Certification Process

A.1  Levels of Certification:

Core Center (Core) B meets all required components and minimums as defined in the standards for a Core center

Expanded Center (EXP) B meets all required components and minimums as defined in the standards for an Expanded center

Both Core and Expanded centers are encouraged to follow recommended components, but are not required to meet these for certification.

A.2   Administrative Procedures:

  1. Sites may certify individually by making application as a Core or an Expanded center.
  2. A school-based health center system may certify more than one site as a Core or an Expanded site on the same application providing each center meets each requirement individually.
  3. Initial certification will involve both a written application (completion of the standards checklist and required assurances) as well as a site visit. A request for a waiver for any standard must accompany the application and must include a satisfactory explanation as to why the standard can not be met and a written plan with a time line to correct that standard.
  4. Re-certification will occur every 2 years in conjunction with the state legislative funding cycle and will include an updated standards checklist and required assurances.
  5. At the state’s discretion, if a center’s certification lapses either a new (initial certification) or re-certification will be required.
  6. At any time after initial certification, a site may request an administrative review of compliance. The review will be considered a no penalty review with the exception of gross violation or negligence which may require site closure or temporary suspension of services.

A.3   Compliance Requirements:

  1. After initial certification, sites must notify the state technical assistance office (TAO) within 60 days of any changes (e.g. inability to recruit to a vacant staff position, decrease in hours of operation) which bring the site out-of-compliance with the standards for a period of more than 20 center working days. A written plan that delineates actions including a timeline to return to compliance must accompany the notification.
  2. The state TAO reserves the right to review all or any selected standards for compliance at all certified sites with a minimum notification of at least 5 center working days if issues of compliance are raised or come into question.

A.4   Out of Compliance Procedure:

  1. Site notifies state (see Compliance Requirements, A.3.a). State TAO will review outcomes in accordance with the written plan:
      • Remedied B no further action necessary
      • Not remedied B see step b
  2. If a site is determined to be out of compliance with the standards, the state TAO may choose one of the following actions:
    (1) Require a written plan with a timeline to correct deficiency
    (2) Issue a written warning with a timeline to correct deficiency
    (3) Issue a letter of non-compliance and;

    1. Suspend (no transfer of funds until remedied)
    2. Sanction (reduce funding level during current fiscal year)
    3. Terminate (withdraw funding B current or subsequent fiscal year)
  3. For steps b.(1) and b.(2), the state TAO will review outcomes in accordance with the written plan or warning and if remedied no further action is necessary. If not remedied, step b.(3) will be initiated.
  4. For sites entering steps b.(3), a site visit to verify remedies prior to re-instatement and/or re-certification of the site may be required.


Sponsoring Agency/ Facility

B.1   Sponsoring Agency Requirements:

  1. A sponsoring agency is defined as an agency that has a written agreement with the school-based health center (SBHC) to provide one or more of the following:
    • funding
    • staffing
    • medical oversight
    • liability insurance
  2. All sponsoring agencies must have a written agreement with the SBHC describing their role in SBHC operations.
  3. A SBHC may have more than one sponsor, but at least one of the sponsors must meet the definition of a medical sponsor.

B.2   Medical Sponsorship Requirements:

  1. Medical sponsorship shall include:
    • designation of a SBHC medical director (health care provider with a license to practice independently with the population being served and who has prescriptive authority, e.g., MD, DO, NP) (see also C.6.d)
    • evidence of ongoing (at least quarterly) involvement of the medical director in clinical policy & procedures development, records review and clinical oversight
    • medical liability coverage
    • ownership of medical records
  2. Appropriate medical sponsors may be one of the following entities providing they meet the requirements in (B.2.a):
    • Local health department
    • Federally qualified health center/community health center
    • Hospital
    • Private medical practice/group
    • Nurse practitioner clinic
    • University medical center
    • Managed care organization
  3. Medical sponsors must assure unbiased care regardless of client insurance status or insurance carrier. The sponsor will also assure that clients will not be required or pressured to change insurance carriers for the benefit of a sponsoring agency.
  4. The local health authority retains the right to approve expenditure of public funds utilized to provide public health services on the local level (ORS 431.375 section 3) and thus have first right of refusal to become the SBHC medical sponsor when public funds are awarded for SBHCs. Once relinquished in accordance with the rules, the decision will be reviewed each biennial funding cycle.

B.3   Facility Requirements:

  1. A SBHC facility is defined as a permanent space located within a school building or on the school campus used exclusively for the purpose of providing primary health care, preventive health, mental health and health education services.
  2. The facility must meet ADA requirements for accommodation of individuals with disabilities.
  3. The facility must meet local building codes, OSHA and any other local, state or federal requirements for occupancy and use.
  4. Though there may be differences in SBHCs from site to site, and multiple-use spaces are allowable, the following must be present within the center:
    • waiting/reception area
    • exam room(s) with sink
    • bathroom facility
    • office area
    • secure records storage area
    • secure storage area for supplies (e.g. medications, lab supplies)
    • designated lab space with sink and separate clean and dirty areas
    • confidential phone (for placing confidential phone calls and receiving confidential messages)
    • confidential fax (SBHC staff access only)
  5. For the purposes of confidentiality, there must be at least 2 separate rooms with appropriate soundproofing, window coverings and doors that provide necessary sound and sight security for private examination and conversations, both in person and on the telephone.
  6. To optimize utilization of staff, there must be at least one exam/ counseling room available per FTE provider (RN, NP, PA, MD, DO or mental health provider) staffed during hours of operation.
  7. The design of functional spaces shall at all times consider the necessity of maintaining patient confidentiality, secure records, secure storage and safety.
  8. A facility floor plan (to scale) must be submitted for approval to the state program office with the certification application.

B.4   Facility Recommendations:

  1. In addition to required areas, the following are advisable:
    • family/group meeting room
    • resting/triage area when separate school nursing facilities are not available
    • outside entrance for before/after school or summer hours
  2. The following are square footage guidelines for design/remodeling of SBHC space. The recommended minimum square footage (providing space requirements are met) for a Core center is 675 square feet and for an Expanded center is 1000 square feet.
Estimated Space
waiting reception area 150-200 (square feet)
exam/counseling room (each) 100-120
bathroom facility 75-100
office area (each) 100-120
confidential phone/fax
secure records storage 25-50
secure storage area for supplies 25-50
lab area 25-50
resting/triage area 75-100
custodial 25-50
general storage 50-75
staff room 100-120
conference room 150-200