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Preparation for Your HRSA Operational Site Visit

Presented by

March 19, 2019

› Individuals Participate in entire webinar Answer polls when they are provided

› Groups Group leader is the person who registered & logged on to the webinar Answer polls when they are provided Complete group attendance form Group leader sign bottom of form Submit group attendance form to training@bkd.com within 24 hours of webinar

› If all eligibility requirements are met, each participant will be emailed their CPE certificate within 15 business days of webinar

To Receive CPE Credit

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YourPanelists

Catherine GilpinDirector

cgilpin@bkd.com

Jeff AdestPartner/Director

jadest@garfunkelwild.com

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Preparing for Site Visits2

3 Best Practices & Real-Life Observations

CHC Compliance Requirements

Today’s Topics – HRSA Site Visits

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› Eligible organizations are private nonprofit entities or public agencies & Tribal/Urban Indian organizations

› Changes after CHC Compliance Manual Issuance: Dual Status – Organizations will not be awarded federal funding or look-alike designation that would result in dual status

• What does this mean for our Health Center/FQHC Clients?

Eligibility

› Grantee notified in writing via Notice of Grant Award in EHB

• Nature of finding• Reason condition is imposed• How to remove condition• Time allowed to satisfy the grant condition• Method for requesting reconsideration of the

condition

Program Oversight

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› Progressive Action Process• Time-phased approach for resolution of compliance issues with

program• 90/60/30 days

› Implementation Phase – 120 days to implement proposed action

Program Oversight

› HRSA-imposed conditions for non-compliance• DRAWDOWN RESTRICTIONS/WITHHOLDS

• DISALLOWANCE OF COSTS

• Require additional monitoring• Require technical assistance• Initiate suspension or debarment proceedings• Suspend award activities• Take other legally available remedies

Program Oversight

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› HRSA Assessment of HC Compliance at Service Area Competition

• Poor history of compliance• # of current conditions on grant @ SAC submission• Conditions in 60/30 progressive action phases

› COULD RESULT IN ONE-YEAR PROJECT PERIOD

› After two consecutive one-year project periods, a Health Center could not be selected for third …

Program Oversight

› The Health Center must define & annually review it’s service area, including the identification of the medically underserved populations to ensure that sites are appropriate & accessible

› The health Center must assess the unmet need for health services in the catchment area utilizing the following factors

• Available health resources in the area, including ratios of physicians (general, family practice, internal medicine, pediatrics or obstetrics & gynecology) to its population

• Health indices for the population of the area

• Economic factors affecting the population’s access to health services

• Demographic factors affecting the population’s need & demand for health services (example 65+ & over)

Needs Assessment

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Needs Assessment: OSV Tips

› Review utilization data (UDS) & update Form 5B

› Health Center should be able to demonstrate how they have utilized results of needs assessment to improve the delivery of health center services

• For example, diabetes, cardiovascular disease, cancer, low birth weight or behavioral health

› The Health Center must operate in a manner that no patient will be denied service due to an individual’s inability to pay

› The Health Center will prepare a schedule of fees consistent with prevailing rates designed to cover it’s costs

› The Health Center must establish systems for (sliding fee) eligibility determination

› The Health Center’s schedule of discounts will provide• A full discount to individuals earning under 100% of FPG• No discount to individuals earning over 200% of FPG

Sliding Fee Discounts

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› Are all services provided on Sliding Fee Discount Schedule?• DISPENSATION OF PHARMACEUTICALS, LABS, X-RAYS, ETC. …

› Focus on POLICIES in place at HC – Required language

› Federal Poverty Guidelines current on SFDS

› Be prepared to discuss how the Health Center analyzes program to ensure no financial barriers to access of care

• Medicare/Medicaid co-pays, patient satisfaction surveys• What has Health Center changed as a result of patient feedback?

› Contracts for all services provided via Column III

Sliding Fee Discounts: OSV Tips

› The Health Center must have position descriptions for key personnel that set forth training & experience qualifications necessary to carry out the activities of the Health Center

› The Health Center must maintain key personnel to carry out the activities of the Health Centers

› The Health Center must request prior approval from HRSA for a change in the key person specified as the Program Director

› The Health Center must directly employ its Project Director/CEO

Key Management Staff

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› Updated organizational chart & position descriptions (including experience & education requirements)

› Maintain biographies or resumes for key management staff supporting knowledge, skills & abilities that align with positions directions

› Directly employ CEO

› If any key management staff are part time, be able to justify

Key Management Staff: OSV Tips

› The Health Center must determine whether an individual agreement will result in a contract or subaward

› The Health Center must use its own documented procurement procedures that conform with 45 CFR 75

› The Health Center must maintain financial records & supporting documents for procurement transactions

› The Health Center will request approval from HRSA before making subaward & will ensure subrecipients comply with all applicable requirements of the award

Contracts & Subawards

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› Health Center should have written Policy (with supporting procedures) regarding procurements related to federal award –align with Uniform Grants Guidance

› Retain contracts for 3 years from submission of final FFR

› Contractor oversight & required contract provisions

› How does the Health Center monitor subrecipients?

› Do agreements with subrecipients contain appropriate language?

Contracts & Subawards: OSV Tips

› The Health Center must maintain effective control over all funds, property & other assets in order to adequately safeguard & ensure authorized use

› The Health Center’s financial management system will identify receipts & expenditures of federal funds

› The Health Center will have written procedures for ensuring cash management (3-day rule) & allowability of costs

› The Health Center will procure an audit if it expends more than $750,000 in federal awards

Financial Management & Accounting Systems

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› Update policies & procedures (hint: A110, A122 & A133)

› Make sure policy is in place regarding using non-grant funds

› Track grant revenue & expenditures in general ledger & perform federal budget to actual analysis

› Make sure support exists for all grant draws tying back to the payment made by the Health Center

› Address all findings related to audits in timely manner

› Generate accurate & timely financial information during year

Financial Management & Accounting Systems: OSV Tips

› The Health Center must prepare a schedule of fees for services consistent with locally prevailing rates & designed to cover costs

› The Health Center must assure fee required for services will be reduced or waived in order to assure that no patient will be denied such services due to an inability to pay

› The Health Center must make reasonable efforts to contract with & collect from third-party payors (including Medicare, Medicaid & Commercial)

Billing & Collections

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› Make sure fee schedule is up to date & based on costs &/or locally prevailing rates (is there a policy supporting calculations?)

› Update billing & collection policies prior to OSV (including waiver policy, refusal to pay, payment incentives & plans)

› Be prepared to discuss allowance analysis related to patient accounts receivable & collection efforts made regarding amounts owed to the Health Center

Billing & Collections: OSV Tips

› Develop budget that identifies costs supported by the Health Center program & project consistent with cost principles

› Submit the budget annually to HRSA by date specified

Budget

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› Be prepared to discuss 330 grant & operating budget development methodologies with reviewer

› Prepare reconciliation of budgeted to actual expenditures of federal funds to ensure appropriate expenditures & to identify potential budget modifications needing to be made

› Other lines of business – make sure that they are self-supporting & excluded from 330 grant budget

Budget: OSV Tips

The Health Center must establish systems for monitoring program to ensure oversight of operations of federal award, performance expectations are being achieved, areas for improvement in outcomes & productivity are identified

The Health Center will compile & report data regarding costs of operations, patterns of utilization, availability & accessibility of Health Center services, & other matters relating to operations of the Health Center Program project

Program Monitoring & Data Reporting

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› Review Health Center Trend & Performance Comparison reports in Electronic Handbook (UDS module) & ensure performance improvement efforts are appropriately targeted

› Prepare analysis of provider productivity to goals

› Prepare & submit cost report & Uniform Data System reports in a timely manner

› Ensure financial information is accurate & prepared in a timely manner

Program Monitoring & Data Reporting: OSV Tips

Required & Additional Health Services› Health Center provides all required primary, preventive, enabling health

services, e.g., general primary care, labs, radiology, gynecology, obstetrics

› Health Center provides additional health services as appropriate/necessary

› Services must be provided either • Directly, or

• Through written contracts &/or cooperative arrangements(which may include formal referrals

› If serving a substantial portion of patients with Limited English Proficiency (LEP), must

• develop an interpretation & translation plan &

• provide guidance to staff on cultural sensitivities

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› Check Forms 5A, 5B & 5C

› Make sure correct columns are marked

› For services provided by contract, there must be an actual written agreement

› Services provided through arrangements with independent contractors & professional services agreements should (also) be recorded on Column II of Form 5A, even if they are performed at the Health Center

› If the Health Center provides other services, they must be listed on the form

› Make sure any party the Center has a referral relationship with agrees to comply with sliding fee requirements

Required & Additional Health Services: OSV Tips

› Health Center ensures that it has clinical staff in place to carry out all required & additional health services as appropriate & necessary, either directly or through established contracts or cooperative arrangements

› Health Centers are not required to employ their clinical staff. With certain limited exceptions, they can have contracts with providers or provider organizations to carry out the required/additional services in the scope of project

› Staff must be appropriately licensed, credentialed & privileged & have appropriate training & experience

› Credentialing & privileging must occur at time of hiring & every 2 years thereafter

Clinical Staffing

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› Health Centers have discretion to determine who has approval authority for credentialing & privileging of their clinical staff (subject to applicable state law)

› Health Centers determine how credentialing will be implemented (for example, a Health Center may contract with a credentials verification organization to perform credentialing activities or may have its own staff conduct credentialing)

• If using a credentials verification organization, note this directly into the operating policy for credentialing/privileging

› Verification of current clinical competence can now be done via peer review or other comparable methods (for example, supervisory performance reviews)

› If providers are contracted & Health Center is not credentialing them, ensure the entity providing the practitioners credentials & privileges them & make sure they will give you copies of the provider’s files upon request

Clinical Staff: OSV Tips

› The Health Center’s required services are available & accessible promptly, as appropriate & in a manner which ensures continuity of service to its patients

› Health Centers demonstrate compliance when• Service sites are accessible to the patient population considering

where they live or work, including consideration of access barriers & time & distance for patients to travel

• The Health Center’s total number & scheduled hours of operation are responsive to patient needs

• The sites are accurately reported to HRSA

Accessible Locations & Hours & Operation

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› Make sure the Board approves the locations & hours on an annual basis

› The Board must also annually review & identify the service area (new requirement)

› Health Center has discretion in determining which methods to use for obtaining patient input on the accessibility of its service sites & hours of operation (for example, annual survey, focus groups, input from patient Board members)

Accessible Locations & Hours: OSV Tips

› Health Center has provisions for promptly responding to patient medical emergencies during both regularly scheduled hours & after hours when the Center is closed

› To demonstrate compliance, the Health Center must have• At least one staff member certified in BLS present at each HRSA-

approved site• Operating procedures on responding to patient medical emergencies

during regular hours

Coverage for Medical Emergencies During & After Hours

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› Demonstrating compliance (cont'd)• After-hours coverage must ensure telephone or face-to-face communication

by a qualified individual who can determine a patient’s need for emergency care

• Coverage must include the ability to refer the patient to a licensed professional for further consult or to an emergency room or urgent care, as needed

• Patients (including those with LEP) are informed of & are able to access after-hours coverage

• Documentation of after-hours calls & any necessary follow-up is maintained

Coverage for Medical Emergencies During & After Hours

› Make sure the Health Center’s main number “rolls over” to the after-hours information/coverage lines

› If physicians have specific extensions, make sure those numbers also roll over to after-hours information/coverage lines

› Ensure that the after-hours line has appropriate linguistic capabilities

› Ensure that patient information about after-hours coverage is in the appropriate language/literacy level(s)

› Make sure there is signage on the website & in patient areas about after-hours coverage

› If using an outside answering service, be sure to add it to Column II of Form 5A

Coverage: OSV Tips

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› Health Centers must have a QI/QA Plan/Program that addresses• Quality & utilization of Health Center services;

• Patient satisfaction & patient grievance processes; &

• Patient safety, including adverse events

› The Health Center’s operating procedures must address

• Adhering to current evidence-based clinical guidelines, standards of care & standards of practice;

• Addressing patient safety & adverse events, & implementing follow-up

• Hearing & resolving patient grievances;

• Assessing patient satisfaction;

• Completing periodic QI/QA assessments on at least a quarterly basis; &

• QI/QA reporting to key management staff & the Board

Quality Improvement/Assurance

› Form & identify in the QA Plan, a Quality Assurance Committee to oversee quality issues within the Health Center

• Committee members should include the Medical Director/CMO, the QI/QA Director (if applicable), members of senior management & department/services representatives

• The Committee should meet at least quarterly

• The minutes should reflect discussions on performance measures, patient satisfaction, QI Assessments conducted, quality initiatives & findings/results, chart audits/peer review & risk management topics, e.g., patient grievances, adverse events

› Ensure that QA activities are reported to the Board on a regular basis

Quality Improvement/Assurance: OSV Tips

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› Health Center maintains written standards of conduct covering conflicts of interest & actions of its employees engaged in selection, award & administration of contracts

• Standards must include disciplinary actions for violations

› No employee, officer or agent may participate in contract where federal funds are used if she or he has a real or apparent conflict

› Officers, employees & agents of a Health Center may not solicit or receive gifts or favors from contractors or subcontractors

Conflict of Interest

› Make sure the Conflict of Interest Policy is reviewed periodically

› Ensure the policy contains standards of conduct relating to procurements

› Make sure disclosure statements are completed annually & kept on file

› Focus on actual conflicts & not just “signing the form”

Conflict of Interest: OSV Tips

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› Health Center must have (a) physicians who have admitting privileges at one or more hospitals; or (b) formal arrangements with one or more hospitals for hospital admission of Center’s patients, e.g., Health Centers can determine the number & types of hospitals with which their providers have admitting arrangements & whether to use providers with admitting privileges or hospital arrangements, or both.

› Health Center has & follows its operating procedures &/or formal written arrangements that address

• Receipt & recording of medical information related to a hospital or ED visit, e.g., discharge instructions, laboratory, radiology or other results

• Follow-up actions by Health Center staff, when appropriate

• Health Centers & have discretion in how they receive discharge/follow-up information

Continuity of Care & Hospital Admitting

› Determine how the Center arranges for coverage for patients who are in the hospital

› Ensure that the Health Center has an arrangement with a hospital that patients can reasonably access – the Health Center does not need to have an arrangement with every hospital in the area

› Contract with the hospital should state that the hospital will provide the Health Center with information about the patient’s condition & that the hospital will refer the patient back to the Health Center for follow-up care

› Ensure that the Health Center has policies & practices that address hospital, referral & diagnostic/lab tracking

Continuity of Care: OSV Tips

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› Health Center makes efforts to establish & maintain collaborative relationships with other health care providers in its service area, such as

• Hospitals

• Other Health Centers

• Private providers

• Community stakeholders

› Health Center must coordinate & integrate project activities to the extent possible

› If a Health Center expands its scope of project, it must obtain letters or other appropriate documents describing areas of coordination or collaboration with providers serving similar patient populations in the service area. However, if the Health Center is unable to obtain these letters/documentation, the Health Center must document its attempts to coordinate or collaborate with these providers.

Collaborative Relationships

Document collaborative relationships in writing, e.g., through an MOU

Collaborative relationships can be with both health care & non-

health care entities

Community groups & professional/trade

organizations can be considered collaborative

relationships

Collaborative Relationships: OSV Tips

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› Health Center board maintains appropriate authority to oversee the Center, including but not limited to

• Holding monthly meetings;• Developing bylaws;• Assuring that the Health Center is operated in compliance with applicable law & standards;• Selection/dismissal & performance evaluation of the CEO;• Establishment of policies for financial management, sliding fee, personnel & health care quality;• Selection of services to be provided, service sites & hours of operations & any subawards;• Approval of Health Center annual budget & application;• Oversight over overall plan for the Health Center;

Board Authority

• Long-range planning at least once every 3 years, including identifying priorities & 3-year plan for financial management & capital expenditures;

• Ensuring that a process is developed for hearing & resolving patient grievances • Evaluating the performance of the Health Center based on QA/QI assessment & other

information received from senior management, & ensuring appropriate follow-up actions are taken regarding

› Achievement of project objectives through evaluation of activities;› Service utilization patterns;› Quality of Care;› Efficiency & effectiveness; &› Patient satisfaction, including patient grievance

Board Authority

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› The Health Center’s board of directors is no longer required to perform a self-assessment

› The Board must evaluate the performance of the Health Center

› The Board has discretion to determine whether to establish standing committees, including the number & type of such committees

› The Board has discretion to determine how often the Project Director’s/CEO’s performance is evaluated

Board Authority: OSV Tips

› HRSA is focusing on whether there was a quorum at a meeting (if not, HRSA is taking the position that the meeting does not count)

› Consider changing quorum requirements (subject to state law)

› If it is not documented, it did not happen

› Spread actions out throughout the year rather than all at once at one meeting

› Make sure that training/education about the Program Requirements & the Health Center’s compliance with the requirements is provided to the Board in advance of the OSV

Board Authority: OSV Tips

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› The Health Center governing board is composed of between 9 & 25 individuals, the majority of whom who are patients of the Health Center (the have received at least 1 in-scope service in the prior 24 months that generated a visit) & who, as a group, reasonably represent the individuals served by the Health Center in terms of demographic factors such as race, ethnicity & gender

› Remaining non-consumer members of the board must be

• representative of the community in the Center’s service area • selected for their expertise in community affairs, local government, finance & banking,

legal affairs, trade unions & other commercial & industrial concerns, or social service agencies within the community

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

› No board member can be an employee of the Health Center or an immediate family member of an employee

Board Composition

› Board composition should be reviewed at least annually

› Evaluate whether the Board represents patients in terms of race, gender, etc.

› Members only count as User/Consumer Board members if they had a visit that would be billable within the past 24 months

Board Composition: OSV Tips

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› Health Centers have discretion in how they define “Health Center industry” for purposes of Board composition & how to determine the percentage of annual income of each non-patient board member derived from the health care industry

› Health Centers must periodically verify that the Board does not include members who are current employees of the Health Center or immediate family members of the current Health Center employees, i.e., spouses, children, parents, or siblings through blood, adoption or marriage

Board Composition: OSV Tips

› Health Centers must submit an annual deeming application that demonstrates that the Health Center

• Implemented policies to reduce risk of malpractice & lawsuits • Credentials its physicians & other clinical staff in accordance with

requirements• Has no history of claims, or if such history exists, fully cooperates with

the U.S. Attorney General• Affirms that it will fully cooperate with the U.S. Attorney General & other

applicable agencies

Federal Tort Claims Act Deeming Requirements

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› Health Centers must provide risk management reports to the Board, & provide documentation to the Board & key management staff showing that any related follow-up actions have been implemented

› Health Centers also need to set risk management goals & report back to the Board on success in achieving the goals

› Health Centers determine how to inform patients that it is deemed a federal public health service employee, i.e., through website, promotional materials &/or within areas in the Health Center that is visible to patients

Federal Tort Claims Act Deeming Requirements

› Establish a risk management training plan

› Develop Incident Reporting Form that identifies issues, any relevant witnesses• Incidents should be tracked & any trends identified

• Report incidents to Quality Assurance Committee

• Include in reports to key management & the Board

› Develop patient grievance process

› Establish risk management goals that reduce identified risk, e.g., reduce response time to patient grievances

› Identify ways to track progress in achieving goals, e.g., patients were contacted 1 day sooner to discuss their grievances

› Ensure that the Health Center has policies & practices that address hospital, referral & diagnostic/lab tracking

Federal Tort Claims Act: OSV Tips

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Continuing Professional Education (CPE) Credit

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org.

The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

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CPE Credit

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The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.