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HRSA 19 Program Requirements Patty Linduska, Tom Taylor, Tara Ferguson, John Middleton, Cherise Fowler & Sara Schroeder APCA Training and Technical Assistance.

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Presentation on theme: "HRSA 19 Program Requirements Patty Linduska, Tom Taylor, Tara Ferguson, John Middleton, Cherise Fowler & Sara Schroeder APCA Training and Technical Assistance."— Presentation transcript:

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

3 A GENDA FOR J ANUARY 14, /14/2014 Training and Technical Assistance 2 8:00 to 8:30Registration 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 Break 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

4 O VERVIEW  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 3

5 O VERVIEW, 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 4

6 P ROGRAM R EQUIREMENT S OURCES  Health Center Program Statute—Section 330 of the Public Health Service (PHS) Act (42 U.S.C. §254b)  ml ml  Program Regulations—42 CFR Part 51c and 42 CFR Parts for Community and Migrant Health Centers  idx?c=ecfr;sid=f141dbc68d6d3a084d2177ebbe01e543;rgn=di v5;view=text;node=42: ;idno=42;cc=ecfr idx?c=ecfr;sid=f141dbc68d6d3a084d2177ebbe01e543;rgn=di v5;view=text;node=42: ;idno=42;cc=ecfr  idx?c=ecfr;sid=56fe3e657938f6c32805f19f4cbca824;rgn=div5; view=text;node=42: ;idno=42;cc=ecfr idx?c=ecfr;sid=56fe3e657938f6c32805f19f4cbca824;rgn=div5; view=text;node=42: ;idno=42;cc=ecfr  Grants Regulations—45 CFR Part 74  idx?c=ecfr&sid=9de47029ddc8d e389e539f183&rgn= div5&view=text&node=45: &idno=45 idx?c=ecfr&sid=9de47029ddc8d e389e539f183&rgn= div5&view=text&node=45: &idno=45 1/14/2014 Training and Technical Assistance 5

7 1. N EEDS A SSESSMENT 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 6

8 N EEDS A SSESSMENT  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 7

9 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance 8

10 2. R EQUIRED AND A DDITIONAL S ERVICES 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 9

11 R EQUIRED & A DDITIONAL S ERVICES  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 10

12 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance 11

13 R EQUIRED S ERVICES  Required primary health services must be provided directly by the grantee or through an established arrangement 11 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 12

14 R EQUIRED S ERVICES  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 13

15 3. S TAFFING R EQUIREMENT 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 14

16 S TAFFING R EQUIREMENT  Staff composition and numbers must support the health center’s Clinical Performance Goals and ability to provide required and additional services.  A LL 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 risk.html. risk.html  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 15

17 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance 16

18 C REDENTIALING & P RIVILEGING  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 /14/2014 Training and Technical Assistance 17

19 C REDENTIALING & P RIVILEGING  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 18

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

21 C REDENTIALING & P RIVILEGING  Comparison Summary of Requirements for Credentialing and Privileging from ECRI Institute 1/14/2014 Training and Technical Assistance 20

22 C REDENTIALING & P RIVILEGING  Sample Credentialing & Privileging Policy from ECRI Institute 1/14/2014 Training and Technical Assistance 21

23 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 22

24 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 23

25 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 24

26 4. Accessible Hours of Operations / Locations Documents / Resources to Review: Hours of Operation Most Recent Form 5B: Service SitesForm 5B 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 Services Page 01/14/2014 Training and Technical Assistance 25

27 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 26

28 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 27

29 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 28

30 5. After Hours Coverage Documents / Resources to Review: Policy for after-hours coverage HRSA/BPHC Health Center Collaboration Program Assistance Letter Program Assistance Letter Self-Assessment Tool Program Requirement 5: After Hours Coverage section, page 22, of the Health Center Site Visit Guide for HRSA GranteesHealth 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 29

31 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 30

32 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 31

33 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 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 GranteesHealth Center Site Visit Guide for HRSA Grantees 01/14/2014 Training and Technical Assistance 32

34 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 33

35 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 34

36 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 35

37 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.”Form 3 01/14/2014 Training and Technical Assistance 36

38 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 37

39 8. Program Requirement 1/14/2014 Health Center Program Requirements 38

40 8. Program Requirement 1/14/2014 Health Center Program Requirements 39 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? d Result in the institution of such change, where indicated.* Used to inform and change the provision of services if necessary?

41 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 40

42 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 41

43 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 42

44 Program Requirement 1.Health center has an ongoing Quality Improvement/ Quality Assurance (QI/QA) program that: a.Includes clinical services and management b.Maintains the confidentiality of patient records. c.Includes a clinical director whose focus of responsibility is to support the QI/QA program and the provision of high quality patient care.* 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.* Health Center Program Requirements 43

45 Program Requirement 2.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: a.Be conducted by physicians or by other licensed health professionals under the supervision of physicians.* b.Be 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.* d.Result in the institution of such change, where indicated.* Health Center Program Requirements 44

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

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

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

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

50 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 html 1/14/2014 Health Center Program Requirements 49

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

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

53 Testing for Improvement 1/14/2014 Health Center Program Requirements 52

54 Performance Improvement  Letters regarding Accreditation and Patient Centered Medical/Health Home Initiatives;Accreditation and Patient Centered Medical/Health Home Initiatives  HRSA Quality Improvement Resources;Quality Improvement Resources  ECRI Institute Clinical Risk Management Program provided on behalf of HRSA (available to health center grantees and free clinics);Clinical Risk Management Program  HHS OIG Quality and Compliance Resources;Quality and Compliance Resources  HRSA Health Center Patient Satisfaction Survey.Patient Satisfaction Survey 1/14/2014 Health Center Program Requirements 53

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

56 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 55

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

58 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 57

59 Documents/Resources 1)Health center organizational chart; 2)Key management staff position descriptions and biographical sketches; 3)Key management vacancy announcements (if applicable). 1/14/2014 Health Center Program Requirements 58

60 Resources  Chief Executive Officer/Performance Assessment managementandfinance/epeformanceassessment.pdf  Chief Financial Officer/Job Description managementandfinance/chieffinancialofficerjobdescripti on.pdf 1/14/2014 Health Center Program Requirements 59

61 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 60

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

63 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 62

64 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 63

65 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 64

66 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 65

67 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 66

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

69 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 68

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

71 Resources  mentandfinance/affiliationsbetweenhealthcentersandothercom munitybas.pdf mentandfinance/affiliationsbetweenhealthcentersandothercom munitybas.pdf   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 70

72 Financial Management & Control Policies Date Published Departmnent/Title of Slides 71  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  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 Relates to Program Requirement #12

73 Financial Management & Control Policies 11/18/2013 Training and Technical Assistance 72 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 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 Relates to Program Requirement #12

74 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 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 73 Relates to Program Requirement #12 Financial Management & Control Policies

75 Audit Submission  As an example some questions from a review of Newly Funded Health Center: o 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 o Is the Audit performed annually IAW Federal requirements? o Does corrective action plan address all findings? o Does the Board review the grantee’s corrective action regularly? Audit Submission  As an example some questions from a review of Newly Funded Health Center: o 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 o Is the Audit performed annually IAW Federal requirements? o Does corrective action plan address all findings? o Does the Board review the grantee’s corrective action regularly? 11/18/2013 Training and Technical Assistance 74 Relates to Program Requirement #12 Financial Management & Control Policies

76 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 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 75 Relates to Program Requirement #12

77 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 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 76 Relates to Program Requirement #13

78 Billing & Collections 11/18/2013 Training and Technical Assistance 77 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 Relates to Program Requirement #13

79 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. 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 78 Relates to Program Requirement #14

80 11/18/2013 Training and Technical Assistance 79 Federal Object Classes

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

82 Line – Item Budget 11/18/2013 Training and Technical Assistance 81 Net Patient Revenue$100,000 Federal Grants500,000 Other Grants and Contributions150,000 Total Income$750,000 Expenses Salaries$750,000 Benefits150,000 Payroll taxes93,750 Professional Fees45,000 Supplies500,000 IT & Communication15,000 Occupancy50,000 R&M and Small Equipment25,000 Insurance3,700 Travel2,500 Total Expenses$1,649,950 Excess/ (Defecit)($899,950) 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

83 Program–Based Budget 11/18/2013 Training and Technical Assistance 82 IncomeMedicalDentalAdministrativeFundraisingTotal Net Patient Revenue$700,000$300,000$0 $1,000,000 Federal Grants 400, , $500,000 Other Grants and Contributions 125,000 25, $150,000 Total Income$1,225,000$425,000$0 $1,650,000 Expenses Salaries$422,000$200,000$120,000$8,000$750,000 Benefits 84,400 40,000 24,000 1,600$150,000 Payroll taxes 52,750 25,000 15,000 1,000$93,750 Professional Fees 4,200 8,000 32, $45,000 Supplies 340, ,000 8,500 1,200$500,000 IT & Communication 9,650 5, $15,000 Occupancy 36,500 12,000 1,500 -$50,000 R&M and Small Equipment 17,000 8, $25,000 Insurance 2,200 1, $3,700 Travel ,400 -$2,500 Depreciation 9,800 4, $15,000 Total Expenses$979,450$454,150$203,750$12,600$1,649,950 Excess/ (Defecit)$245,550($29,150)($203,750)($12,600)$50 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. 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.

84 Income – Based Budget 11/18/2013 Training and Technical Assistance 83  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. The income – based budget starts the budget process with income rather than expenses – and NOT JUST ANY income but with realistic and probable income. Relates to Program Requirement #14

85 Capital Budget 11/18/2013 Training and Technical Assistance 84 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. Relates to Program Requirement #14

86 8 Steps to Preparing a Successful Budget 11/18/2013 Training and Technical Assistance 85

87 8 Steps to Preparing a Successful Budget 11/18/2013 Training and Technical Assistance 86

88 8 Steps to Preparing a Successful Budget 11/18/2013 Training and Technical Assistance 87

89 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. 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 88 Relates to Program Requirement #14

90 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. 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 89 Relates to Program Requirement #14

91 Budget limitations 11/18/2013 Training and Technical Assistance 90 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 Relates to Program Requirement #14

92 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.  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 91 Relates to Program Requirement #14

93 Things to Consider  Creating spreadsheets for those grants that do not coincide with the annual budgeting cycle can help ensure- o That only available funds are included in the subsequent year’s budget. o 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.  Creating spreadsheets for those grants that do not coincide with the annual budgeting cycle can help ensure- o That only available funds are included in the subsequent year’s budget. o 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 92 Relates to Program Requirement #14

94 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 o Copier supplies and maintenance costs o Telephone connectivity and usage costs o Postage o 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.  Developing and applying an equitable system of distributing common costs to departments and divisions is a challenge for most nonprofits – examples include o Copier supplies and maintenance costs o Telephone connectivity and usage costs o Postage o 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 93

95 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  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 94

96 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  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 95

97 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  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 96

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

99 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 98

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

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

102 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.” 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 101 Relates to Program Requirement #14

103 Program Data Reporting Systems 11/18/2013 Training and Technical Assistance 102 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 Relates to Program Requirement #15

104 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 103

105 Program Data Reporting Systems 11/18/2013 Training and Technical Assistance 104

106 Financial Management Webinars 11/18/2013 Training and Technical Assistance 105 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

107 16. S COPE OF P ROJECT 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 106

108 S COPE OF P ROJECT  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 ance.html. ance.html  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 107

109 S COPE OF P ROJECT  F IVE C ORE E LEMENTS O F S COPE O F P ROJECT  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 108

110 S COPE OF P ROJECT  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 109

111 S COPE OF P ROJECT  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 110

112 S COPE OF P ROJECT  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 111

113 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance A Program Requirement

114 17. B OARD A UTHORITY 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 113

115 B OARD A UTHORITY  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 114

116 B OARD A UTHORITY  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 115

117 B OARD A UTHORITY  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 116

118 B OARD A UTHORITY  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 117

119 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance A Program Requirement

120 18. B OARD C OMPOSITION 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 119

121 B OARD C OMPOSITION  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 120

122 B OARD C OMPOSITION  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 121

123 B OARD C OMPOSITION  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 122

124 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance A. Program Requirement

125 19. C ONFLICT OF I NTEREST P OLICY 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 124

126 C ONFLICT OF I NTEREST P OLICY  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 125

127 C ONFLICT OF I NTEREST  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 126

128 C ONFLICT OF I NTEREST  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 127

129 C ONFLICT OF I NTEREST  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 128

130 R ELATED O PERATIONAL S ITE V ISIT I NFORMATION 1/14/2014 Training and Technical Assistance A. Program Requirement


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