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.

1. www.compliantfqhc.com
Continuous Compliance Series- It’s not JUST an
OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Michelle Layton BSN, MBA
marketing@fqhcwebinar.com

2. Chapter 4
Required and Additional Health
Services

3. Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG).
 This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
 Not employed by MSCG or BPHC.
 Independent Consultant who is contracted to conduct Operational
SiteVisits (OSV), provideTechnical Assistance and assist health
centers with preparation for their OSV.
 This information should not be considered legal advice.
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned
parties.

4. Purpose of the Compliatric Series
 HRSA’s evaluation of compliance during COVID-19 continues via
Virtual Operational SiteVisits (VOSV)
 Provides an overview of the health center program requirements
 Provides updates to the SiteVisit Protocol andVOSV Process
 Provides tips on “What to Expect”
 Provides tips on “How to Prepare”
 Provides a reviewer perspective

5. Purpose of the Compliatric Series
 Compliance maintains HRSA funding
◦ Non-compliance can impact other Federal Programs (i.e., FTCA)
 Continuous Compliance supports high performing health centers
◦ Eliminates the chaos of having to “prepare”
◦ Develops operational excellence for the health center

6. Agenda
 Requirements for Compliance
 Evaluation of Compliance
 Maintaining Continuous Compliance
 Clinical Reviewer Insight
 Question and Answer Session

7. Requirements for Compliance

8. Requirements for Compliance
 Health center must provide required services
◦ Substance Abuse Services are considered a required service if
receiving 330(h) funding
 Health center “may” provide additional and specialty
services
◦ Must be appropriate for the health center’s patient population
◦ Must be approved by HRSA

9. Requirements for Compliance
Element a: Providing and Documenting Services
within Scope of Project
The health center provides access to all services included in its
HRSA-approved scope of project (Form 5A) through one or more
service delivery methods
 Directly (Form 5A, Column I)
 Formal Written Contract (Column II, health center pays)
 Formal Written Referral Arrangement (Column III, health center does not pay)

10. Requirements for Compliance
What is Scope of Project?
The health center’s scope of project defines the activities
supported by the Health Center Program project budget.
Specifically, scope of project defines the approved service
sites, services, providers, service area(s) and target
population(s).
Scope of Project | Bureau of Primary Health Care (hrsa.gov)

11. Requirements for Compliance
What is Scope of Project?
 Form 5A – Defines the service being provided and method of
service delivery
 Form 5B – Identifies site(s) where services on Form 5A are
provided
 Form 5C – Outlines other activities the health center may be
conducting, such as health fairs, nursing home rounds, etc.
* The focus of Chapter 4 is on Form 5A and the associated agreements

12. Requirements for Compliance
What is Form 5A?
 Outlines the Required,Additional and Specialty Services provided
by the health center.
 Defines the method utilized to deliver services:
◦ Column I – Services are provided directly by W-2 employees, volunteers or
National Health Service Corps.
◦ Column II – Services are provided through a formal written contract which the
health center pays for. This includes 1099 staff who provide services on site.
◦ Column III – Services are provided through a formal written referral
arrangement which the health center does NOT pay for.

16. Requirements for Compliance
Contract Language for Column II Services
 How the service will be documented in the patient’s medical record
 How the health center will pay for the service
 Appropriate credentialing and privileging of the provider for the
contracted service, per Chapter 5,“Clinical Staffing” of the Health
Center Compliance Manual
 Sliding Fee Language

17. Requirements for Compliance
Contract Language for Column III Services
 The manner by which referrals are made and managed
 The process for tracking and referring patients back to the health
center for appropriate follow-up care
 Appropriate credentialing and privileging of the provider for the
referred service, per Chapter 5,“Clinical Staffing” of the
Compliance Manual
 Sliding Fee Language

18. Requirements for Compliance
Work-arounds for Clinical Contract Language
 Column II formal written contracts:
◦ Compliance can be demonstrated through internal operating procedures that
address how the service will be documented in the patient’s medical record.
*Column II contracts must still include how the health center will pay for the
service
 Column III formal written referral arrangements:
◦ Compliance can be demonstrated through internal referral tracking procedures
that address how referrals are made and managed, as well as the process for
tracking.

19. Requirements for Compliance
Review of Contracts/Agreements and Patient
Records
 Column II Services
◦ At least one, but no more than three written
contracts/agreements for EACH Required and EACH Additional
Service
◦ Based on three Required and two Additional Health Services:
Review three to five patient records for patients who have
received these services in the past 24 months

20. Requirements for Compliance
Review of Contracts/Agreements and Patient
Records
 Column III Services
◦ At least one, but no more than three written referral
arrangements for EACH Required and EACH Additional Service
◦ Based on three Required and two Additional Health Services:
Review three to five patient records for patients who have
received these services in the past 24 months

21. Requirements for Compliance
 Health center must address the needs of Limited
English Proficiency (LEP) patient population
◦ Arrangements for translation services
◦ Translation of key health center documents in languages
appropriate to the patient population (i.e., health education
materials, new patient packet)
◦ Provide guidance to staff regarding cultural sensitivities (i.e.,
cultural competency training)
 What is the magic number?
◦ Not clearly defined in the HRSA Compliance Manual

22. Requirements for Compliance
Element b: Ensuring Access for Limited English
Proficient Patients
Health center patients with Limited English Proficiency
(LEP) are provided with interpretation and translation (i.e.,
bilingual providers, on-site interpreters, video/remote
interpretation services) that ensure reasonable access to
health center services.
* Translation should be reflective of the patient population

23. Requirements for Compliance
Element c: Providing Culturally Appropriate Care
The health center makes arrangements and/or provides
resources (i.e., training) that enable staff to deliver
services in a manner that is culturally sensitive and bridges
linguistic and cultural differences
* Cultural competency training for all staff

24. Evaluation of Compliance

25. Evaluation of Compliance
 Virtual Tour(s)
 Review of Form 5A for accuracy
 Review of contracts/agreements and formal written referral
arrangements for Column II and Column III services
 Review of Referral Tracking Policy and Procedures
 Review of patient samples for Column II and Column III
services and any Column I service not observed during the
tour
 Review of translated patient documentation/handouts
 Verification of Cultural Competency Training

26. Maintaining Continuous
Compliance

27. Maintaining Continuous Compliance
 Form 5A should be a working document that is reflective of the
operations of the health center
 Utilize the HRSA Self-Assessment Worksheet to evaluate Form 5A
on a regular basis
 Scope must be accurate for the purposes of
◦ Medicare/Medicaid FQHC Reimbursement
◦ FTCA Coverage
◦ 340B Drug Pricing Program Benefits

29. Maintaining Continuous Compliance
 Involve key leadership with the management of Form 5A
 Review contracts/agreements on a regular basis
 Review Referral and Lab/DiagnosticTestTracking Policies and
Procedures on a regular basis
 Perform medical record audits to ensure compliance with Referral
and Lab/DiagnosticTest Tracking procedures.

30. Maintaining Continuous Compliance
 Evaluate the needs of your patient population on a
regular basis
◦ Language
◦ Literacy Levels
◦ Access to services
 Administer patient satisfaction surveys on a regular
basis and address areas in need of improvement
◦ Mini-survey
◦ Focused survey

31. Clinical Reviewer Insight
 Just because a service is provided at a health center site does not
mean it is a Column I Service
 Just because a service is provided directly and through a formal
referral arrangement does not mean it needs to be listed in both
Column I and Column III
 All services provided via formal contracts that the health center
pays for must be listed in Column II
 Providing bus tokens to patients is considered a Column I service
 340B Pharmacy services are considered a Column II service

32. Clinical Reviewer Insight
 Telehealth is a mechanism for service delivery. Services
provided via telehealth should be documented on Form
5A like all other services
 If you are unsure of which Column a service should be
listed in, submit the question to HRSA
 Remember that Form 5A should be a working
document and will change as the health center adds or
removes services

33. Resources for Completing Form 5A
Form 5A Service Descriptors
Service Descriptors for Form 5A: Services Provided
Form 5A Column Descriptors
Form 5A Service Delivery Methods

34. Resources for Completing Form 5A
Policy Information Notice (PIN) 2008-01
Defining Scope of Project and Policy for Requesting
Changes
Program Assistance Letter (PAL) 2020-01
Telehealth and Health Center Scope of Project

35. Additional Resources
Compliatric
https://www.compliatric.com/
HRSA Health Center Compliance Manual
Health Center Compliance Manual
Health Center Program SiteVisit Protocol
SiteVisit Protocol

36. Additional Resources
Health Center Self-AssessmentWorksheet for Services
Provided
Form 5A Self-AssessmentWorksheet
Health Resources and Services Administration
Scope of Project

37. Questions & Answers

38. Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
marketing@fqhcwebinar.com