health center program site visit report · jeremy sharrard ahs hr compliance auditor yes no no...

This report has been prepared on behalf of the Health Resources and Services Administration, Bureau of Primary Health Care

(HRSA/BPHC) for the purposes of oversight and guidance of HRSA/BPHC programs. The report contains final findings and

recommendations reviewed and approved by HRSA/BPHC. This report identifies any findings of non-compliance with

Health Center program requirements and may also include a review of clinical and financial performance.

of 31

Health Center Program Site Visit Report

TA Request Details

TA Request Number: TA001669

Grantee Information: Alameda County Health Care Services Agency 1900 Fruitvale Ave.

Oakland, CA

Contact: Damon Francis, M.D

[email protected]; (510) 532-1930

Type of Visit: Operational Site Visit

Date(s) of Visit: August 18 – 21, 2015

Consultants

Carol Lightsey (Team Leader - Board Authority); [email protected]; (201) 833-9219

Barbara Rosa (Clinical); [email protected]; (415) 285-5057

Karen White (Financial); [email protected]; (641) 777-5186

Site Visit Participants

Name Title Interviewed Entrance Exit

Damon Francis, M.D. Interim

Director/HCH

Medical Director

Yes Yes Yes

Nancy Halloran HCSA Policy

Director

Yes Yes Yes

David Cox AHS CFO Yes Yes Yes

Guy Qvistgaard AHS Chief

Ambulatory

Organization

Yes Yes No

John Chapman AHS Highland

CAO

Yes Yes Yes

David Modershach Grant

Manager/Special

Yes Yes Yes





of 31

Operations

Suzanne Warner HCH Deputy

Director

Yes Yes Yes

Heather Fine Manager @ AHS Yes Yes Yes

Quyen Tran HCH Fiscal

Manager

Yes Yes Yes

Kinkini Baneyee AHS Trustee Yes Yes Yes

Rebecca Gebhart Health Department

Finance Director

Yes Yes No

Dave Brown Supervisor Chan’s

Office

Yes Yes No

Jody Copeland Director of Finance Yes No No

Rick Kibler Internal Audit Yes No No

Margaret Loomis Director of Billing Yes No No

Heather MacDonald Finance Yes No No

Catherine Wada Finance Dept.

Contracts

Yes No No

April Bass Patient Access Yes No No

Don Wright VP of Revenue

Cycle

Yes No No

Jeremy Sharrard AHS HR

Compliance

Auditor

Yes No No

Barry Zorthian AHS Trustee Yes No No

Jim Lugamani AHS Trustee(On

Phone)

Yes No No

Kathleen Clanon, MD HCSA Medical

Director

Yes No Yes

Cherrie Rondon Departmental

Personal Officer

Yes No No

Kyndall K. Bayard Sentry Data

Systems, Inc. 340B

Yes No No

Satira Dalton Giovannetti AHS Medical Staff

Services Director

Yes No No

Mark Maus, MD Medical Director,

Eastmont Clinic

Yes No No

Holly Garcia, RD Medical Home

Manager

Yes No No

Jamie Bowers Pharmacist Yes No No





of 31

Charles Brucklier HRSA/BPHC

Project Officer

Yes Yes Yes

Program Requirement Compliance Review Summary

Program Requirement Compliance Review Compliance Status

1. Needs Assessment Met

2. Required and Additional Services Met

3. Staffing Requirement Met

4. Accessible Hours of Operation/Locations Met

5. After-Hours Coverage Met

6. Hospital Admitting Privileges and Continuum of Care Met

7. Sliding Fee Discounts Met

8. Quality Improvement/Assurance Plan Not Met

9. Key Management Staff Met

10. Contractual/Affiliation Agreements Met

11. Collaborative Relationships Met

12. Financial Management and Control Policies Met

13. Billing and Collections Not Met

14. Budget Met

15. Program Data Reporting Systems Met

16. Scope of Project Not Met

17. Board Authority Not Met

18. Board Composition Met

19. Conflict of Interest Policy Met





of 31

Section 1. Need - Program Requirement #1

Program Requirement #1 - Needs Assessment

Health center demonstrates and documents the needs of its target population, updating its service

area, when appropriate. (Section 330(k)(2) and (k)(3)(J) of the PHS Act)

Compliance Status: Met.

Documents reviewed onsite or in advance:

Most recent Needs Assessment(s)

Service Area Map

UDS patient origin data

Health center’s list of sites with service area zip codes (Form 5B)

Other: Point-in-Time Homeless Count

Compliance Review Findings:

Alameda County Health Care Services Agency (ACHCSA) has a comprehensive Needs

Assessment from 2014-2015 of Health Care Needs of People Experiencing Homelessness in

Alameda County, which defines and describes the target population and specific service areas

where sites and/or services are provided. There was a map provided for review of all areas

presently being served by either fixed sites or the mobile van. These sites correspond to Form

5B and are consistent with the zip codes of patient origins presented on the most current UDS.

The Needs Assessment is constantly being updated. It is an ongoing effort of the staff and is

being organized by a Key Management Staff member, David Modershach, who has and

continues to cover a broad overview of demographics of more than 10,000 individuals

experiencing homelessness who utilize the county’s homeless services.





of 31

Section 2. Services - Program Requirement #2

Program Requirement #2 - Required and Additional Services

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) and (h)(2) of the PHS Act)



Health center’s official Scope of Project for services (Form 5A)

Clinical Practice Protocols and/or other policies and procedures that support the delivery of

health center services

Contracts, MOAs, MOUs, etc. for services provided via formal written agreements and/or formal

written referral arrangements, including general tracking and referral policies and procedures


ACHCSA provides all required health care for the homeless, adult primary care, prevention, and

emergency care through a sub-recipient arrangement with the Alameda Health Services (AHS), a

public entity in Alameda County with its ambulatory clinics and Highland Hospital’s emergency

and inpatient services and Fairmont Hospital’s rehabilitation and long-term care services.

Pediatric and obstetrical care is also provided through this sub-recipient arrangement via a

referral to the pediatric or OB practices at AHS sites if the patient is determined to be homeless.

There are formal contracts for dental services with LifeLong Medical Services, and for

behavioral health and the required HCH substance abuse services with East Oakland Recovery

Center and Second Chance, non-profit organizations in the county. ACHCSA has a 340B

contract with CVS Pharmacy. Radiology services are provided at San Leandro Hospital through

a formal contract.

Form 5A is incorrect and the finding will be addressed in PR #16.

The sub-recipient agreement between the ACHCSA and the AHS is extremely detailed and describes how referrals are made and managed using language contained within the BPHC Program Requirements. Since AHS is providing all the medical care for homeless patients; the systems in place for all patients receiving primary care in the AHS system are applied to the homeless population.

The sub-recipient agreement and other service contracts address each party’s responsibilities in following up with referrals and care provided inside and outside the system, including documentation requirements and payment arrangements. Staff is assigned to track referrals,





of 31

follow-up with hospitalized patients, and case manage complicated patients. There are written internal policies and procedures for staff to use in tracking outside care and services. AHS created a Homeless Coordinating Program with a Homeless Coordination Advisory Committee that meets monthly to address and remedy the barriers homeless patients experience in receiving services from the system.

Alameda County is an extremely culturally diverse county with dozens of languages spoken by

county residents. The orientation brochure for the services provided to the homeless patients has

access information in eight different languages and there are 30 languages spoken by the in-

house staff at the various sites where homeless patients are seen. Additionally, each permanent

clinic site has the access information posted on the walls in the eight most common languages.

All staff completes annual training on how to access interpreter services. There is a contract with

a language line service for the few languages that are not available on site. Each of the clinics

have phone numbers to call after hours posted on the outside doors. The central appointment

number is accessible to hard of hearing clients and each clinic site has the ability to converse

with hearing impaired clients through designated phone lines in the system.


Program Requirement #3 - Staffing

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)



Staffing Profile

Provider contracts, agreements, and any subrecipient arrangements related to staffing (as

applicable)

Credentialing and Privileging Policies and/or Procedures

Documentation of provider licensure or certification for all licensed or certified health center

practitioners

Privileging Lists


Through its sub-recipient agreement with AHS and the other service contracts, the ACHCSA

Health Care for the Homeless Program is appropriately staffed with Family Practitioners,





of 31

Internists, Pediatricians, OB-GYNs, NPs, PAs, Dentists, Dental Hygienists, Pharmacists, and

LCSWs, who are supported by RNs, LPNs, MAs, Dental Hygienists and Dental Assistants.

The providers associated with the Healthcare for the Homeless Program are credentialed and

privileged according to the Medical Staff Bylaws of AHS. There is a written Credentialing and

Privileging Policy and Procedure that is part of those bylaws, which has been reviewed and

approved by the AHS Board of Trustees. The Medical Staff Services of AHS is responsible for

all credentialing and privileging activities for LIPs and maintains a database of providers’

records through a software program called ECHO. The Human Resources Department of AHS

and of ACHCSA use primary source verification for credentialing all other certified and licensed

employees of both entities. A review of a sampling of licensed staffs credential files reveals

complete documentation and primary source verification. The files are extraordinarily well

organized and up-to-date. The National Practitioner Data Bank is queried on a continuous basis.

The process meets all the requirements of PIN 2002-22 and includes an appeals process for those

providers who are not re-privileged, and a process for providing temporary privileges. There is a

privileging form that is filled out by each candidate and reviewed and approved by the

Credentialing Committee of the medical staff.


Program Requirement #4 - Accessible Hours of Operation / Locations

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)



Hours of operation for health center sites

Most recent Form 5B: Service Sites (Note that the form lists only the TOTAL number of hours

per week each site is open, not the specific schedule.)

Form 5C: Other Activities/Locations

Service Area Map with site locations noted


ACHCSA, through its subrecipient agreement with AHS, operates four primary care clinics

throughout the county that are open Monday through Friday, 8:30 a.m. to 5 p.m. Two of those

clinics have half-day Saturday hours and the Same Day Clinic at Highland Hospital is open

Monday through Sunday, from 8 a.m. to 5 p.m. ACHCSA also operates two mobile health vans

that are currently awaiting resolution of staffing/labor union issues to resume drop-in medical

services. The vans currently provide enabling services and staff assist patients in registering for





of 31

health insurance and housing assistance. All fixed clinic sites are near transit centers and are bus

accessible. Additionally, AHS provides bus shuttles from the Bay Area Rapid Transit (BART)

System’s stations to the clinics and Highland Hospital.


Program Requirement #5 – After-Hours Coverage

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))



Health center’s After-Hours Coverage Policies and/or Procedures

Agreements, systems and/or contracts that support after-hours coverage, if applicable

Most recent Form 5A: Services Provided, see Coverage for Emergencies During and After

Hours


The sub-recipient, AHS, provides after-hours coverage for all ACHCSA homeless patients

through the sub-recipient agreement. After-hours services are provided by OakCare, a private

physician group serving AHS patients, including the homeless, as well as by physicians

employed directly by ACHSCA. Those providers are part of the Union of American Physicians

and Dentists. Additionally, there is a nurse advice line that takes the initial call and refers to the

on-call physician when appropriate. The clinics have brochures describing how to access the

after-hours services by using the regular clinic phone number. See PR #2 for details on LEP and

disability access.


Program Requirement #6 - Hospital Admitting Privileges and Continuum of

Care

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)





of 31



Hospital admitting privileges agreements/documentation

Most recent Form 5C: Other Activities/Locations (If applicable, hospitals where health center

providers have admitting privileges should be noted on the form.)


Through its sub-recipient agreement with AHS, the homeless patients have access to Highland Hospital, Fairmont Hospital and San Leandro Hospital with the vast majority of patients receiving in-patient services at Highland Hospital. There are written internal policies and procedures for staff to follow to track and follow-up on patients who were seen in the ER or who were hospitalized, as well as procedures to follow when the clinic is sending a patient to the ER. All MDs are able to admit to Highland Hospital, but generally use the hospitalist group at Highland to manage inpatient care. Providers have access to hospitalization records through electronic portals of the shared EHR, NextGen. Continuity of care is maintained by a program created expressly for the homeless patients called the Homeless Focus Care Team, which participates in discharge planning for all high risk patients, arranges respite care as appropriate, and develops transition plans through a sub-set of staff known as the Transitions Team.


Program Requirement #7 - Sliding Fee Discounts

Health center has a system in place to determine eligibility for patient discounts adjusted on the

basis of the patient’s ability to pay. (Section 330(k)(3)(G) of the PHS Act and 42 CFR Part

51c.303(f) and (u))



Schedule of Fees/Charges for all services in scope

Sliding Fee Discount Schedule/Schedule of Discounts (often referred to as the Sliding Fee Scale)

Policies for the Sliding Fee Discount Program

Supporting operating procedures for the Sliding Fee Discount Program

Documents/forms that support the eligibility process for the Sliding Fee Discount Program





of 31


The health center and sub-recipient have a system in place to determine eligibility for patient

discounts adjusted on the basis of the patient’s ability to pay. Patients whose incomes are at or

below 100% of the Federal Poverty Guidelines (FPG) do not have to pay. As a homeless only

grantee, patients whose incomes fall between 100% and 200% of the FPG also receive a full

discount. Patients whose incomes are over 200% of the FPG are not offered a sliding fee (SF)

discount. These patients, however, are available for a charity care policy of Alameda Health

System (AHS), a public hospital authority.

No patient will be denied health care services due to an individual’s inability to pay. The Sliding

Fee Schedule discount categories are determined based on income level and family size. The

2015 Federal Poverty Guidelines are being utilized. Provisions are in place to evaluate the

Sliding Fee Program annually to assure that financial barriers to care are minimized.

The Fee Schedule is consistent with locally prevailing rates or charges and designed to cover the

reasonable costs of operation.

The health center has written, Board-approved policies and procedures that include all of the

required language listed in PIN 2014-02, that support the implementation of the Sliding Fee

Discount Program, and which assure that it is applied equally to all eligible patients. The Sliding

Fee Discount Schedule allows for three discount categories between 100% and 200% of the FPL.

Each of these categories permit a full discount as allowed as homeless only grantee. The SF

Policy includes definitions of income and family size.

Provisions are in place to assure that if a patient is insured by a public or private third-party

payor and the patient’s cost-sharing amount is more than the amount that would have been

charged as an uninsured patient who participates in the Sliding Fee Discount Program (SFDP),

the health center will reduce the cost-sharing amount to the applicable SFDS level as permitted

by the public or private third-party payor contract.

Signs are available in the check-in area to communicate the availability of the Sliding Fee Scale

discount for qualified patients. The SFS applies to all services within the approved Scope of

Project. Contracts for services provided on Form 5A, Column III, include appropriate sliding fee

language. All new patients will have the SFSD explained to them during the registration process.

All notices are written in appropriate languages and literacy levels of the health center patients.

The health center’s population speaks primary English, Spanish or Mandarin; however, staff is

available to interpret in 37 different languages and other languages are available via a language

line.





of 31


Program Requirement #8 - Quality Improvement / Assurance Plan

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. (Section 330(k)(3)(C) of the PHS Act, 45 CFR Part 74.25 (c)(2)-(3), and 42 CFR Part

51c.303(c)(1)-(2))

Compliance Status: Not Met.


Quality Improvement/Quality Assurance (QI/QA) Plan and related and/or supporting policies

and/or procedures (e.g., Incident Reporting System, Risk Management Policies, Patient Safety

Policies)

Clinical Director’s job description

HIPAA-compliant Patient Confidentiality and Medical Records Policies and/or Procedures

Clinical Care Policies and/or Procedures

Clinical Information Tracking Policies and/or Procedures


The ACHCSA Healthcare for the Homeless Program collects and reports UDS data, but it does

not have a formal mechanism or structure for monitoring services and quality. The sub-recipient,

AHS, provides the majority of medical care, but at this time, it also does not have a formal

mechanism for systematically monitoring care and services and making improvements based on

outcomes. Metrics are collected throughout the AHS system and there is an Ambulatory Care

draft QI Plan that has not been finalized. ACHCSA has constituted a Homeless Coordination

Advisory Committee that addresses specific issues for the homeless patients, and the committee

has had three meetings with some time spent focusing on discussing barriers that homeless

patients experience in trying to access health services, but there is no organized process to

implement improvements using principles of QI, such as PDSAs or root cause analysis.

The sub-recipient, AHS, uses NextGen EHR and every patient has their own record. All patients sign a release of information form at their initial registration. Privacy is maintained through job descriptions that give access permissions to the patient’s EHR.

If Not Met - Steps/Actions Recommended for Compliance:

A Quality Management Program must be described in a written Board-approved document that

identifies the mission, scope, participation, logistics, goals, actions and expected outcomes of the

program.





of 31

A committee must be formed or existing committees restructured to review and monitor data and

recommend areas for improvement. A clinician must be identified who will be the chair of the

Quality Committee with support coming from the Homeless Program Manager and the Medical

Home Manager who has AHS responsibility for developing data reports. Meeting minutes must

document the quality activity and outcomes of the improvement work.

ACHCSA must develop a methodology to regularly report homeless-specific data to the co-

applicant BOD or Board of Trustees and senior management that can be used to identify and

document changes to services and systems that will improve the quality of care, help meet

performance goals, and bring the homeless program up to and exceeding national standards.

The BPHC has many other excellent resources available at the following website to assist

organizations in the development of quality management programs:

http://bphc.hrsa.gov/technicalassistance/resourcecenter/clinicalservices/.

Additional online resources can be found at: http://www.ihi.org , a nationally recognized health

care organization focused on improving health outcomes across the spectrum of delivery

organizations.

The Program Manager and Medical Home Manager were sent a QI/QA Committee Meeting

Minutes Template from the ECRI Institute’s website: https://www.ecri.org. This organization

works with health centers across the country to develop Quality and Risk Management programs

that address the needs of FQHCs.

http://bphc.hrsa.gov/technicalassistance/resourcecenter/clinicalservices/

http://www.ihi.org/

https://www.ecri.org/





of 31

Section 3. Management and Finance - Program Requirement #9

Program Requirement #9 - Key Management Staff

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))



Health center Organizational Chart

Key Management Staff position descriptions and biographical sketches

Key management vacancy announcements (if applicable)

Health center’s official Scope of Project for services and sites (Form 5A and Form 5B)

UDS Summary Report

Other: Organizational Chart from sub-recipient and job descriptions


ACHCSA has a CEO in place who is currently in an interim position. The current Interim CEO,

Dr. Damon Francis, is very knowledgeable of the Alameda County’s Health Care for the

Homeless Program and has worked as a provider and administrator in the program for a few

years. He is very capable in overseeing the program in its interim position and has garnered trust

and respect from his Key Management Staff and the sub-recipient contractors’ key management.

There is a current search in place to find a permanent CEO for this program.

Because this grantee is a public entity, the relationship(s) and sub-recipient agreement presented

for review during this OSV were reviewed as related to having the organizational structure and

positions in place to ensure appropriate oversight of the program with the staff as described with

each entity’s Table of Organizations; this was found to be appropriate. Specific Table of

Organizational Charts of the grantee and its sub-recipient can be found on the grantee’s EHB’s

most recent SAC.





of 31


Program Requirement #10 - Contractual/Affiliation Agreements

Health center exercises appropriate oversight and authority over all contracted services,

including assuring that any subrecipient(s) meets Health Center Program requirements. (Section

330(k)(3)(I)(ii) of the PHS Act, 42 CFR Part 51c.303(n) and (t), Section 1861(aa)(4) and

1905(l)(2)(B) of the Social Security Act, and 45 CFR Part 74.1(a)(2))



Contract(s) or sub-award(s) (subrecipient agreements) for a substantial portion of the Health

Center Project

Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial portion of the

Health Center Project

Contract with another organization for core primary care providers

Contract with another organization for staffing the health center including any contracted Key

Management Staff (e.g., CEO, CMO, CFO)

Any other key affiliation agreements, if applicable

Procurement and/or other policies and/or procedures that support oversight of contracts or

affiliations

Other: Alameda County General Services Agency’s County Selection (Contracting) Guidelines


ACHCSA is a public entity that has embraced the HRSA/BPHC requirements that comply with

this Program Requirement. There were policies and procedures presented that represented the

language of both the State of California as well as federal regulations. These policies provide

departmental contracting staff with information as to what qualifies or disqualifies an individual

from being placed on a county Selection Committee formed for the purpose of evaluating and

ranking bidders competing for a county contract that has been accepted by the Governance Board

of the grantee. Adherence to these guidelines serves to prevent a conflict of interest, or even the

appearance of a conflict of interest while following and mirroring the language of the

HRSA/BPHC’s requirements in accordance with the statute.

It should be noted that none of the contract agreements reviewed illustrated that the grantee has

compromised its position in following all of its BPHC regulations and requirements of the grant.





of 31


Program Requirement #11 - Collaborative Relationships

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))



Letters of Support

Memoranda of Agreement/Understanding

Other relevant documentation of collaborative relationships


ACHCSA has established and maintained a variety of collaborative relationships with

other health care providers, including other health centers, throughout Alameda County and its

contiguous areas. The grantee has secured over 10 Letters of Support, including the

Alameda County Consortium that includes other FQHCs for caring and servicing the Homeless

Population within the county. Because the grantee is a public entity, it has resources to a myriad

of services for behavioral health, oral health and specialty services provided throughout the

county. The program also works with other programs throughout the county that focus on

providing services to the homeless population. These organizations include but are not limited to

the following:

Alameda Health System - sub-recipient

Community Health Clinic and Medical Homes (FQHCs); i.e., Lifelong Medical Care, La

Clinica de la Raza, Tri City Health Center, Axis Community Health

Street Medicine Outreach Partners

Drug/Alcohol Recovery Partners

Alameda County Behavioral Health Care Services

Other HCHP Homeless Health Care and social services that include shelter, housing and

services information





of 31


Program Requirement #12 - Financial Management and Control Policies

Health center maintains accounting and internal control systems appropriate to the size and

complexity of the organization reflecting Generally Accepted Accounting Principles (GAAP)

and separates functions appropriate to organizational size to safeguard assets and maintain

financial stability. Health center assures an annual independent financial audit is performed in

accordance with Federal audit requirements, including submission of a corrective action plan

addressing all findings, questioned costs, reportable conditions, and material weaknesses cited in

the Audit Report. (Section 330(k)(3)(D) and (q) of the PHS Act and 45 CFR Parts 74.14, 74.21,

and 74.26)



Most recent independent financial audit and Management Letter, including audit Corrective

Action Plans based on prior year audit findings, if applicable

Most recent A-133 Compliance Supplement (grantees only)

Financial Management/Accounting and Internal Control Policies and/or Procedures

Chart of Accounts

Balance Sheet

Income Statement

Most recent Health Center Program required Financial Performance Measures/UDS Report


Within the Alameda County Health Care Services Agency (ACHCSA) (the grantee), the

Alameda County Health Care for the Homeless Program (ACHCHP) is housed within the

Community Health Services Division, and reports to the Director of the Public Health

Department, to the County Health Officer and the Director of the Agency.

The health center maintains the accounting and internal control systems appropriate to the size

and complexity of the organization reflecting Generally Accepted Accounting Principles

(GAAP) and separates functions appropriate to the organizational size to safeguard assets and

maintain financial stability. ACHCSA has established a set of written, Board-approved financial

policies and procedures that were last reviewed and updated in April 2015.

An independent financial audit is performed in accordance with federal audit requirements. The

most recent audit for the fiscal year ending June 30, 2014, reported an unmodified opinion with

no material weakness and no significant deficiencies and no matters of non-compliance material

to financial statements. The review of the Federal Awards portion of the audit did not identify





of 31

any internal control concerns, material weaknesses, or significant deficiencies. Since the health

center did not have any reportable conditions, a Corrective Action Plan is not necessary.

An independent financial audit is performed in accordance with federal audit requirements for

the sub-recipient, AHS. The most recent audit for the fiscal year ending June 30, 2014, reported

an unmodified opinion with no material weakness, one significant deficiency, and no matters of

non-compliance material to financial statements. The significant deficiency relates to the

eligibility requirement of the HIV Care Formula grants.

A variety of software products are used within the county and AHS. For accounting software

ACHCSA uses Alcolink, a countywide web-based tool hosted by Oracle/PeopleSoft that captures

all financial transactions through the auditor’s office. ACHCSA also utilizes Grant Expenditure

Management System (GEMS). This tool was developed by the public health department to

capture expenditure by budget/cost center for each public health program. Transactions that post

in the Alcolink system are directly transmitted to GEMS. GEMS can be manually adjusted by

public health department level administration staff, working in collaboration with program staff,

to address delays in Alcolink posting and transmissions. AHS uses Lawson accounting software.

These software products appropriately collect, organize, and report financial data. These systems

have the capacity to accumulate and record expenditures by each cost category within the grant.

The Chart of Accounts is sufficiently detailed to provide for allocation of revenue and expenses

by grant. There are adequate compensating controls for authorization and approval of grantee

issued checks. Federal transactions are tracked via the use of a grant code in the general ledger.

All revenue and expense transactions pertaining to the federal grant utilize this grant code.

The Board of Supervisors receives encounters, the grant budget, and data related to a contract,

but they do not receive a profit and loss for the program. Internally, the quarterly expenditure

report goes to the key management team. The Board of Trustees for AHS receives monthly

financial statements for the organization and recently began receiving financial statements for the

health services program.


Program Requirement #13 - Billing and Collections

Health center has systems in place to maximize collections and reimbursement for its costs in

providing health services, including written billing, credit and collection policies and procedures.

(Section 330(k)(3)(F) and (G) of the PHS Act)






of 31


Policies and/or procedures for billing and collection

Most recent Health Center Program required Financial Performance Measures/UDS Report

Other: Form 5B


ACHCSA and/or AHS have systems in place to maximize (see exception below) collections and

reimbursement for its costs in providing health services, including written Board-approved,

Billing, Credit and Collection Policies and Procedures. Neither entity has a Refusal to Pay

Policy. All charges are waived for homeless patients; any staff person can approve after the

eligibility process has been completed and homeless status has been verified.

AHS does not have a separate Medicare FQHC billing number for its sites. It does, however,

have FQHC Medicaid billing numbers and does in fact receive a cost-based reimbursement rate

for all Medicaid encounters for the sites listed on Form 5B. AHS documents participation in all

Medicaid and CHIP programs. It participates in other third-party payors as appropriate, either on

a participating or non-participating basis.

The health center and sub-recipient make reasonable efforts to secure payment from patients for

amounts owed for services based on the established Sliding Fee Discount Schedule in a manner

that assures that no patient will be denied services based on an inability to pay. AHS makes

every realistic effort to collect reimbursement for services provided to persons covered by

private insurance.


Each site within the Scope of Project must have a separate Medicare FQHC billing number.

Revenue cannot be maximized if enhanced reimbursement (Medicare) is not received for all

eligible services. As noted on the Notice of Awards: “Grantees are reminded that separate

Medicare enrollment applications must be submitted for each ‘permanent unit’ at which they

provide services. This includes units considered both ‘permanent sites’ and ‘seasonal sites’ under

their HRSA Scope of Project. (For the definition of permanent and seasonal sites under the

Scope of Project, see Section III of Program Information Notice 200801, Defining Scope of

Project and Policy for Requesting Changes at:

http://bphc.hrsa.gov/policy/pin0801/definingscope.htm. Therefore, for Medicare purposes, a

single health center organization may consist of two or more FQHCs, each of which must be

separately enrolled in Medicare and submit bills using its unique Medicare Billing Number.”

AHS must apply for Medicare numbers for the following sites: Highland, Eastmont, Hayward

and Newark.

http://bphc.hrsa.gov/policy/pin0801/definingscope.htm





of 31


Program Requirement #14 - Budget

Health center has developed a budget that reflects the costs of operations, expenses, and revenues

(including the Federal grant) necessary to accomplish the service delivery plan, including the

number of patients to be served. (Section 330(k)(3)(D) and (k)(3)(I)(i) of the PHS Act and 45

CFR Part 74.25)



Annual budget

Most recent Income Analysis (Form 3)

Most recent Staffing Profile


ACHCSA has a budget that reflects the costs of operations, expenses, and revenues necessary to

accomplish the service delivery plan, including the number of patients to be served. The budget

includes the $3,694,751 of federal funds authorized on the Notice of Award dated August 5,

2015.

The budget is based on an analysis of historical data, current year data, trends, and known

information about the upcoming fiscal year and incorporates goals and objectives developed

from the organization-wide planning process. The budget includes information from the sub-

recipient and other organization under contract for services.

Grant drawdowns are done quarterly under the reimbursement method. There are budgetary

controls in effect that preclude drawing down funds in excess of the total funds authorized on the

notice of award. The HCH fiscal manager at ACHCSA codes each HCH invoice by the

appropriate grant code. Each quarter, an expenditure report is run for the previous quarter

detailing the transactions for the quarter. The report is verified and then grant funds are

requested.





of 31


Program Requirement #15 - Program Data Reporting Systems

Health center has systems which accurately collect and organize data for program reporting and

which support management decision-making. (Section 330(k)(3)(I)(ii) of the PHS Act)



Most recent UDS Report and UDS Health Center Trend Report

Most recent Clinical and Financial Performance Measures Forms

Clinical and financial information systems (e.g., EHR, practice management systems, billing

systems)


ACHCSA and AHS (sub-recipient) have systems in place that accurately collect and organize

data for program reporting, including UDS, FFR and performance measures, and support

management decision-making.

Currently ACHCSA only provides enabling services. However, it does have a sub-recipient

agreement with AHS to provide medical, dental, and behavioral health services. The sub-

recipient agreement states that, “AHS shall provide the following primary, urgent, and emergent

care services to the homeless population of Alameda County at its clinics.” The agreement goes

on to specify the services to be provided. Even though AHS bills Medi-Cal at the FQHC rate for

all of its visits at the in-scope service sites, only the homeless portion of these visits and related

income are reported on the UDS Report. The 2014 UDS guidance states (page 14): “For each

grant report, patients reported are those who have at least one visit during the year within the

scope of project activities supported by the specific BPHC grant.” In this case, the sub-recipient

agreement describes the Scope of Project as homeless only patients.

Patient data has been used to assess the sub-recipient (AHS) and contract services under this

grant. Monthly, AHS and the contracted agencies report encounter data, this data is used to

assess whether AHS and the contractors are on track to meet the visits that are promised via the

contract or sub-recipient agreement. Agencies who are underperforming are contacted to

determine whether levels will be met by the end of the contract period. This analysis is used to

determine the effectiveness of the contract and whether or not ACHCSA will offer a future

contract to this agency(s). On a quarterly basis, AHS and contract agencies are required to

provide detailed homeless data. This data is analyzed to be assured that all homeless data is

being captured accurately.





of 31

A variety of software products are used within the county and AHS. For accounting software,

ACHCSA uses Alcolink, a countywide web-based tool hosted by Oracle/PeopleSoft that captures

all financial transactions through the auditor’s office. ACHCSA also utilizes Grant Expenditure

Management System (GEMS). AHS uses Lawson accounting software. All encounters for all

contractors and AHS are entered in ACHCSA software called Sorrian, a Cerner product.


Program Requirement #16 - Scope of Project

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)



Health Center UDS Trend Report

Health center’s official Scope of Project for sites and services (Forms 5A, 5B, and 5C)

Most Recent Form 2 - Staffing Profile

Notice of Award and information for any recent New Access Point or other supplemental grant

awards


ACHCSA’s Form 5A is incorrect. Well child services and obstetrical care, i.e., prenatal care, intrapartum care and postpartum care, are currently only entered in Column III. They should be removed from Column III and moved to Column II since the sub-recipient agreement with AHS includes those services and there are no other agreements with agencies providing those services. Screenings and immunizations are included in all three columns but should only appear in Column I and II. Form 5B is lacking the FQHC Medicare numbers for the four permanent AHS clinic sites. Additionally, ACHCSA is awaiting contract finalization for contractors providing in-scope services and may have location changes to Form 5B based on those contracts.


ACHCSA, working with the Project Officer, must submit a Change in Scope for the inaccuracies on Form 5A. As contracts are finalized, it must submit updates to Form 5B to accurately reflect the locations and hours of in-scope services.

The detail regarding FQHC billing numbers on Form 5B and recommendations are discussed in

PR #13, Billing and Collections.





of 31

Section 4. Governance - Program Requirement #17

Program Requirement #17 - Board Authority

Health center governing Board maintains appropriate authority to oversee the operations of the

center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304)



Organizational/Corporate bylaws

Minutes of recent Board meetings

List of Board Committees

Other: California Codes (hsc: 101850-51 - Health and Safe Code Section (Enabling Legislation))


Governance does not comply with all Bureau regulations. There is a sub-recipient agreement;

however, there is not an agreement in place that clearly defines which Board has the

full PHS Statute requirements for overseeing the authority of a funded health center operation

(including homeless grantees) as guided by the Governance PIN of 2014-01.

The grantee program HCSA has a sub-recipient agreement with the Alameda Hospital Authority,

which has been granted the Board of Authority for the HCSA through the Alameda County

Board of Supervisors who oversee the HCSA as well as the Alameda Hospital Authority. The

review during this Site Visit indicated that the Alameda Hospital Authority, which has been

designated as the Governing Board for the grantee, is carrying out most of its responsibilities,

with the exception of monthly meetings. The Board is beginning now to carry out this

responsibility. The challenge in this review is that the Alameda County Board of Supervisors

(the grantee) wants to retain exclusive selection of the Board members to the Alameda Hospital

Authority which now serves as the Board for the Homeless Program. The designated Board of

the grantee, Alameda Hospital Authority, is doing the following as per the sub-recipient

agreement and its current bylaws:

Holding Monthly Meetings: The Board has of the last four to five months’ meeting

minutes and has begun to meet monthly.

Approval of the health center grant application and budget: Yes. As per the monthly

meeting minutes, the AHA reviewed and approved the application and budget to be

submitted, as per an overall budget approval by the Board of Supervisors. The fact that

the Board of Supervisors has final decisions on all county budgets does not suggest

complete autonomy by the AHA.





of 31

Selection/dismissal and performance evaluation of the health center CEO: Yes. The

Board of Supervisors has given partial authority to the AHA. The selection of a CEO is

contingent upon the Board of Supervisors’ final approval.

Measuring/evaluating the program’s progress: It was clear during the meeting with the

Board and others that everyone is aware of and maintains progress of the organization’s

status. However, it is not documented in any of the minutes of the Board presented for

review. The actual Strategic Plan did not exclusively outline all of the visions articulated

in the meeting with the Board. The Strategic Plan was folded into the county’s

Ambulatory Care Plan, without specific representations to the overall homeless program

as funded by HRSA.

Bylaws require updating to reflect that this sub-recipient relationship resembles that of

the need for this relationship between the County Supervisors and the Hospital Authority

to be a co-applicant agreement.

Policies and procedures are adopted as per the county’s Administrative Policies.


The grantee must, at a minimum, put in place the following:

An established calendar to ensure monthly meetings;

Evidence that the AHA Board can approve the health center budget and submission of

application without confirmation for the county Board of Supervisors;

Establish a Strategic Plan that exclusively highlights the projections of the Homeless

Program exclusively;

The selection process for the future CEO of the program;

Minutes that reflect that the AHA reviews and evaluates the Homeless Program’s

performance; and

Establishment of Policies and Procedures that are current and specific to the grantee.

All of the aforementioned must be put forward in some type of an agreement, which might

include an affiliation agreement, management agreement (with an independent CHC status), or, a

co-applicant agreement.

It is highly recommended that the Board of Supervisors establish a co-applicant

agreement arrangement with the AHA in order to address the non-compliant areas sited in the

findings as indicated in the Governance PIN 2014-01 under Public Entities. It should be noted

that the AHA Board is acting in great part as a quasi-independent board for the Health Center.

The exception to this must particularly focus on the member selection of the Board of Directors

for the grantee’s oversight which now has final confirmation by the Board of

Supervisors. Additional reference for selection of members, especially when there is a third

party interest, can be found in the Checklist for Bylaws for Community Based Health Centers.

This document was left with the grantee as a reference point.





of 31


Program Requirement #18 - Board Composition

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. (Section 330(k)(3)(I) of

the PHS Act, 42 CFR Part 51c.303(p), and 45 CFR Part 74.25(c)(2)-(3))



Composition of Board of Directors/Most recent Form 6A: Board Composition

Organizational/Corporate bylaws


ACHCSA is a public entity grantee. It currently has a waiver in place for this particular Program

Requirement that was granted in the last SAC application. The NOA issued on November 1,

2011, is the document reviewed that confirmed that the waiver was approved. The current

composition of the AHA Board that oversees the health center consists of individuals from the

Board of Board of Supervisors (1), and the remainder from the AHA Board. There is a

Community Advisory Board in place that gives input on the needs of the population being

served. However, this Advisory committee has not been as active as it should be to ensure a

formalized input that is documented by this group of individuals. It was suggested that this

group be made a formal entity of the organization and included in their mechanism for receiving

information about the needs of the community it serves within a co-applicant agreement between

the AHA and the Board of Supervisors.


Program Requirement #19 - Conflict of Interest Policy

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. (45 CFR Part 74.42 and 42 CFR Part 51c.304(b))







of 31

Corporate Bylaws

Most recent update of Conflict of Interest Policy and related procedures

Procurement Policies and/or Procedures

Other: Alameda County, GSA-Purchasing, Conflict of Interest Statement


ACHCSA has a very comprehensive Conflict of Interest Statement and Policy in place for its

Homeless Program funded by HRSA/BPHC. The policy provisions are based on The County of

Alameda, State of California Government Code Section 1090 on Conflict of Interest and Section

87100 that is used by all county departments and agencies that use staff and/or community

volunteers for proposals or invitations for bids on behalf of county departments and agencies.

The policy corresponds to that of the BPHC requirements which state that, “The County’s

officers, employees and agents, including contractors, their agents and volunteers shall neither

solicit nor accept gratuities, favors or anything of monetary value from anyone who have the

potential to furnish goods and services to the organization. It also states the “kinship clause,”

which no member or employee shall be related in any employment or contract negotiations.”

The bylaws of the ACHCSA Board state that the Project Director or CEO of the program is a

non-voting ex-officio member of the Governing Board of the Health Center.

It should be noted (as indicated in Program Requirement #17) that there is a Community

Advisory Board for the program that has been working somewhat along with the ACHCSA

Board of Directors. This board should be formalized and specific become a more effective part

of providing information to the AHA Board on the needs of the individuals being served.





of 31

Section 5. Clinical and Financial Performance

Clinical Measure #1 - Percentage of diabetic patients whose HbA1c levels are less

than 7 percent, less than 8 percent, less than or equal to 9 percent, or greater

than 9 percent


UDS Trend, Comparison and Summary Reports

Clinical and Financial Performance Measure Forms from most recent SAC/Designation

Application

Clinical Performance Analysis:

Reason(s) for selecting the measure:

Since there is no quality improvement structure to monitor and analyze data; plan and make

improvements; and monitor trends and outcomes as reported in PR #8, this analysis is done to

demonstrate the challenges in collecting accurate and complete indicator data as demonstrated by

looking at the UDS Reports from 2012, 2013 and 2014. It also provides ACHCSA and AHS an

opportunity to begin a structured process that will result in even better outcomes for the

homeless patients with diabetes.

Performance measure status and trend:

The following data is from the three-year UDS Trend Report:

Percent of ACHCSA DM patients with a HbA1c < = 9%

2012=27.14%

2013=50%

2014=75.71%

2014 state average=67.41%

2014 National average=68.78%





of 31

ACHCSA specific data from 2013 and 2014:

Criteria 2013 2014

Total patients with DM 487 539

Total patients sampled (% of total) 70 (14%) 70 (13%)

HbA1c < 7 (% of 70) 13 (18%) No data for 2014

HbA1c <8 (% of 70) 14 (20%) 45 (64%)

HbA1c < 9 (% of 70) 8 (11%) 8 (11%)

Hba1c > 9 or no test (%of 70) 35 (50%) 17 (24%)

Key factors (internal and external) contributing to and/or restricting the health center’s

performance on the measure:

The lack of a structured program to monitor and analyze data and to oversee an improvement to the process or outcome is the main internal contributing factor restricting the performance.

The trend data for 2012, 2013 and 2014 clearly indicates a more accurate process of collecting

the UDS indicator data over time. However, the apparent improvement in the percent of patients

with a HbA1c less than or equal to 9 is skewed by the fact that the data comes from a sample of

only 70 patients, which is approximately 14% and 13% of the total for 2013 and 2014,

respectively. Additionally, half of the patients in 2013 and one quarter in 2014 either had no test

or had a test result of above 9. Extrapolating to the entire eligible diabetic population

demonstrates a significant opportunity for both process and outcome improvements.

Health center’s in-process and/or proposed action to improve performance on the measure:

1. Collect data on the entire eligible population as soon as possible. If data collection on the universe of patients is not possible for all indicators, select two or three indicators and make those a priority and collect and report data on the whole population within that indicator. i2i Tracks, a population management software program that AHS has installed, should be able to extract the data from the NextGen system.

2. Using the FOCUS-PDSA process, develop teams to pilot various strategies to improve the testing rates and then to work on the outcomes.

3. Make sure to record and document activities using data to support conclusions and recommendations.

4. Develop a dashBoard that can be used to inform staff, providers, management, Boards and other stakeholders of the progress.





of 31

Financial Measure #1 - Total cost per patient


UDS Trend, Comparison, and Summary Reports

Clinical and Financial Performance Measure Forms from most recent SAC/Designation

Application

Financial Performance Analysis:

Reason(s) for selecting the measure:

ACHCSA is preforming higher than state and national averages for this measure. Due to the fact

that all services are provided by other agencies, the total number of patients is the only measure

this grantee can control. All contracts for services specify the number of patients to be served.

Performance measure status and trend:

2012 2013 2014 State 2014

National

Medical

Cost/Medical

Patient

$341.23 $1099.88 $1277.38 $841.51 $762.62

ACHCSA is trending 52% higher than state averages and 68% higher than national average. It is

preforming similar to other public center homeless only programs across the State of California

(grantee supplied statistics).

Key factors (internal and external) contributing to and/or restricting the health center’s

performance on the measure:

The following are the key factors contributing to or restricting the health center performance on

this measure:

Working a vulnerable homeless population;

Low number of visits in 2014 due to mobile health van at AHS was only providing

enabling services and not medical or behavior health services;

Cost of the van, such as high gas costs;

Difficulty carving out of the cost for homeless patients prior to the new CFO at AHS;

Public center higher cost for benefits; and

High cost area of California.





of 31

Health center’s in-process and/or proposed action to improve performance on the measure:

Providing services via a contract or sub-recipient basis to other FQHC or entities that

already have the infrastructure in place;

Strengthening community partnerships;

Closely monitoring all of the contracts;

Analysis of job vacancies before they are filled to assure they are a needed position;

Rent and occupancy cost for main site and trust site will now be covered by general funds

through the county for the first time this fiscal year (effective July 1, 2015); and

Getting more accurate information due to better access to the information, since a new

CFO was hired at AHS.





of 31

Section 6. Capital and Other Grant Progress Review

Capital Grant Program(s) Reviewed:

N/A – The grantee does not have any active capital grant funding.





of 31

Section 7. Innovative/Best Practices

Program Requirement #6 addresses the need for patients to maintain continuity with their

primary care providers and medical home during and following either an emergency room visit

or inpatient hospitalization. This need is extremely essential to the care of the homeless patient

who often has not only severe medical needs, but also mental health, substance use and addiction

care needs as well as enabling services and housing needs. ACHCSA has created an outstanding

Homeless Focus Care Team that has a Transitions Team to work specifically with hospital

discharge planners, providers and other community agencies to assure the homeless patient has

shelter and can access care following discharge from the hospital. Respite care can be arranged,

clinic appointments are made, and patients are assisted with transportation where necessary.