on the checklist.

Scope of 100% expectation100% thresholds apply across accessibility, appearance, waiting/exam room adequacy, and recordkeeping items as shown on Site Visit: Medical Practitioner forms.

Medical record availability / organization threshold

Site Visit Conduct, Follow-up, and Credentialing Actions

Note

Site Visit Conduct

Site visits are conducted by trained SWHP/ICSW Provider Relations staff. Delegated entities may conduct site visits for their contracted provider offices only if the delegation agreement permits. Visits are scheduled whenever a reasonable member complaint is received and for facilities that are not accredited (a current CMS or Texas DADS passing inspection letter may be accepted in lieu of a visit). A designated office representative must be present during the site visit.

Site visits performed by trained SWHP/ICSW Provider Relations staff (delegation allowed per agreement).
Scheduled within 60 days of a member complaint.
Accredited facilities may be waived if a current passing CMS or Texas DADS inspection letter is provided.

Documentation Required

Follow-up and Remediation

Deficiencies identified during the site visit are documented on the Site Visit Form (SWHP PNO.O14.A1 or SWHP PNO.O14.A2). A copy of the completed form is provided to the practitioner/provider and filed in the provider’s credentialing file. Providers are expected to correct deficiencies within 30 days; when major construction is involved, an extension may be considered by the SWHP/ICSW Chief Medical Officer or Medical Director designee.

Definitions and Facility/Record Expectations

Defined terms

Defined terms in this policyNone — the document states there are no defined terms within this policy; additional defined terms may be found in the BSWH P&P Definitions document.

Reference for other definitionsBSWH P&P Definitions document contains any additional defined terms referenced by this policy.

Capitalized words usageWhen used with initial capital letter(s), the policy would define terms here; however, this section explicitly lists 'None.'

Medical Record Availability / Organization

Availability during office hoursMedical records are required to be available during office hours (item on Facility Provider form: 'Medical records are available during office hours').

Organization and retrieval

Policy Summary

PayerBaylor Scott & White Health Plan

PolicySite Visit Performance Standards

Policy CodePolicy SWHP PNO.O14.P

Change TypeNo material changes

Effective Date04/14/2021

Next Review Date

Key ActionConduct site visits by trained Provider Relations staff, document deficiencies, and require corrections within specified timeframes with follow-up evaluations.

SourceLink

On This Page

Fire alarms and sprinklers present (expected response: YES/NO/NIA).

Fire extinguishers visible and accessible (expected response: YES/NO/NIA).

Facility clean, neat, well-lit and well-maintained (expected response: YES/NO/NIA).

Waiting/exam rooms adequate for patient volume with sufficient seating (expected response: YES/NO/NIA).

Corridors and exits clear and clearly marked (expected response: YES/NO/NIA).

Written policies present and posted as applicable: OSHA, patient confidentiality, triage/emergencies, handling narcotics, inspection of emergency equipment (expected response: YES/NO/NIA).

Laboratory area/services (if performed in office): CLIA certification or waiver posted and area clean and organized (expected response: YES/NO/NIA).

Radiology area/services (if performed in office): current certificate/license for radiology services (expected response: Yes/No/NIA).

Each chart includes a sample problem list and required record components (patient ID, allergies, consult notes, progress/history notes) (expected response: YES/NO/NIA).

Scoring: Total points possible / Threshold: Individual checklist items typically Threshold = 100%; overall threshold for facility section and credentialing is 90%.

Record availability expectationMedical records must be organized and stored to allow easy retrieval during office hours — Threshold: 100%.

Record components requiredRecords should include patient identification (name/DOB/medical record number), allergy notation, ancillary studies (labs/X‑rays), consult notes, correspondence, and progress/history notes.

Individualization and protectionMedical records must be individualized by patient name/ID and protected from public access or inadvertent exposure.

Containment of external reportsConsults, labs, and X‑rays should be contained within the medical record (checked on the form).

Deficiencies recorded on SWHP PNO.O14.A1 or SWHP PNO.O14.A2.
Copy of completed form filed in provider credentialing file.
Standard correction timeframe: 30 days (extensions considered for major construction).

Denial Risk

Follow-up Timeline and Escalation

If deficiencies persist after the initial corrective period, a follow-up evaluation or second site visit focused on correction of deficiencies is conducted within six (6) months. An action plan for improvement may be requested and re-evaluations must continue at least every six (6) months until full compliance (90% threshold) is achieved. Failure to rectify ongoing deficiencies will be reported to the SWHP/ICSW Credentials Committee for review and possible action.

Second site visit (when applicable) within six (6) months.
Re-evaluations at least every six (6) months until 90% compliance reached.
Unresolved deficiencies reported to the SWHP/ICSW Credentials Committee.

Prior Authorization

Credentialing Threshold and Corrective Action

Providers must meet a minimum site visit performance threshold of 90% compliance to be credentialed as an approved provider. Sites that meet the 90% threshold but have noted deficiencies may still be subject to a second site review within six (6) months if submitted evidence of improvement is unsatisfactory. Documentation of deficiencies, follow-up visits, and resolution is tracked until performance thresholds are met.

Minimum credentialing threshold: 90% compliance.
Deficiencies corrected within 30 days; second review within six (6) months if improvements unsatisfactory.
All documentation tracked until threshold met.

Records must be organized and stored to allow easy retrieval (explicitly stated: 'organized and stored in a manner that allows easy retrieval').

Individualization and protectionRecords must be individualized by patient name or ID and protected from public access/inadvertent exposure.

Record contentsRecords should include patient ID, allergy notation, ancillary studies (labs/X‑ray), consult notes, correspondence, and problem lists and progress/history notes where applicable.

Facility Adequacy and Safety

Accessibility for persons with disabilitiesFacility must be accessible to persons with disabilities and have features such as ramps or single low step and accessible exam rooms (checked under 'Facility accessible to persons with disabilities').

Fire safety equipment and exitsFire alarms/sprinklers must be present and fire extinguishers visible and accessible; exits must be clearly marked.

Cleanliness and environmentFacility should be clean, neat, well‑lit and well‑maintained with clear corridors and adequate waiting/exam room space/seating for patient volume.

Exam room privacy and suppliesExam rooms must assure patient privacy and be equipped with necessary supplies; biohazard and sharps disposal must be available and properly maintained.

Emergency equipment and signageEmergency equipment presence and mechanisms to inform patients of hours of operation and clearly marked external signage are assessed.

Written Policies / Certifications

Required written policiesSite must maintain written policies for OSHA guidelines, patient confidentiality, triage/emergencies, and handling narcotics.

Emergency equipment inspectionWritten procedures for inspection of emergency equipment are required (checked on the form).

Laboratory and radiology requirementsIf laboratory services are performed, CLIA certification/waiver must be posted and lab area clean/organized; radiology services require current certificate/registration with the Bureau of Radiation Control (current within past 3 years).

Area organization and documentationLaboratory and radiology areas must be clean and organized and any applicable certificates/dates documented on the Site Visit form.