HRSA 19 Program Requirements

Patty Linduska, Tom Taylor, Tara Ferguson, John Middleton, Cherise Fowler & Sara Schroeder

APCA Training and Technical Assistance TeamTA@alaskapca.org

907-929-2722

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AGENDA FOR JANUARY 14, 2014

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8:00 to 8:30 Registration8:30 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 12-15 with emphasis on Budget

2:30 to 2:45 Break2:45 to 4:15 Afternoon Session 2:

Program Requirements 16-19 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

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OVERVIEW

Health centers are non-profit private or public entities that serve designated medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless, or residents of public housing. 

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OVERVIEW, CONT. There are 19 Key Health Center Program

Requirements. http://www.bphc.hrsa.gov/about/requirements/index.html

Requirements are divided into four categories: Need Services Management & Finance Governance

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PROGRAM REQUIREMENT SOURCES Health Center Program Statute—Section 330 of the

Public Health Service (PHS) Act (42 U.S.C. §254b) http://bphc.hrsa.gov/policiesregulations/legislatio

n/index.html

Program Regulations—42 CFR Part 51c and 42 CFR Parts 56.201-56.604 for Community and Migrant Health Centers http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecf

r;sid=f141dbc68d6d3a084d2177ebbe01e543;rgn=div5;view=text;node=42:1.0.1.4.25;idno=42;cc=ecfr

http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr;sid=56fe3e657938f6c32805f19f4cbca824;rgn=div5;view=text;node=42:1.0.1.4.40;idno=42;cc=ecfr

Grants Regulations—45 CFR Part 74 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecf

r&sid=9de47029ddc8d5924737e389e539f183&rgn=div5&view=text&node=45:1.0.1.1.35&idno=45

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1. NEEDS ASSESSMENT

Requirement:

• Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate.

(Section 330(k)(2) and section 330(k)(3)(J) of the PHS Act)

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NEEDS ASSESSMENT Health center performs periodic needs assessments. Assessments document the needs of its target

population in order to inform and improve its delivery of appropriate services

A needs assessment typically includes, but is not limited to data on: Population to Primary Care Physician FTE ratio. Percent of population at or below 200% of poverty. Percent of uninsured population. Proximity to providers who accept Medicaid and/or

uninsured patients. Health indicators (e.g., diabetes, hypertension, low

birth weight, immunization rates).

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RELATED OPERATIONAL SITE VISIT INFORMATION

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2. REQUIRED AND ADDITIONAL SERVICESRequirement:

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)

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REQUIRED & ADDITIONAL SERVICES Ensures the health center is directly providing or has

written arrangements and referrals in place to provide a comprehensive array of required and as necessary, additional primary and preventive services that meet the needs of the populations it serves.

All services in the health center’s scope of project must be reasonably accessible and available on a sliding fee scale to health center patients.

In scope referral arrangements must be formally documented in a written agreement (MOA, MOU, etc.) that at a minimum describes the manner by which the referral will be made and managed and the process for referring patients back to the health center for appropriate follow-up care.

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RELATED OPERATIONAL SITE VISIT INFORMATION

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REQUIRED SERVICES Required primary health services must be provided

directly by the grantee or through an established arrangement11 such as through a formal agreement or through a formal referral arrangement.

In addition, required services provided directly by the grantee or by formal agreements or formal referral arrangements must be offered on a sliding fee scale and available equally to all patients regardless of ability to pay.

Therefore, informal referral arrangements are not acceptable for the provision of a required service.

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REQUIRED SERVICES Grantees should ensure that all

agreements/contracts/arrangements with other providers and organizations comply with section 330 requirements and administrative regulations for the Department of Health and Human Services.12

Grantees should also ensure that providers for any formal arrangements/agreements are properly credentialed and licensed to perform the activities and procedures expected of them by the grantee.

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3. STAFFING REQUIREMENTRequirement:

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)

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STAFFING REQUIREMENT Staff composition and numbers must support the

health center’s Clinical Performance Goals and ability to provide required and additional services.

ALL health center providers are appropriately licensed, credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project. See BPHC credentialing and privileging policies for more

information at http://www.bphc.hrsa.gov/policiesregulations/policies/qualityrisk.html.

Staffing should be culturally and linguistically appropriate for the population being served and as noted in the health center’s needs assessment.

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RELATED OPERATIONAL SITE VISIT INFORMATION

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CREDENTIALING & PRIVILEGING Refer to Policy Information Notices (PINs)

2001-16: Credentialing and Privileging of Health Center Practitioners

2002-22: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy outlined in Policy Information Notice 2001-16

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CREDENTIALING & PRIVILEGING Credentialing: the process of assessing and confirming the

qualifications of a licensed or certified health care practitioner. Primary Source Verification: Verification by the original source of

a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner.

Secondary Source Verification: Methods of verifying a credential that are not considered an acceptable form of primary source verification. These methods may be used when primary source verification is not required. Examples of secondary source verification methods include, but are not limited to, the original credential, notarized copy of the credential, a copy of the credential (when the copy is made from an original by approved Health Center staff).

Privileging/Competency: The process of authorizing a licensed or certified health care practitioner’s specific scope and content of patient care services. This is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.

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CREDENTIALING & PRIVILEGING ECRI Institute has a Credentialing Toolkit at their

website: https://www.ecri.org/Pages/default.aspx

All HRSA Grantees can request access. 1/1

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Supporting Toolkit DocumentsRight click and choose “Save as” to save the Word file on your computer. Sample Credentialing and Privileging Policy Credentialing: Step-by-Step Process Table: Comparative Summary of Requirements for Credentialing and Privileging “Licensed or C

ertified Health Care Practitioners” Credentialing Timeline Credentialing Application Packet Guide for Preparing Files for an FTCA Site Visit Preparing Credentialing List for FTCA Deeming Application Flowchart 1: Initial Credentialing Process Flowchart 2: Initial Privileging Process Flowchart 3: Renewal of Credentials and Privileges Peer Review/Chart Review Peer Review Checklist

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CREDENTIALING & PRIVILEGING Comparison Summary

of Requirements for Credentialing and Privileging from ECRI Institute

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CREDENTIALING & PRIVILEGING Sample Credentialing &

Privileging Policy from ECRI Institute

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4. Accessible Hours of Operations / LocationsRequirement:

• 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)

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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.

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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.

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4. Accessible Hours of Operations / Locations• Documents / Resources to Review:

• Hours of Operation• Most Recent Form 5B: Service Sites• Service Area Map with site locations noted• HRSA/BPHC Scope of Project Policies

• Links and Additional Resources• Patient Satisfaction Survey • The Samples and Template Resource Center

Services Page

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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))

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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.

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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.

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5. After Hours Coverage• Documents / Resources to Review:

• Policy for after-hours coverage• HRSA/BPHC Health Center Collaboration

Program Assistance Letter 2011-02

• Self-Assessment Tool• Program Requirement 5: After Hours Coverage

section, page 22, of the Health Center Site Visit Guide for HRSA Grantees

• Commonwealth Fund article:• After-Hours and its coordination with Primary Care

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6. Hospital Admitting Privileges and Continuum of CareRequirement:

• 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)

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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.

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6. Hospital Admitting Privileges and Continuum of Care• Documents / Resources to Review:

• Hospital or other arrangements• Form 5C: Other Activities / Locations• Program Assistance Letter 2011-02 • HRSA Patient-Centered Medical/Health Hom

e Initiative

• AHRQ PCMH Resource Center • Self-assessment tool:

• Program Requirement 6: Hospital Admitting Privileges and Continuum of Care section, page 23, of the Health Center Site Visit Guide for HRSA Grantees

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7. Sliding Fee DiscountsRequirement:

• 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))

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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 http://aspe.hhs.gov/poverty/ and must be updated annually.

• Patients must be notified/made aware of the availability of the sliding fee discounts.

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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.)

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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.”

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8. Quality Improvement/ Assurance PlanRequirement:

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 74.25 (c)(2), (3) and 42 CFR Part 51c.303(c)(1-2))

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8. Program Requirement

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Requirements Questions

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Health center has an ongoing Quality Improvement/ Quality Assurance (QI/QA) program that: Does the health center's QI/QA program:

a Includes clinical services and management. Address both clinical services and management (inclusive of all services in scope e.g., primary care, dental, behavioral health, etc.)?

b Maintains the confidentiality of patient records.

b.1. Maintain a clinical record for every patient receiving ongoing care at the health center?

b.2. Ensure that medical records are properly secured during times when the medical record staff is not present?

b.3. Include procedures to enable patients to give consent for release of medical record information?

b.4. Include appropriate procedures for signing-out patient records? b.5. Include a follow-up procedure to pursue unreturned medical

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.*

c.1. Have a clinical director? Note: clinical directors may be full or part time staff and should have appropriate training/background (e.g., MD, RN, MPH, etc.) as determined by the needs/size of the health center.

8. Program Requirement

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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):

aBe 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?

cIdentify 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?

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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.

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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. 41

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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)

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Program Requirement1. Health center has an ongoing Quality

Improvement/ Quality Assurance (QI/QA) program that:

a. Includes clinical services and managementb. 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.*

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Program Requirement2. 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.*

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QI/QA Plan

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Incident Reporting Policy

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Risk Management Policy

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Clinical Director Job Description

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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 Ai

ms• Redesigning a System of Care to Promote QI• Testing for Improvement

http://www.hrsa.gov/quality/toolbox/methodology/index.html

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Testing for ImprovementA Preferred Approach: The Model for Improvement

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Testing for Improvement

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Testing for Improvement

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Performance Improvement Letters regarding

Accreditation and Patient Centered Medical/Health Home Initiatives;

HRSA Quality Improvement Resources; ECRI Institute Clinical Risk Management Program

provided on behalf of HRSA (available to health center grantees and free clinics);

HHS OIG Quality and Compliance Resources; HRSA Health Center Patient Satisfaction Survey.

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ResourcesPolicy and Procedure Template http://bphc.hrsa.gov/technicalassistance/resourcecenter/general/policytemplateandexplanation.pdf

Quality Improvement http://www.hrsa.gov/quality/toolbox/methodology/index.html http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/qipoliciesandprocedures.pdf http://www.hrsa.gov/quality/toolbox/index.html http://oig.hhs.gov/fraud/docs/complianceguidance/CorporateResponsibilityFinal%209-4-07.pdf http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/performanceimprovementplanphcinc.pdf http://

bphc.hrsa.gov/technicalassistance/resourcecenter/services/sampleperformanceimprovementplanprimaryhealthcareinc.pdf

http://bphc.hrsa.gov/technicalassistance/resourcecenter/clinicalservices/samplechcpiqlan.pdf http://www.migrantclinician.org/toolsource/120/quality-improvement-plans/index.html

Risk Management http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/howtodevelopariskmanagementplan.pdf http://www.nachc.com/client/documents/publications-resources/rm_11_05.pdf http://

bphc.hrsa.gov/technicalassistance/resourcecenter/services/riskmanagementpoliciesandprocedurestemplate.pdf

http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/sampleriskmanagementplanshastachc.pdf

FTCA http://bphc.hrsa.gov/ftca/index.html http://bphc.hrsa.gov/ftca/about/ftcapolicies.html

Incident Reporting http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/incidentreportingpoliciesandprocedures.pdf

Safety http://bphc.hrsa.gov/technicalassistance/resourcecenter/services/safetyandhealthpoliciesandprocedures.pdf

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9. Key Management StaffRequirement:

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))

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Requirements Questions Response

1

Health center maintains a fully staffed health center management team as appropriate for the size and needs of the center. If applicable, prior approval by HRSA of a change in the Project Director/ Executive Director/CEO position is required.

Does the health center have a Chief Executive Officer or Executive Director/Project Director?

Is the management team’s size and composition appropriate for the size and needs of the health center?

Is the team fully staffed, with each of the positions listed above filled as appropriate? Note: If the grantee has an open position for or pending change in the Project Director position, the PO and/or consultant may wish to remind the grantee that this change will required a “Prior Approval Request” which must be submitted/ processed via the EHB Prior Approval Module and to contact their Project Officer for further information as needed.

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.

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Documents/Resources1) Health center organizational chart; 2) Key management staff position descriptions and

biographical sketches; 3) Key management vacancy announcements (if

applicable).

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Resources Chief Executive Officer/Performance Assessmenthttp://bphc.hrsa.gov/technicalassistance/resourcecenter/managementandfinance/epeformanceassessment.pdf

Chief Financial Officer/Job Descriptionhttp://bphc.hrsa.gov/technicalassistance/resourcecenter/managementandfinance/chieffinancialofficerjobdescription.pdf

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10. Contractual/Affiliation AgreementsRequirement:

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))

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10. Program Requirement

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Requirements Questions Yes/No

1 Health center exercises appropriate oversight and authority over all contracted services.

Do any of the grantee's contracts or affiliation agreements have the potential to: a. Threaten the grantee's integrity? b. Limit its autonomy? c. Compromise its compliance with Federal program requirements in

terms of corporate structure, governance, management, finance, health services, and/or clinical operations?

2 Health center assures that any subrecipient(s) meets the Health Center Program requirements Applies only to grantees s with subrecipients

For grantees with subrecipient arrangements ONLY: Does the grantee have assurances in place that the subrecipient organization complies with all Health Center Program statutory and regulatory requirements?

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).

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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.

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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 97-27 and 98-24); Federal procurement grant regulations ( 45 CFR

Part 74.41-74.48)) applicable to all contractual arrangements in scope.

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Resources Your grant application’s Form 8: “Health Center

Affiliation Certification and Health Center Affiliation Checklist” contains your existing agreements with other entities.

PIN 1997-27: Affiliation Agreements. PIN 1998-24: Amendment to PIN 1997-27

Regarding Affiliation Agreements of Community & Migrant Health Centers.

Program Assistance Letter 2011-02 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.

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11. Collaborative RelationshipsRequirement:

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))

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11. Program Requirement

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Requirements Questions Yes/No

1

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.

Does the health center work to establish and maintain collaborative relationships with other health care providers in its service area, in particular other health centers?

2

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.

If there is another health center in the health center’s service area, was the grantee able to secure letter(s) of support from the health center(s) for its most recent Service Area Competition or other competitive grant application?

If the health center was unable to get letter(s) of support from the other health center(s) in the service area, did it explain why and is it working to improve or implement collaborative relationships with these health centers?

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.

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Documents/Resources Letters of Support; Memoranda of Agreement/Understanding; HRSA/BPHC Health Center Collaboration Program

Assistance Letter 2011-02. 1/1

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Resources http://

bphc.hrsa.gov/technicalassistance/resourcecenter/managementandfinance/affiliationsbetweenhealthcentersandothercommunitybas.pdf

http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html

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 97-27 Regarding Affiliation Agreements of Community and Migrant Health Centers.

Program Assistance Letter (PAL) 2011-02: 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.

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Financial Management & Control Policies

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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

Financial Management & Control Policies

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• 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

• 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

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Financial Management & Control Policies

• 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?

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Financial Management & Control Policies

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

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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

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Billing & Collections

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• 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

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.

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Federal Object ClassesDEPARTMENT OF HEALTH AND HUMAN

SERVICES Health Resources and Services Administration

FEDERAL OBJECT CLASS CATEGORIES

FOR HRSA USE ONLY

Grant Number Application Tracking

Number

Total Proposed Budget Amount Section 330 Federal funding (from Total Federal - New or Revised Budget on Section A – Budget Summary)

$ 270000.00

Non-Federal funding (from Total Non-Federal - New or Revised Budget on Section A – Budget Summary)

$ 750000.00

Total Budget Categories Object Class Category Federal Non Federal Total (from Section B –

Budget Categories) a. Personnel $ 175000.00 $ 175000.00 b. Fringe Benefits $ 38500.00 $38500.00 c. Travel $ 25000.00 $ 25000.00 d. Equipment $ 11500.00 $ 11500.00 e. Supplies $ 2500.00 $2500.00 f. Contractual $ 75000.00 $ 75000.00 g. Construction h. Other i. Total Direct Charges (sum of a-

h) $ 252500.00 $ 327500.00

j. Indirect Charges $17500.00 $ 17500.00 k. Total Budget Specified in

Section A - Budget Summary $ 270000.00 $ 345000.00

Choose a Budget Approach• Line-Item budget

• Program–based budget• Income–based budget

• Capital budget

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Line – Item Budget

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Net Patient Revenue $100,000 Federal Grants 500,000Other Grants and Contributions 150,000Total Income $750,000

Expenses Salaries $750,000 Benefits 150,000 Payroll taxes 93,750 Professional Fees 45,000 Supplies 500,000 IT & Communication 15,000 Occupancy 50,000 R&M and Small Equipment 25,000 Insurance 3,700 Travel 2,500Total 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

Program–Based Budget

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Income Medical Dental Administrative Fundraising Total

Net Patient Revenue $700,000 $300,000 $0 $0 $1,000,00

0

Federal Grants 400,000 100,000 - - $500,000 Other Grants and Contributions 125,000   25,000   -   -   $150,000

Total Income $1,225,000 $425,000 $0 $0 $1,650,00

0

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 32,000 800 $45,000

Supplies 340,300 150,000 8,500 1,200 $500,000

IT & Communication 9,650 5,000 350 - $15,000

Occupancy 36,500 12,000 1,500 - $50,000

R&M and Small Equipment 17,000 8,000 - - $25,000

Insurance 2,200 1,200 300 - $3,700

Travel 650 450 1,400 - $2,500

Depreciation 9,800   4,500   700   -   $15,000

Total Expenses $979,450 $454,150 $203,750 $12,600 $1,649,95

0

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.

Income – Based Budget

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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

Capital Budget

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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

8 Steps to Preparing a Successful Budget

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• Plan your budget timelineStep One

• Identify goals and priorities for the upcoming budget year

Step Two

• Develop income and expense projections to the end of the current FY

Step Three

8 Steps to Preparing a Successful Budget

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• Analyze budget-to-actual variances for the current FY

Step Four

• Budget income FIRSTStep Five

• Develop expense projectionsStep Six

8 Steps to Preparing a Successful Budget

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• Balance expenses to projected incomeStep Seven

• Finalize board approved budget before the new year begins

Step Eight

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.

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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.

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Budget limitations

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• Salary Limitation The Consolidated Appropriations Act, 2012 (P.L. 112-74) 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

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.

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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.

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Things to Consider Developing and applying an equitable system of distributing

common costs to departments and divisions is a challenge for most nonprofits – examples includeo Copier supplies and maintenance costso Telephone connectivity and usage costso Postageo 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.

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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

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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

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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

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SummaryBudgeting: The Road Map to Success

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Where Are We Going?

Are We There Yet?

DriveDefensively

Know the Rulesof the Road

Preventive and Regular Maintenance Check-ups

Keep You in theDriver Seat

Bumps Along the Road

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

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Budget

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It’s MY Budget.

I can buy what I want.

Right?

Budget

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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.”

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Program Data Reporting Systems

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• 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

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

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Program Data Reporting Systems

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Financial Management Webinars

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Webinar Name 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

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16. SCOPE OF PROJECT

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)

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SCOPE OF PROJECT The section 330 approved Scope of Project stipulates

what the total grant-related project budget supports (including program income and other non-section 330 funds). Five core elements: Services, Sites, Providers, Target

Population, Service Area. Changes in scope may affect eligibility and coverage. Significant changes in scope must be approved by

HRSA/BPHC See Scope of Project policies for further guidance at

http://www.bphc.hrsa.gov/policiesregulations/policies/managefinance.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.

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SCOPE OF PROJECT

FIVE CORE ELEMENTS OF SCOPE OF

PROJECT Five core elements constitute scope of project and

address these fundamental questions: Where will services be provided (service sites)? What services will be provided (services)? Who will provide the services (providers)? What geographic area will the project serve (service

area)? Who will the project serve (target population)?

(excerpt from PIN 2008-01)

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SCOPE OF PROJECT Scope of project defines:

the activities that the total approved section 330 grant-related project budget supports;

the parameters for using these grant funds; the basis for Medicare and Medicaid Federally

Qualified Health Center reimbursements; Federal Tort Claims Act coverage; 340B Drug Pricing eligibility; and other essential benefits. Therefore, proper recording of scope of project is critical in the oversight and management of programs funded under section 330 of the PHS Act.

(excerpt from PIN 2008-01)

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SCOPE OF PROJECT A health center’s scope of project is

important because it: Stipulates the total approved section 330

grant-related project budget, specifically defining the services, sites, providers, target population, and service area for which grant funds have been approved. This total project budget includes program income and other non-section 330 funds.

Determines the maximum potential scope of coverage (subject to certain exceptions) of the Federal Tort Claims Act (FTCA) program that provides medical malpractice coverage for deemed health centers and most individual employees .

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SCOPE OF PROJECT Provides the necessary site information which

enables covered entities to purchase discounted drugs for their patients under the section 340B Drug Pricing Program.

Defines the approved service sites and services necessary for State Medicaid Agencies to calculate payment rates under the Prospective Payment System (PPS) or other State-approved alternative payment methodology.

Defines the approved service sites necessary for the Centers for Medicare and Medicaid Services (CMS) to determine a health center’s eligibility for Federally Qualified Health Center (FQHC) Medicare all-inclusive rate.

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16.A Program Requirement

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17. BOARD AUTHORITY

Requirement:

Health center governing board maintains appropriate authority to oversee the operations of the center, including:

holding monthly meetings; approval of the health center grant application and budget; selection/dismissal and performance evaluation of the health center CEO; selection of services to be provided and the health center hours of

operations; measuring and evaluating the organization’s progress in meeting its annual

and long-term programmatic and financial goals and developing plans for the long-range viability of the organization by engaging in strategic planning, ongoing review of the organization’s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance;* and

establishment of general policies for the health center.

(Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) NOTE: In the case of public centers (also referred to as public entities) with co-applicant governing boards, the public center is

permitted to retain authority for establishing general policies (fiscal and personnel policies) for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304(d)(iii) and (iv))

NOTE: Upon a showing of good cause, the Secretary may waive, for the length of the project period, the monthly meeting requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p). (Section 330(k)(3)(H) of the PHS Act)

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BOARD AUTHORITY Health center’s board:

Meets monthly. Health centers with approved waivers ONLY:

Appropriate strategies are in place to ensure regular oversight, if the board does not meet monthly.

Reviews and approves the annual health center (renewal) application and budget.

Conducts an annual review of the CEO’s performance (with clear authority to select a new CEO and/or dismiss the current CEO if needed).

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BOARD AUTHORITY Health center’s board:

Reviews and approves the services to be provided and the health center’s hours of operation.

Measures and evaluates the health center’s progress in meeting annual and long term clinical and financial goals.

Engages in strategic and/or long term planning for the health center.

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BOARD AUTHORITY Health center’s board:

Reviews the health center’s mission and bylaws as necessary on a periodic basis.

Receives appropriate information that enables it to evaluate health center patient satisfaction, organizational assets, and performance.

Establishes the general policies, which must include, but are not limited to: personnel, health care, fiscal, and quality assurance/improvement policies for the organization (with the exception of fiscal and personnel policies in the case of a public agency grantee in a co-applicant arrangement).

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BOARD AUTHORITY For Public Center Grantees with Co-Applicant

Arrangements ONLY—Public center (entity) grantee of record has a formal co-applicant agreement that stipulates Roles, responsibilities, and the delegation of

authorities. Any shared/split responsibilities between the public

center and co-applicant board.

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RELATED OPERATIONAL SITE VISIT INFORMATION

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18. BOARD COMPOSITIONRequirement:

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).

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BOARD COMPOSITION A majority (at least 51%) of the board members receive

services (i.e., are patients) at the health center. As a group, the “patient/consumer” board members must

reasonably represent the individuals who are served by the health center in terms of race, ethnicity, and sex. NOTE: There is no established ratio for board members to

population served; however, board composition must be reasonably representative of the populations being (i.e., race, ethnicity, sex) served.

Health centers with approved waivers ONLY–appropriate strategies are in place to ensure consumer/patient participation and input from the target population (given board is not 51% consumers/patients) in the direction and ongoing governance of the organization.

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BOARD COMPOSITION Health centers that receive part of their section

330 funding to serve special populations and are not eligible for a waiver—the board includes representation from/for these special populations group(s), as appropriate (e.g., an advocate for the homeless, the director of a Migrant Head Start program, a formerly homeless individual).

The board has between 9 and 25 members. The size of the board is appropriate for the

complexity of the organization and the diversity of the community served.

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BOARD COMPOSITION The board includes a member (or members) with

expertise in any of the following: Community affairs Local government Finance and banking Legal affairs Trade union and other commercial and industrial

concerns Community social service agencies

No more than 50% of the non-consumer board members may derive more than 10% of their annual income from the health care industry.

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19. CONFLICT OF INTEREST POLICYRequirement:

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

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CONFLICT OF INTEREST POLICY The bylaws or other policy documents include a

conflict of interest provision(s).

No current board member(s) is an employee of the health center or an immediate family member of an employee.

The CEO/Program Director does not participate as a voting member of the board.

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CONFLICT OF INTEREST The health center’s conflict of interest policy must

address such issues as: disclosure of business and personal relationships,

including nepotism, that create an actual or potential conflict of interest;

extent to which a board member can participate in board decisions where the member has a personal or financial interest;

using board members to provide services to the center; board member expense reimbursement policies; acceptance of gifts and gratuities; personal political activities of board members; and statement of consequences for violating the conflict

policy.

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CONFLICT OF INTEREST When section 330 grantees procure supplies and other

expendable property, equipment, real property, and other services, the health center's conflict of interest policy must also address the following:

The health center grantee must have written standards of conduct governing the performance of its employees engaged in the award and administration of contracts.

No health center employee, board member, or agent may participate in the selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of interest would be involved. Such a conflict would arise when a health center employee, board member or agent, or any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for an award.

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CONFLICT OF INTEREST The board members, employees, and agents of the

health center grantee shall neither solicit nor accept gratuities, favors, or anything of monetary value from contractors, or parties to sub-agreements.

However, recipients may set standards for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value.

The standards of conduct must provide for disciplinary actions to be applied for violations of such standards by board members, employers, or agents of the health center grantee.

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