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HRSA 19 Program Requirements

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1 HRSA 19 Program Requirements
Helping to create healthy communities by supporting vibrant and effective community health centers HRSA 19 Program Requirements Patty Linduska, Tom Taylor, Tara Ferguson, John Middleton, Cherise Fowler & Sara Schroeder APCA Training and Technical Assistance Team

2 Agenda for January 14, 2014 8:00 to 8:30 Registration 8:30 to 10:15
Morning Session 1: Program Requirements 1-6 with emphasis on Credentialing and Privileging 10:15 to 10:30 Break 10:30 to 12:30 Morning Session 2: Program Requirements 7-11 with emphasis on Quality Improvement/Assurance Plan 12:30 to 1:30 Lunch on Your Own 1:30 to 2:30 Afternoon Session 1: Program Requirements with emphasis on Budget 2:30 to 2:45 2:45 to 4:15 Afternoon Session 2: Program Requirements with emphasis on Scope of Project Training and Technical Assistance Services & Program Outreach and Enrollment Information/Update Strengthening the Oral Health Safety Net Information/Update Patient Centered Medical Home Operational Site Visits Fee Analysis Other 4:15 to 4:30 Evaluation 1/14/2014 Training and Technical Assistance

3 Overview Health centers are non-profit private or public entities that serve designated medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless, or residents of public housing.  1/14/2014 Training and Technical Assistance

4 Overview, cont. There are 19 Key Health Center Program Requirements.
Requirements are divided into four categories: Need Services Management & Finance Governance 1/14/2014 Training and Technical Assistance

5 Program Requirement Sources
Health Center Program Statute—Section 330 of the Public Health Service (PHS) Act (42 U.S.C. §254b) Program Regulations—42 CFR Part 51c and 42 CFR Parts for Community and Migrant Health Centers Grants Regulations—45 CFR Part 74 1/14/2014 Training and Technical Assistance

6 1. Needs Assessment Requirement: Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate. (Section 330(k)(2) and section 330(k)(3)(J) of the PHS Act) 1/14/2014 Training and Technical Assistance

7 Needs Assessment Health center performs periodic needs assessments.
Assessments document the needs of its target population in order to inform and improve its delivery of appropriate services A needs assessment typically includes, but is not limited to data on: Population to Primary Care Physician FTE ratio. Percent of population at or below 200% of poverty. Percent of uninsured population. Proximity to providers who accept Medicaid and/or uninsured patients. Health indicators (e.g., diabetes, hypertension, low birth weight, immunization rates). 1/14/2014 Training and Technical Assistance

8 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance

9 2. Required and Additional Services
Requirement: Health center provides all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. (Section 330(a) of the PHS Act) NOTE: Health centers requesting funding to serve homeless individuals and their families must provide substance abuse services among their required services. (Section 330(h)(2) of the PHS Act) 1/14/2014 Training and Technical Assistance

10 Required & Additional Services
Ensures the health center is directly providing or has written arrangements and referrals in place to provide a comprehensive array of required and as necessary, additional primary and preventive services that meet the needs of the populations it serves. All services in the health center’s scope of project must be reasonably accessible and available on a sliding fee scale to health center patients. In scope referral arrangements must be formally documented in a written agreement (MOA, MOU, etc.) that at a minimum describes the manner by which the referral will be made and managed and the process for referring patients back to the health center for appropriate follow-up care. 1/14/2014 Training and Technical Assistance

11 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance

12 Required Services Required primary health services must be provided directly by the grantee or through an established arrangement11 such as through a formal agreement or through a formal referral arrangement. In addition, required services provided directly by the grantee or by formal agreements or formal referral arrangements must be offered on a sliding fee scale and available equally to all patients regardless of ability to pay. Therefore, informal referral arrangements are not acceptable for the provision of a required service. 1/14/2014 Training and Technical Assistance

13 Required Services Grantees should ensure that all agreements/contracts/arrangements with other providers and organizations comply with section 330 requirements and administrative regulations for the Department of Health and Human Services.12 Grantees should also ensure that providers for any formal arrangements/agreements are properly credentialed and licensed to perform the activities and procedures expected of them by the grantee. 1/14/2014 Training and Technical Assistance

14 3. Staffing Requirement Requirement: Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. (Section 330(a)(1),(b)(1)-(2),(k)(3)(C), and (k)(3)(I) of the PHS Act) 1/14/2014 Training and Technical Assistance

15 Staffing Requirement Staff composition and numbers must support the health center’s Clinical Performance Goals and ability to provide required and additional services. All health center providers are appropriately licensed, credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project. See BPHC credentialing and privileging policies for more information at Staffing should be culturally and linguistically appropriate for the population being served and as noted in the health center’s needs assessment. 1/14/2014 Training and Technical Assistance

16 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance

17 Credentialing & Privileging
Refer to Policy Information Notices (PINs) : Credentialing and Privileging of Health Center Practitioners : Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 1/14/2014 Training and Technical Assistance

18 Credentialing & Privileging
Credentialing: the process of assessing and confirming the qualifications of a licensed or certified health care practitioner. Primary Source Verification: Verification by the original source of a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. Secondary Source Verification: Methods of verifying a credential that are not considered an acceptable form of primary source verification. These methods may be used when primary source verification is not required. Examples of secondary source verification methods include, but are not limited to, the original credential, notarized copy of the credential, a copy of the credential (when the copy is made from an original by approved Health Center staff). Privileging/Competency: The process of authorizing a licensed or certified health care practitioner’s specific scope and content of patient care services. This is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance. 1/14/2014 Training and Technical Assistance

19 Credentialing & Privileging
ECRI Institute has a Credentialing Toolkit at their website: https://www.ecri.org/Pages/default.aspx All HRSA Grantees can request access. 1/14/2014 Supporting Toolkit Documents Right click and choose “Save as” to save the Word file on your computer. Sample Credentialing and Privileging Policy Credentialing: Step-by-Step Process Table: Comparative Summary of Requirements for Credentialing and Privileging “Licensed or Certified Health Care Practitioners” Credentialing Timeline Credentialing Application Packet Guide for Preparing Files for an FTCA Site Visit Preparing Credentialing List for FTCA Deeming Application Flowchart 1: Initial Credentialing Process Flowchart 2: Initial Privileging Process Flowchart 3: Renewal of Credentials and Privileges Peer Review/Chart Review Peer Review Checklist Training and Technical Assistance

20 Credentialing & Privileging
Comparison Summary of Requirements for Credentialing and Privileging from ECRI Institute 1/14/2014 Training and Technical Assistance

21 Credentialing & Privileging
Sample Credentialing & Privileging Policy from ECRI Institute 1/14/2014 Training and Technical Assistance

22 4. Accessible Hours of Operations / Locations
Requirement: Health center provides services at times and locations that assure accessibility and meet the needs of the population to be served. (Section 330(k)(3)(A) of the PHS Act) 01/14/2014 Training and Technical Assistance

23 4. Accessible Hours of Operations / Locations
The times/hours that services are provided are appropriate to ensure access for the health center’s patient population. For example, the health center should offer some appointments after normal work hours based on input/feedback from patients. The locations at which services are provided must be accessible to the patient population. For example, sites are generally located in the areas where the health center’s target population lives/works. 01/14/2014 Training and Technical Assistance

24 4. Accessible Hours of Operations / Locations
Appropriate consideration is taken into account in determining site/service locations and hours of operation for health centers serving special populations. For example, services are offered at migrant camps by grantees targeting migrant and seasonal farmworkers. 01/14/2014 Training and Technical Assistance

25 4. Accessible Hours of Operations / Locations
Documents / Resources to Review: Hours of Operation Most Recent Form 5B: Service Sites Service Area Map with site locations noted HRSA/BPHC Scope of Project Policies Links and Additional Resources Patient Satisfaction Survey The Samples and Template Resource Center Services Page 01/14/2014 Training and Technical Assistance

26 5. After Hours Coverage Requirement:
Health center provides professional coverage for medical emergencies during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act and 42 CFR Part 51c.102(h)(4)) 01/14/2014 Training and Technical Assistance

27 5. After Hours Coverage After hours coverage includes the provision, through clearly defined arrangements, for access of health center patients to professional coverage for medical emergencies after the center's regularly scheduled hours. Specific arrangements for after-hours coverage (such as in a rural area) may vary by community. However, all health centers must have some type of clear arrangement(s) for after hours coverage. 01/14/2014 Training and Technical Assistance

28 5. After Hours Coverage The coverage system should ensure telephone access to a covering clinician (not necessarily a health center clinician) who can exercise independent professional judgment in assessing a health center patient's need for emergency medical care and who can refer patients to appropriate locations for such care, including emergency rooms, when warranted. 01/14/2014 Training and Technical Assistance

29 5. After Hours Coverage Documents / Resources to Review:
Policy for after-hours coverage HRSA/BPHC Health Center Collaboration Program Assistance Letter Self-Assessment Tool Program Requirement 5: After Hours Coverage section, page 22, of the Health Center Site Visit Guide for HRSA Grantees Commonwealth Fund article: After-Hours and its coordination with Primary Care 01/14/2014 Training and Technical Assistance

30 6. Hospital Admitting Privileges and Continuum of Care
Requirement: Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act) 01/14/2014 Training and Technical Assistance

31 6. Hospital Admitting Privileges and Continuum of Care
All health centers must either have admitting privileges for their physicians at one or more referral hospitals, or some other arrangements that ensure continuity of care. In cases where hospital admitting privileges and membership are not possible, the health center must have firmly established arrangements for patient hospitalization, discharge planning, and tracking. 01/14/2014 Training and Technical Assistance

32 6. Hospital Admitting Privileges and Continuum of Care
Documents / Resources to Review: Hospital or other arrangements Form 5C: Other Activities / Locations Program Assistance Letter HRSA Patient-Centered Medical/Health Home Initiative AHRQ PCMH Resource Center Self-assessment tool: Program Requirement 6: Hospital Admitting Privileges and Continuum of Care section, page 23, of the Health Center Site Visit Guide for HRSA Grantees 01/14/2014 Training and Technical Assistance

33 7. Sliding Fee Discounts Requirement:
Health center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay. This system must provide a full discount to individuals and families with annual incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* No discounts may be provided to patients with incomes over 200 % of the Federal poverty guidelines.* No patient will be denied health care services due to an individual’s inability to pay for such services by the health center, assuring that any fees or payments required by the center for such services will be reduced or waived. (Section 330(k)(3)(G) of the PHS Act, 42 CFR Part 51c.303(f)), and 42 CFR Part 51c.303(u)) 01/14/2014 Training and Technical Assistance

34 7. Sliding Fee Discounts Individuals at or below 100% FPL must receive a full discount on fees for services, however a nominal fee may be charged. The fee schedule must slide/provide varying discount levels on charges to individuals between 101% and 200% of the FPL. There must be no discount for patients above 200% FPL. The fee schedule must be based on the most recent Federal Poverty Level/Guidelines, available at and must be updated annually. Patients must be notified/made aware of the availability of the sliding fee discounts. 01/14/2014 Training and Technical Assistance

35 7. Sliding Fee Discounts PIN: Clarification of Sliding Fee Discount Program Requirements A Sliding Fee Schedule may be different for health center service categories (medical, dental, behavioral health) HOWEVER The sliding fee must apply to ALL services within that category (Crowns, Dentures, etc.) 01/14/2014 Training and Technical Assistance

36 7. Sliding Fee Discounts Documents / Resources to Review
Schedule of Fees / Charges for all services in scope Sliding Fee Discount Schedule Implementing policies and procedures for the Sliding Fee Discount Schedule Sliding fee signage and notification methods Most recent Federal Poverty Guidelines HRSA/BPHC Scope of Project Policies Your grant application’s Form 3: “Income Analysis Form.” 01/14/2014 Training and Technical Assistance

37 8. Quality Improvement/ Assurance Plan
Requirement: Health center has an ongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinical services and management, and that maintains the confidentiality of patient records. The QI/QA program must include: a clinical director whose focus of responsibility is 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 and the quality of services provided or proposed to be provided to individuals served by the health center; and such assessments shall: * be conducted by physicians or by other licensed health professionals under the supervision of physicians;* be 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 health center and result in the institution of such change, where indicated.* (Section 330(k)(3)(C) of the PHS Act, 45 CFR Part (c)(2), (3) and 42 CFR Part 51c.303(c)(1-2)) Health Center Program Requirements

38 8. Program Requirement 1/14/2014 Health Center Program Requirements
In JD of Clinical Director-Lack of clear definition that QI Director is leading QI. Strengthen Minutes Peer Review Process QI/QA Program is not led by a Clinical Director. No current QI/QA plan is in place. P&P Needed for Narcotic/Pain Management which include focused clinical guidelines. Chose indicators to monitor narcotic dispensing and audit strongly. Implement and document the QI Program and meeting minutes Conduct chart audits and use the PDSA to test improvements Consider using a calendar to monitor: KPI’s And assess performance Satisfaction surveys Peer reviews Clinical guidelines do not need to be approved by board Consider doing peer reviews with like organizations Emergency management: write up codes and review as you have enough real codes to use for review in place of mock codes Fire extinguishers need to be checked (last check was 6/2013)

39 8. Program Requirement 1/14/2014 Health Center Program Requirements
d Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center.* Include periodic assessments of the appropriateness of both the utilization and quality of services? These assessments (see d, above) shall: Are these assessments (see d., above): a Be conducted by physicians or by other licensed health professionals under the supervision of physicians.* Conducted by physicians or licensed health professionals under physician supervision? b Be based on the systematic collection and evaluation of patient records.* Based on the systematic collection and evaluation of patient records? c Identify and document the necessity for change in the provision of services by the health center.* Used to identify and document necessary changes? Result in the institution of such change, where indicated.* Used to inform and change the provision of services if necessary? Health Center Program Requirements In JD of Clinical Director-Lack of clear definition that QI Director is leading QI. Strengthen Minutes Peer Review Process QI/QA Program is not led by a Clinical Director. No current QI/QA plan is in place. P&P Needed for Narcotic/Pain Management which include focused clinical guidelines. Chose indicators to monitor narcotic dispensing and audit strongly. Implement and document the QI Program and meeting minutes Conduct chart audits and use the PDSA to test improvements Consider using a calendar to monitor: KPI’s And assess performance Satisfaction surveys Peer reviews Clinical guidelines do not need to be approved by board Consider doing peer reviews with like organizations Emergency management: write up codes and review as you have enough real codes to use for review in place of mock codes Fire extinguishers need to be checked (last check was 6/2013)

40 8. Quality Improvement/ Assurance Plan
QI/QA assessments must be conducted (e.g., assessments of the appropriateness of service utilization, quality of services delivered, the health status/outcomes of health center patients) on a regular basis. The health center must have a clinical director, who may be full or part time staff, and should have appropriate training/background (MD, RN, MPH, etc.), as determined by the needs/size of the health center. Health Center Program Requirements

41 8. Quality Improvement/ Assurance Plan
The clinical director must have clear responsibility, along with other staff as appropriate, for conducting QI/QA assessments/activities. The plan includes methods for measuring and evaluating patient satisfaction. The health center must have clinical information systems in place for tracking/analyzing/reporting key performance data related to the organization’s plan. The findings of the QI/QA process are used to improve organizational performance. Health Center Program Requirements

42 Documents/Resources QI/QA Plan and related Policy and Procedures
Risk Management Policy Incident Reporting System Policy Clinical Directors Job Description HIPAA-Compliant Patient Policy and Procedures Clinical Care Policy and Procedures Clinical Information Tracking Policy and Procedures FTCA Health Center Policy Manual (if applicable) 1/14/2014 Health Center Program Requirements In JD of Clinical Director-Lack of clear definition that QI Director is leading QI. Strengthen Minutes Peer Review Process QI/QA Program is not led by a Clinical Director. No current QI/QA plan is in place. P&P Needed for Narcotic/Pain Management which include focused clinical guidelines. Chose indicators to monitor narcotic dispensing and audit strongly. Implement and document the QI Program and meeting minutes Conduct chart audits and use the PDSA to test improvements Consider using a calendar to monitor: KPI’s And assess performance Satisfaction surveys Peer reviews Clinical guidelines do not need to be approved by board Consider doing peer reviews with like organizations Emergency management: write up codes and review as you have enough real codes to use for review in place of mock codes Fire extinguishers need to be checked (last check was 6/2013) Documents/Resources to Review: 1) Quality Improvement /Quality Assurance (QI/QA) plan and related policies and procedures (including Incident Reporting System and Risk Management Policies); 2) Clinical Director’s job description; 3) HIPAA-Compliant Patient Confidentiality Policies and Procedures; 4) Clinical Care Policies and Procedures; 5) Clinical Information Tracking Policies and Procedures; 6) HRSA/BPHC Federal Tort Claims Act (FTCA) Health Center Policy Manual (if applicable).

43 Program Requirement Health center has an ongoing Quality Improvement/ Quality Assurance (QI/QA) program that: Includes clinical services and management Maintains the confidentiality of patient records. Includes a clinical director whose focus of responsibility is to support the QI/QA program and the provision of high quality patient care.* Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center.* Health Center Program Requirements Does the health center's QI/QA program: Address both clinical services and management (inclusive of all services in scope e.g., primary care, dental, behavioral health, etc.)? Maintain a clinical record for every patient receiving ongoing care at the health center? Ensure that medical records are properly secured during times when the medical record staff is not present? Include procedures to enable patients to give consent for release of medical record information? Include appropriate procedures for signing-out patient records? Include a follow-up procedure to pursue unreturned medical records? Have a clinical director? Note: clinical directors may be full or part time staff and should have appropriate training/background (e.g., MD, RN, MPH, etc.) as determined by the needs/size of the health center. Have a clinical director with clear primary responsibility for carrying out the QI/QA program across the health center, including working with other individual(s) or committee(s) as appropriate? Include periodic assessments of the appropriateness of both the utilization and quality of services? In JD of Clinical Director-Lack of clear definition that QI Director is leading QI. Strengthen Minutes Peer Review Process QI/QA Program is not led by a Clinical Director. No current QI/QA plan is in place. P&P Needed for Narcotic/Pain Management which include focused clinical guidelines. Chose indicators to monitor narcotic dispensing and audit strongly. Implement and document the QI Program and meeting minutes Conduct chart audits and use the PDSA to test improvements Consider using a calendar to monitor: KPI’s And assess performance Satisfaction surveys Peer reviews Clinical guidelines do not need to be approved by board Consider doing peer reviews with like organizations Emergency management: write up codes and review as you have enough real codes to use for review in place of mock codes Fire extinguishers need to be checked (last check was 6/2013)

44 Program Requirement These assessments (Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center) shall: Be conducted by physicians or by other licensed health professionals under the supervision of physicians.* Be based on the systematic collection and evaluation of patient records.* Identify and document the necessity for change in the provision of services by the health center.* Result in the institution of such change, where indicated.* Health Center Program Requirements d Includes periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center.* Include periodic assessments of the appropriateness of both the utilization and quality of services? Are these assessments (see d., above): Conducted by physicians or licensed health professionals under physician supervision? Based on the systematic collection and evaluation of patient records? Used to identify and document necessary changes? Used to inform and change the provision of services if necessary?

45 QI/QA Plan 11/18/2013 Training and Technical Assistance

46 Incident Reporting Policy
1/14/2014 Health Center Program Requirements

47 Risk Management Policy
1/14/2014 Health Center Program Requirements

48 Clinical Director Job Description
1/14/2014 Health Center Program Requirements

49 Quality Improvement Methodology
Developing and Implementing a QI Plan Improvement Teams Managing Data for Performance Improvement Performance Management and Measurement Quality Improvement Readiness Assessment and Developing Project Aims Redesigning a System of Care to Promote QI Testing for Improvement 1/14/2014 Health Center Program Requirements Before I go any further I wanted to talk briefly This is from the HRSA website

50 Testing for Improvement
A Preferred Approach: The Model for Improvement 1/14/2014 Health Center Program Requirements

51 Testing for Improvement
1/14/2014 Health Center Program Requirements

52 Testing for Improvement
1/14/2014 Health Center Program Requirements Tips for Successful Linked Tests of Change3 Plan multiple cycles for testing a change. Think ahead through a couple of cycles. Scale down the test size (the number of patients or location). Test with volunteers. Focus on getting consensus or buy-in from management, staff who will do the work, and patients and families. Be innovative to make the test feasible. Collect useful data during each test. Test over a wide range of conditions. Use a quick test; for example, ask "What change can we test by next Tuesday?"

53 Performance Improvement
Letters regarding Accreditation and Patient Centered Medical/Health Home Initiatives; HRSA Quality Improvement Resources; ECRI Institute Clinical Risk Management Program provided on behalf of HRSA (available to health center grantees and free clinics); HHS OIG Quality and Compliance Resources; HRSA Health Center Patient Satisfaction Survey. 1/14/2014 Health Center Program Requirements An ongoing Quality Improvement/Quality Assurance (QI/QA) program is required for health centers, and investing resources in quality improvement activities can help you meet your other quality-related goals such as moving toward the patient-centered medical home model, achieving meaningful use of health information technology, increasing clinical quality, increasing patient and staff satisfaction, and gaining third party quality recognition (accreditation and/or patient-centered medical home recognition). The Section 330 core program requirements dictate that the QI/QA program should involve periodic assessment of data from patient records, conducted or supervised by a physician, to identify areas for improvement.  In addition, health centers are required to implement changes to the way they provide services to address the areas targeted for improvement.  FTCA requirements also include board approval of the QI/QA plan every three years. In addition to these requirements, there are components that can increase the utility of your QI/QA plan: QI/QA team building and responsibility across a range of staff types Self-assessment of areas to target Setting concrete goals Identifying strategies for improvement Data collection and analysis Evaluation and dissemination of lessons learned Integration with operations and other quality-related activities

54 Resources 1/14/2014 Health Center Program Requirements
Policy and Procedure Template Quality Improvement Risk Management FTCA Incident Reporting Safety 1/14/2014 Health Center Program Requirements

55 9. Key Management Staff Requirement:
Health center maintains a fully staffed health center management team as appropriate for the size and needs of the center. Prior approval by HRSA of a change in the Project Director/Executive Director/CEO position is required. (Section 330(k)(3)(I) of the PHS Act, 42 CFR Part 51c.303(p) and 45 CFR Part 74.25(c)(2),(3)) 1/14/2014 Health Center Program Requirements

56 9. Program Requirement 11/18/2013 Training and Technical Assistance

57 9. Key Management Staff Health center has a management team that is the appropriate size and composition. Health center has a Chief Executive Officer or Executive Director/Project Director. If there has been a change in this leadership position, HRSA requires prior review and approval of this change. The management team (which may include a Clinical Director, Chief Operating Officer, Chief Financial Officer, Chief Information Officer, as appropriate for the size and complexity of the health center) is fully staffed. 1/14/2014 Health Center Program Requirements

58 Documents/Resources Health center organizational chart;
Key management staff position descriptions and biographical sketches; Key management vacancy announcements (if applicable). 1/14/2014 Health Center Program Requirements

59 Resources Chief Executive Officer/Performance Assessment
Chief Financial Officer/Job Description 1/14/2014 Health Center Program Requirements

60 10. Contractual/Affiliation Agreements
Requirement: Health center exercises appropriate oversight and authority over all contracted services, including assuring that any sub recipient(s) meets Health Center Program requirements. (Section 330(k)(3)(I)(ii), 42 CFR Part 51c.303(n), (t)) and Section 1861(aa)(4), Section 1905(l)(2)(B) of the Social Security Act, and 45 CFR Part 74.1(a)(2)) 1/14/2014 Health Center Program Requirements

61 10. Program Requirement 1/14/2014 Health Center Program Requirements

62 10. Contractual/Affiliation Agreements
The health center has the appropriate amount of oversight and the ability to maintain its independence and compliance for all contracted services and affiliation agreements. All contractual arrangements must comply with Federal procurement standards set forth in 45 CFR Part 74 (including conflict of interest standards). 1/14/2014 Health Center Program Requirements

63 10. Contractual/Affiliation Agreements
Affiliation agreements or contracts must not: Threaten the health center’s integrity. Compromise compliance with any other Program Requirements. Limit the health center’s autonomy. Health centers with sub-recipient arrangements must ensure that their sub-recipient(s) comply with all statutory and regulatory requirements applicable to section 330 grantees. 1/14/2014 Health Center Program Requirements

64 Documents/Resources Contracts for core providers, including key management staff if applicable (e.g., CMO, CIO, CFO); Contracts or MOAs/MOUs for other substantial portion(s) of the project; Sub recipient Agreement(s) if applicable; Any other key affiliation agreements if applicable; Procurement policies and procedures; HRSA/BPHC Affiliation Agreement Policy Information Notices (PINs and 98-24); Federal procurement grant regulations ( 45 CFR Part )) applicable to all contractual arrangements in scope. 1/14/2014 Health Center Program Requirements

65 Resources Your grant application’s Form 8: “Health Center Affiliation Certification and Health Center Affiliation Checklist” contains your existing agreements with other entities. PIN : Affiliation Agreements. PIN : Amendment to PIN Regarding Affiliation Agreements of Community & Migrant Health Centers. Program Assistance Letter As a self-assessment tool, please refer to the Program Requirement 10: Contractual/Affiliation Agreements section, page 32, of the Health Center Site Visit Guide for HRSA Grantees. 1/14/2014 Health Center Program Requirements

66 11. Collaborative Relationships
Requirement: Health center makes effort to establish and maintain collaborative relationships with other health care providers, including other health centers, in the service area of the center. The health center secures letter(s) of support from existing health centers (section 330 grantees and FQHC Look-Alikes) in the service area or provides an explanation for why such letter(s) of support cannot be obtained. (Section 330(k)(3)(B) of the PHS Act and 42 CFR Part 51c.303(n)) 1/14/2014 Health Center Program Requirements

67 11. Program Requirement 1/14/2014 Health Center Program Requirements

68 11. Collaborative Relationships
The health center has collaborative relationships with other appropriate providers and organizations in the area, including other health centers (section 330 grantees and FQHC Look-Alikes). Public Housing Primary Care grantees must show how residents are involved in the administration of the program. In the SAC application, health centers must have letter(s) of support from service area health centers and are encouraged to have letters from other community and health organizations. If no letters are attached, the health center must have a written explanation of why letters are not available. 1/14/2014 Health Center Program Requirements

69 Documents/Resources Letters of Support;
Memoranda of Agreement/Understanding; HRSA/BPHC Health Center Collaboration Program Assistance Letter 1/14/2014 Health Center Program Requirements

70 Resources UDS Mapper tool, available at USD Mapper (free login required). PIN 97-27: Affiliation Agreements of Community and Migrant Health Centers. PIN 98-24: Amendment to PIN Regarding Affiliation Agreements of Community and Migrant Health Centers. Program Assistance Letter (PAL) : Health Center Collaboration As a self-assessment tool, please refer to the Program Requirement 11: Collaborative Relationships section, page 34, of the Health Center Site Visit Guide for HRSA Grantees. 1/14/2014 Health Center Program Requirements

71 Financial Management & Control Policies
What do I need ? Accounting & Internal Control systems that are appropriate to the organization and reflect Generally Accepted Accounting Principles (GAAP) Are appropriate to the size and complexity of the organization Reflects Generally Accepted Accounting Principles (GAAP) Separates functions in a manner appropriate to the organization’s size in order to safeguard assets and maintain financial stability Date Published Departmnent/Title of Slides Relates to Program Requirement #12

72 Financial Management & Control Policies
Policies & Processes that safeguard the organization’s asset Purchase, payroll, disbursements. Billing Collections Corporate Compliance Financial Management Financial Management and Control Policies Key Management Staff Miscellaneous 11/18/2013 Training and Technical Assistance Relates to Program Requirement #12

73 Financial Management & Control Policies
Audit Submission Health center assures that: An annual independent audit is performed IAW Federal audit requirements A corrective action plan addressing all findings, questioned costs, reportable conditions, and material weaknesses cited in the Audit report 11/18/2013 Training and Technical Assistance Relates to Program Requirement #12

74 Financial Management & Control Policies
Audit Submission As an example some questions from a review of Newly Funded Health Center: Are the grantee’s accounting and internal control systems: Appropriate to the organization’s size and complexity? Reflective of GAAP? Designed to separate functions and safeguard assets? Designed to separate functions and safeguard financial stability Is the Audit performed annually IAW Federal requirements? Does corrective action plan address all findings? Does the Board review the grantee’s corrective action regularly? 11/18/2013 Training and Technical Assistance Relates to Program Requirement #12

75 Relates to Program Requirement #12
Audit Submission In September 2010, the Office of Management and Budget issued Interim Final Guidance in the Federal Register (Volume 75, No. 177, September 14, 2010, 2 CFR Part 170) to establish reporting requirements necessary for the implementation of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L. 109–282), as amended by section 6202 of Public Law 110–252.  According to Part 3 of the A-133 Compliance Supplement dated June 2012, the auditor’s compliance testing shall include the following key data elements: Subaward Date Subaward DUNS # Subaward Amount Subaward Obligation/Action Date Date of Report Submission Subaward Number 11/18/2013 Training and Technical Assistance Relates to Program Requirement #12

76 Relates to Program Requirement #13
Billing & Collections Must have systems in place to maximize collections and reimbursements for its costs in providing health services, which include: Written and documented billing policies and procedures in place to maximize reimbursement Collection policies and procedures in place to maximize reimbursement Credit policies and procedures in place to maximize reimbursement Must also bill Medicare, Medicaid, CHIP, and other applicable public or private third party payors 11/18/2013 Training and Technical Assistance Relates to Program Requirement #13

77 Relates to Program Requirement #13
Billing & Collections Managing Accounts receivable – money owed to the business Accounts payable – money owed by the business Billing and collections convert account receivable into readily available income 11/18/2013 Training and Technical Assistance Relates to Program Requirement #13

78 Relates to Program Requirement #14
Budget Must establish a budget that reflects the costs of operations, expenses, and revenues ( including the Federal grant) necessary to accomplish the servicers delivery plan, i.e. “Total Budget” Your grant application Form3 “Income Analysis Form” displays your budgetary assumptions “total budget” or “operational budget” which includes section 330 grant funds and all other sources of revenue in support of the approved health center scope of project; and “non-grant funds” which refers to the sources of revenue other than section 330 grant funds, including program income, that are budgeted and accounted for under the approved health center scope of project. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

79 Federal Object Classes
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80 Choose a Budget Approach
Line-Item budget Program–based budget Income–based budget Capital budget 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

81 Line – Item Budget The line-item budget is a method of presenting an overall categorical picture of your agency’s income and expense items. It gives you an at-a-glance look at what your expected income and expenses will be for a given period Net Patient Revenue $100,000 Federal Grants 500,000 Other Grants and Contributions 150,000 Total Income $750,000 Expenses Salaries Benefits Payroll taxes 93,750 Professional Fees 45,000 Supplies IT & Communication 15,000 Occupancy 50,000 R&M and Small Equipment 25,000 Insurance 3,700 Travel 2,500 Total Expenses $1,649,950 Excess/ (Defecit) ($899,950) 11/18/2013 Training and Technical Assistance

82 The program-based budget has two purposes.
First, to isolate the activities of individual programs from one another. Second, it segregates program expenses from administrative or fundraising costs. Income Medical Dental Administrative Fundraising Total Net Patient Revenue $700,000 $300,000 $0 $1,000,000 Federal Grants 400,000 100,000 - $500,000 Other Grants and Contributions 125,000 25,000 $150,000 Total Income $1,225,000 $425,000 $1,650,000 Expenses Salaries $422,000 $200,000 $120,000 $8,000 $750,000 Benefits 84,400 40,000 24,000 1,600 Payroll taxes 52,750 15,000 1,000 $93,750 Professional Fees 4,200 8,000 32,000 800 $45,000 Supplies 340,300 150,000 8,500 1,200 IT & Communication 9,650 5,000 350 $15,000 Occupancy 36,500 12,000 1,500 $50,000 R&M and Small Equipment 17,000 $25,000 Insurance 2,200 300 $3,700 Travel 650 450 1,400 $2,500 Depreciation 9,800 4,500 700 Total Expenses $979,450 $454,150 $203,750 $12,600 $1,649,950 Excess/ (Defecit) $245,550 ($29,150) ($203,750) ($12,600) $50 11/18/2013 Training and Technical Assistance

83 Relates to Program Requirement #14
Income – Based Budget The income – based budget starts the budget process with income rather than expenses – and NOT JUST ANY income but with realistic and probable income. Certain – Income already received or committed and available to spend. Reasonably certain – income fairly certain to be received that can be spent on next year’s activities. Uncertain/Possibility – Income that has not been applied for, promised, received in the past, or has difficult conditions attached. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

84 Relates to Program Requirement #14
Capital Budget Two fundamental things to remember about budgeting capital items: Capital purchases (land, buildings, and generally items over the capitalization threshold) require their own budget and financial treatment. Separate budget and separate sources of income. The capital budget and the annual operating budget do not exist independently. Remember capital purchases do not flow through as expenses, however increases related to those purchases will, (i.e. debt service, insurance, utilities, janitorial) Outlines the expenditures and corresponding income required to acquire or replace fixed assets or to keep them in good repair usually over a multi-year basis. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

85 8 Steps to Preparing a Successful Budget
Plan your budget timeline Step One Identify goals and priorities for the upcoming budget year Step Two Develop income and expense projections to the end of the current FY Step Three 11/18/2013 Training and Technical Assistance

86 8 Steps to Preparing a Successful Budget
Analyze budget-to-actual variances for the current FY Step Four Budget income FIRST Step Five Develop expense projections Step Six 11/18/2013 Training and Technical Assistance

87 8 Steps to Preparing a Successful Budget
Balance expenses to projected income Step Seven Finalize board approved budget before the new year begins Step Eight 11/18/2013 Training and Technical Assistance

88 Relates to Program Requirement #14
Budgeting Budgeting - How does a budget differ from a forecast? Budgets are summaries of short-term operational activities. A firm may prepare a cash budget to predict cash inflows and outflows or, a production budget to plan its production levels. Budgets are quantitative representations. A forecast is a prediction, and usually there are many ifs and buts before a forecast resembles reality. A forecaster cannot shape the events. In contrast, a budget is a plan based on facts, events in progress, actions planned, etc. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

89 Budgeting Tools and Tips
Personnel is usually the single largest component of a nonprofit organization’s budget so ensuring that personnel budgets are accurate is very important. Developing a template for budgeting personnel costs can be helpful. Creating a salary matrix that contains existing and anticipated staff positions, the current or expected salary ( setting the matrix up to allow for merit increase adjustments is helpful) and current fringe benefits can help to ensure budgeted personnel costs are accurate and complete. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

90 Relates to Program Requirement #14
Budget limitations Salary Limitation The Consolidated Appropriations Act, 2012 (P.L ) limits the salary amount that may be awarded and charged to HRSA grants. Award funds may not be used to pay the salary of an individual at a rate in excess of Federal Executive Level II of the Federal Executive Pay scale (currently $179,700). This amount reflects an individual’s base salary exclusive of fringe benefits and income that an individual may be permitted to earn outside of the duties to your organization (i.e., the rate limitation only limits the amount that may be awarded and charged to HRSA grants). This salary limitation also applies to sub-awards/subcontracts under a HRSA grant. Salary Limitation – Actual vs. Claimed Current Actual Salary Individual’s actual base full time salary: $225,000 (50% of time will be devoted to the project). Direct Salary $112,500 (225000/2) Fringe (25% of salary) $28,125 Total $140,625 Amount of Actual Salary Eligible to be Claimed on the Application Budget due to the Legislative Salary Limitation Individual’s base full time salary adjusted to Executive Level II: $179,700 (50% of time will be devoted to the project). Direct Salary $89,850 (179700/2) Fringe (25% of salary) $22,462 Total $112,312 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

91 Budgeting Tools and Tips
Fringe benefits can range from 10 to 15% of the total budget Use caution when applying predetermined average rates which include the cost of health coverage and time sensitive benefits such as pension contributions In many organizations the cost to the employer of family coverage is 25-30% higher than the cost of individual coverage Be sure to budget healthcare premiums net of any amounts recovered from employees through payroll deductions. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

92 Relates to Program Requirement #14
Things to Consider Creating spreadsheets for those grants that do not coincide with the annual budgeting cycle can help ensure- That only available funds are included in the subsequent year’s budget. That grant budget line items are within appropriate variance ranges prior to budgeting the subsequent year’s expenditures Often grant budgets that have exceeded allowable line item variances are identified and appropriate action can be taken to revise the grant in a timely manner. 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

93 Things to Consider Developing and applying an equitable system of distributing common costs to departments and divisions is a challenge for most nonprofits – examples include Copier supplies and maintenance costs Telephone connectivity and usage costs Postage Office and other supply costs Establishing a negotiated indirect rate with a federal agency can alleviate much of this allocation work It is important to ensure that once departments have budgeted common costs the sum of the parts equals the actual total cost. 11/18/2013 Training and Technical Assistance

94 Things to Consider Budgeting is a required part of every nonprofit organization Budgets have a due date – you should never enter a fiscal year without an approved budget Timelines are helpful in keeping the budgeting process on track Personnel are a nonprofits greatest asset and greatest cost and should be budgeted with great care and confidentiality Fringe benefits (excluding certain fixed state and federal taxes) can vary greatly between organizations within an organization 11/18/2013 Training and Technical Assistance

95 Things to Consider Creating templates for grants that cross fiscal years can be helpful in ensuring that only unspent funds are budgeted Common costs such as office supplies, copiers, telephone and postage can post budgeting challenges Negotiating an indirect rate with a primary funder can help to alleviate allocation challenges 11/18/2013 Training and Technical Assistance

96 Monitoring the Budget Once the budget is complete it should not be put on a shelf Department and division leaders responsible for developing the budget should receive monthly budget to actual reports Significant variances from the budget should be addressed immediately and proactively rather than waiting until year end Management should be analyzing departmental variances each month and ensuring that significant items are addressed The Board of Director’s financial reports should include, at a minimum, an organization wide budget to actual comparison Reports to management and the Board should be accompanied by a written narrative explaining significant variances and action plans in place to address them 11/18/2013 Training and Technical Assistance

97 Summary Budgeting: The Road Map to Success
Where Are We Going? Know the Rules of the Road 11/18/2013 Preventive and Regular Maintenance Check-ups Keep You in the Driver Seat Are We There Yet? Training and Technical Assistance Drive Defensively Bumps Along the Road

98 To successfully accomplish your program or project objectives within budget, all of the organization’s staff must be on the same road, moving in the same direction 11/18/2013 Training and Technical Assistance

99 Relates to Program Requirement #14
Budget It’s MY Budget. I can buy what I want. Right? 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

100 Relates to Program Requirement #14
Budget 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

101 Relates to Program Requirement #14
Budget Execution Laws Misappropriation Act [Title 31, U.S. Code, Sec 1301] Anti-Deficiency Act [Title 31, U.S. Code, Sec 1341 & 1517 ] Bona Fide Need Rule Over a century ago, the Comptroller of the Treasury stated, “An appropriation should not be used for the purchase of an article not necessary for the use of a fiscal year in which ordered merely in order to use up such an appropriation.” 11/18/2013 Training and Technical Assistance Relates to Program Requirement #14

102 Program Data Reporting Systems
Health center has systems which accurately collect and organize data for program reporting and which support management decision making Have systems, including Management Information Systems (MIS) in place that can accurately collect and produce data to support oversight and direction Submit accurate and timely reports as required Submit complete Clinical and Financial Performance Measures Form with its annual application to demonstrate performance improvement 11/18/2013 Training and Technical Assistance Relates to Program Requirement #15

103 Program Data Reporting Systems
Managing by objectives helps identify where the goals should be set in terms of importance Productivity measures for Registration Average # of patient registered per hour Average waiting time in registration Average time to register a new patient Number of registration errors: (Examples) *Patient type incorrect *Duplicate accounts not deleted timely *Insurance changes not flagged *Insurance subscriber incorrect Productivity measures for the business office Percentage of accurate and completed encounter forms Percentage of rejected bills Number of billing errors: (Examples) *Incorrect or omitted modifiers *CPT/ICD mismatch *Error when adding a charge * No referring doctor or consult 11/18/2013 Training and Technical Assistance

104 Program Data Reporting Systems
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105 Financial Management Webinars
Webinar Name Basics of Financial Management Accounting Accounting for Grants Accounting for Healthcare Budgeting Nuts and Bolts Budgeting for Grants GAAP How Does a GAAP Aid in Healthcare How to Use Excel for GAAP Accounting Cost Accounting Principles Cost Accounting for Grants Accounting for Federal Grants What Is the Difference Between Budgetary Basis Accounting and GAAP Accounting Billing & Collections 11/18/2013 Training and Technical Assistance

106 16. Scope of Project (45 CFR Part 74.25) Requirement:
Health center maintains its funded scope of project (sites, services, service area, target population, and providers), including any increases based on recent grant awards. (45 CFR Part 74.25) 1/14/2014 Training and Technical Assistance

107 Scope of Project The section 330 approved Scope of Project stipulates what the total grant-related project budget supports (including program income and other non-section 330 funds). Five core elements: Services, Sites, Providers, Target Population, Service Area. Changes in scope may affect eligibility and coverage. Significant changes in scope must be approved by HRSA/BPHC See Scope of Project policies for further guidance at Health centers must maintain their approved and funded scope of project in terms of number of patients served, visits, services available, providers, and/or sites. 1/14/2014 Training and Technical Assistance

108 Scope of Project FIVE CORE ELEMENTS OF SCOPE OF PROJECT
Five core elements constitute scope of project and address these fundamental questions: Where will services be provided (service sites)? What services will be provided (services)? Who will provide the services (providers)? What geographic area will the project serve (service area)? Who will the project serve (target population)? (excerpt from PIN ) 1/14/2014 Training and Technical Assistance

109 Scope of Project Scope of project defines:
the activities that the total approved section 330 grant-related project budget supports; the parameters for using these grant funds; the basis for Medicare and Medicaid Federally Qualified Health Center reimbursements; Federal Tort Claims Act coverage; 340B Drug Pricing eligibility; and other essential benefits. Therefore, proper recording of scope of project is critical in the oversight and management of programs funded under section 330 of the PHS Act. (excerpt from PIN ) 1/14/2014 Training and Technical Assistance

110 Scope of Project A health center’s scope of project is important because it: Stipulates the total approved section 330 grant-related project budget, specifically defining the services, sites, providers, target population, and service area for which grant funds have been approved. This total project budget includes program income and other non-section 330 funds. Determines the maximum potential scope of coverage (subject to certain exceptions) of the Federal Tort Claims Act (FTCA) program that provides medical malpractice coverage for deemed health centers and most individual employees . 1/14/2014 Training and Technical Assistance

111 Scope of Project Provides the necessary site information which enables covered entities to purchase discounted drugs for their patients under the section 340B Drug Pricing Program. Defines the approved service sites and services necessary for State Medicaid Agencies to calculate payment rates under the Prospective Payment System (PPS) or other State-approved alternative payment methodology. Defines the approved service sites necessary for the Centers for Medicare and Medicaid Services (CMS) to determine a health center’s eligibility for Federally Qualified Health Center (FQHC) Medicare all-inclusive rate. 1/14/2014 Training and Technical Assistance

112 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance 16.A Program Requirement

113 17. Board Authority Requirement:
Health center governing board maintains appropriate authority to oversee the operations of the center, including: holding monthly meetings; approval of the health center grant application and budget; selection/dismissal and performance evaluation of the health center CEO; selection of services to be provided and the health center hours of operations; measuring and evaluating the organization’s progress in meeting its annual and long-term programmatic and financial goals and developing plans for the long-range viability of the organization by engaging in strategic planning, ongoing review of the organization’s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance;* and establishment of general policies for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) NOTE: In the case of public centers (also referred to as public entities) with co-applicant governing boards, the public center is permitted to retain authority for establishing general policies (fiscal and personnel policies) for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304(d)(iii) and (iv)) NOTE: Upon a showing of good cause, the Secretary may waive, for the length of the project period, the monthly meeting requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p). (Section 330(k)(3)(H) of the PHS Act) 1/14/2014 Training and Technical Assistance

114 Board Authority Health center’s board: Meets monthly.
Health centers with approved waivers ONLY: Appropriate strategies are in place to ensure regular oversight, if the board does not meet monthly. Reviews and approves the annual health center (renewal) application and budget. Conducts an annual review of the CEO’s performance (with clear authority to select a new CEO and/or dismiss the current CEO if needed). 1/14/2014 Training and Technical Assistance

115 Board Authority Health center’s board:
Reviews and approves the services to be provided and the health center’s hours of operation. Measures and evaluates the health center’s progress in meeting annual and long term clinical and financial goals. Engages in strategic and/or long term planning for the health center. 1/14/2014 Training and Technical Assistance

116 Board Authority Health center’s board:
Reviews the health center’s mission and bylaws as necessary on a periodic basis. Receives appropriate information that enables it to evaluate health center patient satisfaction, organizational assets, and performance. Establishes the general policies, which must include, but are not limited to: personnel, health care, fiscal, and quality assurance/improvement policies for the organization (with the exception of fiscal and personnel policies in the case of a public agency grantee in a co-applicant arrangement). 1/14/2014 Training and Technical Assistance

117 Board Authority For Public Center Grantees with Co-Applicant Arrangements ONLY—Public center (entity) grantee of record has a formal co-applicant agreement that stipulates Roles, responsibilities, and the delegation of authorities. Any shared/split responsibilities between the public center and co-applicant board. 1/14/2014 Training and Technical Assistance

118 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance 17.A Program Requirement

119 18. Board Composition Requirement:
The health center governing board is composed of individuals, a majority of whom are being served by the center and, this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex. Specifically: Governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.* The remaining non-consumer members of the board shall be representative of the community in which the center's service area is located and shall be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.* No more than one half (50%) of the non-consumer board members may derive more than 10% of their annual income from the health care industry.* (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) NOTE: Upon a showing of good cause the Secretary may waive, for the length of the project period, the patient majority requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p). 1/14/2014 Training and Technical Assistance

120 Board Composition A majority (at least 51%) of the board members receive services (i.e., are patients) at the health center. As a group, the “patient/consumer” board members must reasonably represent the individuals who are served by the health center in terms of race, ethnicity, and sex. NOTE: There is no established ratio for board members to population served; however, board composition must be reasonably representative of the populations being (i.e., race, ethnicity, sex) served. Health centers with approved waivers ONLY–appropriate strategies are in place to ensure consumer/patient participation and input from the target population (given board is not 51% consumers/patients) in the direction and ongoing governance of the organization. 1/14/2014 Training and Technical Assistance

121 Board Composition Health centers that receive part of their section 330 funding to serve special populations and are not eligible for a waiver—the board includes representation from/for these special populations group(s), as appropriate (e.g., an advocate for the homeless, the director of a Migrant Head Start program, a formerly homeless individual). The board has between 9 and 25 members. The size of the board is appropriate for the complexity of the organization and the diversity of the community served. 1/14/2014 Training and Technical Assistance

122 Board Composition The board includes a member (or members) with expertise in any of the following: Community affairs Local government Finance and banking Legal affairs Trade union and other commercial and industrial concerns Community social service agencies No more than 50% of the non-consumer board members may derive more than 10% of their annual income from the health care industry. 1/14/2014 Training and Technical Assistance

123 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance 18A. Program Requirement

124 19. Conflict of Interest Policy
Requirement: Health center bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the health center. No board member shall be an employee of the health center or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board.* (45 CFR Part and 42 CFR Part 51c.304(b)) 1/14/2014 Training and Technical Assistance

125 Conflict of Interest Policy
The bylaws or other policy documents include a conflict of interest provision(s). No current board member(s) is an employee of the health center or an immediate family member of an employee. The CEO/Program Director does not participate as a voting member of the board. 1/14/2014 Training and Technical Assistance

126 Conflict of Interest The health center’s conflict of interest policy must address such issues as: disclosure of business and personal relationships, including nepotism, that create an actual or potential conflict of interest; extent to which a board member can participate in board decisions where the member has a personal or financial interest; using board members to provide services to the center; board member expense reimbursement policies; acceptance of gifts and gratuities; personal political activities of board members; and statement of consequences for violating the conflict policy. 1/14/2014 Training and Technical Assistance

127 Conflict of Interest When section 330 grantees procure supplies and other expendable property, equipment, real property, and other services, the health center's conflict of interest policy must also address the following: The health center grantee must have written standards of conduct governing the performance of its employees engaged in the award and administration of contracts. No health center employee, board member, or agent may participate in the selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of interest would be involved. Such a conflict would arise when a health center employee, board member or agent, or any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for an award. 1/14/2014 Training and Technical Assistance

128 Conflict of Interest The board members, employees, and agents of the health center grantee shall neither solicit nor accept gratuities, favors, or anything of monetary value from contractors, or parties to sub-agreements. However, recipients may set standards for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value. The standards of conduct must provide for disciplinary actions to be applied for violations of such standards by board members, employers, or agents of the health center grantee. 1/14/2014 Training and Technical Assistance

129 Related Operational Site Visit Information
1/14/2014 Training and Technical Assistance 19A. Program Requirement


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