Watch The Webinar Here: https://compliatric.com/continuous-compliance-2022-its-not-just-an-osv-prep-chapters-11-14/
Compliatric is excited to continue their “Continuous Compliance" Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.
This month’s webinar will focus on the following chapters:
Chapter 11: Key Management Staff
Chapter 14: Collaborative Relationships
Webinar attendee takeaways will include:
· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance - not only based on a site visit
· Improving operational excellence for your Community Health Center
2. This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
This presentation is not endorsed by Health Resources Services
Administration (HRSA) or Bureau of Primary Health Care (BPHC)
Not employed by MSCG or BPHC
Independent Consultant who is contracted to do Operational Site
Visits (OSVs) and Technical Assistance (TA)
Not intended to provide legal advice
5. Do something different than just “plain, old,
boring Operational Site Visit preparation”
◦ Generative approach
What are the requirements?
Do we understand them?
What’s next? How to achieve operational excellence
Virtual OSVs continue until end of FY 2022
AND………………………………….
6.
7. NO changes to the Compliance Manual
Update to the Site Visit Protocol to reflect:
◦ Methodologies and refined questions
◦ Grammar, numbering, formatting
On or after May 26, 2022, will be released on the
HRSA website
Health centers with site visits after May 26, 2022,
should receive a zip file with new documents
◦ Usually, a month before your virtual site visit
8. Review the program
requirements
May 2022: Key Management
and Collaborative
Relationships
Best practices to maintain continuous compliance
How to use the requirement
in everyday practice
Make your Community
Health Center awesome!
10. Compliance:
◦ Composition and Functions of Key Management Staff
Functions and allocation of time for each key management position
sufficient to carry out the scope of project
◦ Documentation of Key Management Staff Positions
Determined by HRSA, NOT during the virtual operational site visit
◦ Process for Filling Key Management Vacancies
If any positions are open, how will the health center fill those positions?
◦ CEO Responsibilities
Directly employed by the health center through W-2, paystub,
employment agreement, or other documentation
Oversee the key management staff in day-to-day activities of the health
center
◦ HRSA Approval for Project Director/CEO Changes
If the health center has had a change (during the start of the project),
did HRSA approve it?
11. Key Management Take-Aways:
◦ Appropriate oversight of the health center program
Based on size and complexity of the organization
If you have part-time senior staff that oversee the program,
are they able to provide appropriate oversight?
The health center decides what key management and
responsibilities look like
12. Key Management Take-Aways:
◦ Vacant key management positions happen!
Health Center decides what a “key management position“ is
Ensure there is a plan/process in place to fill the position
No warm body hires (intentional hiring)
◦ Having a key position vacancy doesn’t mean an area of
non-compliance during a site visit
13. Key Management Take-Aways:
◦ CEO/Project Director
Sometimes this is NOT the same person
Public Entities (funded as co-applicant health centers) may
have a different model. The Project Director/CEO may be
directly employed by the public entity (designee of record)
To assess compliance, the Project Director/CEO should be
directly employed by the health center through W-2,
paystub, employment agreement or other documentation
An Interim CEO must still be employed by the health center
14. Best Practices:
◦ Evaluate your organizational chart and add the number
of “FTEs” to determine oversight
◦ Keep job descriptions current, especially during growth
Can become outdated
Not reflective of current practice
Difficult for accountability
Using systems to operationalize Human Resources?
◦ Notify HRSA if the CEO/Project Director changes
Done through a prior approval with EHB
Resume; Board of Director meeting minutes approval of new
CEO/Project Director
Will receive a new Notice of Funding Award when approved
15. How can a Gap Analysis Help My Community
Health Center?
16. Provides insights
regarding growth of
an organization
•Adding staff,
streamlining services
•Brick and mortar vs
tele-working
Provides insight on
the structure of the
organization
•Other lines of
business
•Reporting
relationships
19. Compliance:
◦ Coordination and Integration of Activities
Local hospitals, providers, social service organizations,
specialty providers
◦ Collaboration with Other Primary Care Providers
Includes efforts to work with other health centers in the
service area
Coordinate/integrate activities with other federally-funded,
state and local health services delivery projects
◦ Expansion of HRSA Approved Scope of Project
Not assessed on a site visit
21. Collaborative Relationships Take-Aways:
◦ Determination of collaborations is up to the
health center
Can be through MOAs, letters, minutes of coalition
meetings, emails, etc.
Can be letters of support between health centers
Can be shared referral arrangements
◦ What if you don’t have a health center in your
service area?
22. Collaborative Relationships Take-Aways:
◦ Health Centers that have special populations
funding:
Homelessness
Public Housing
Migrant and Seasonal Agricultural Worker (MSAW)
◦ “How does your health center work with special
populations?”
23. Best Practices for this program requirement:
◦ Relates to various requirements (Required and Additional
Services & Form 5A)
Evaluate what agencies/resources your community has
Keep a list of entities/individual providers you
collaborate with, OR
Determine any that you’re not collaborating with and
reach out
◦ Goal: To decrease duplication within the service
area
Able to provide services that your health center may be
unable to provide (“can’t be all things to all people”)
24. Part of various certifications
NCQA (PCMH), JACHO, HRSA, etc.
Organization reputation
Community “team player”
“Today’s patient
experience=tomorrow’s reputation”
Patient centered and focused on
social determinants of health