Preparing for a Successful Operational Site Visit

Presented By:

Bridgette Madden, CEOCommunity Health & Dental Care, Inc.

&

Jim Kelly, ConsultantJames P. Kelly, LLC

Keys to a Successful Operational Site Visit• Be prepared• Make Key Staff Available to meet with Reviewers during the entire visit• No Surprises• Complete the HRSA Health Center Site Visit Guide in preparation of visit• Make sure Board members are present for Entrance Conference, Exit Conference and Luncheon with

Reviewers• Don’t fear the visit• Understand the 19 Program Requirements and each component of the requirements• Respond to all requests from the HRSA Project Officer and the Team leader in a timely manner• Respond to requests for information that occur prior to the site visit• Don’t withhold any requested information• Have a key staff member responsible for working with the reviewers on information requests

Preparation• Review the Health Center Site Visit Guide (Updated October 2012)• Go to: BPHC.HRSA.gov/administration/visitguide.pdf

• Review HRSA program Requirements• Go to: BPHC.HRSA.gov/about/requirements.htm

• Visit Explanation of the Visit• Go to: PACHC.com/pdfs/is%20your%20health%20center%20making%20the

%20grade%20-%20HRSA

Requirement #1- Needs Assessment• Health Center demonstrates and documents the needs of its target population,

updating its service area, when appropriate.• Health Center:

• Do you know your community?• Was the needs assessment Board approved? Do you have a Board approved policy for a needs

assessment?• Did you use the UDS Mapper to identify your service area and was it Board approved?• Does your staff understand what components are included in a needs assessment?

• Reviewer:• Is there a written Needs Assessment?• How recent is the Needs Assessment?• Does the Needs Assessment involve other community organizations?• Has the Service Area been updated?

Requirement #2- Required and Additional Services• Health Center provides all required primary, preventive and enabling services as appropriate and necessary, either directly or

through established written arrangements and referrals.

• Health Center:• Do your hospital agreements specify compensation, admission notification, discharge follow-up, exchange of information, credentialing and a

description of proactively tracking referrals?• Do your Specialist agreements specify sliding fee discount, process to track referrals back to and from Health Center, and credentialing?• Do you have adequate translation services for your patients? How are they covered after hours?• Do you have signs posted throughout the Health Center about the sliding fee and is it in appropriate languages?• Do you have a sign on the door indicating what patients should do after hours?• If Health Center has 340B pharmacy do the policies reflect current practice? If sample meds are being utilized, are they logged and secure?• Are training records kept for staff receiving training? • Did you practice “crash cart” emergencies with staff and document results?

• Reviewer:• Are all appropriate written agreements up-to-date and signed?• Are all Memorandums of Understanding (MOUs) up-to-date and signed?• Is the Form 5A from Federal Grant accurate and reflective of services being provided?• Does Health Center provide cultural competency training to staff?• Are there written Procedures/Tracking mechanisms in place for specialty referrals? (FTCA)• Can you track/follow-up on missed specialty care appointments? (FTCA)

Requirement #3- Staffing• Health Center maintains a core staff as necessary to carry out all required primary, preventive and enabling health services,

as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged.

• Health Center:• Do you know your budgeted FTEs compared to actual FTEs and does it fit your organization?• Are employee’s receipts of receiving, reading and signing the employee handbook properly filed in employees file?• What is your process for communicating updated/new policies to the staff?• Are you following your credentialing and privileging policies? Do you offer temporary privileges?• Are you including the mission, vision and values in every job description?• Do you have key staff performance evaluations completed, signed and dated?• Provider contracts- if you use them, read what is expected to be in them.• Staff Orientation- was it completed? Use this time to educate the staff about HRSA and expectations of Program.• Are you sharing staff survey results and recommending improvements to QI/QA and or Performance Improvement Committee?

• Reviewer:• Are all key positions full-time?• Is provider staff sufficient to meet the needs?• Are providers appropriately privileged and credentialed? (FTCA)• Are Job descriptions up-to-date?• Are employment contracts up-to-date and signed?• Does Health Center perform or outsource their Privileging/Credentialing?• Are all components of Privileging/Credentialing appropriately documented and approved by the Board (FTCA)

Requirement #4- Accessible Hours of Operation/Locations• Health Center provides services at times and locations that assure accessibility and meet the needs

of the population to be served.

• Health Center:• Take a walk throughout the Health Center and confirm signage is clear for patients and properly placed• Are offices properly labeled for easy patient flow?• Are operational hours the same as indicated in your grant?

• Reviewer:• Are hours posted and visible to all those entering the Health Center?• Are posted hours in appropriate languages?• Does Health Center have sufficient exam room space to meet the demand?• Are service sites accessible to service area?• Does Health Center offer Saturday hours?

Requirement #5- After Hours Coverage• Health Center provides professional coverage for medical emergencies during hours when the

center is closed.

• Health Center:• If Health Center provides dental, how are emergencies handled after hours?• How does the on-call staff verify it is a registered Health Center patient calling?• Does the answering service provide an activity log to the Health Center the following day so staff can make

sure the emergency/phone call is documented in patient’s chart and proper follow up care is provided?• Test your phone system after hours and add questions on patient survey to rate answering service

satisfaction. • Reviewer:

• Reviewer will call Health Center after hours to assess process in place.• If coverage is provided by non-Health Center staff, are agreements/MOUs in place, up-to-date and signed?• Can answering service communicate in appropriate languages to meet the needs of population?

Requirement #6- Hospital Admitting Privileges and Continuum of Care• Health Center Physicians have admitting privileges at one or more referral hospitals or

other such arrangements to ensure continuity of care. In cases, where hospital arrangements are not possible, Health Center must firmly establish arrangements for hospitalization discharge planning and patient tracking.

• Health Center:• Spell out and detail out how Health Center and hospitals are ensuring continuity of care-

especially with hospitals using hospitalists• Can the Hospital or other Providers easily get in touch with Health Center and not get “stuck” in

the phone tree?• Work collaboratively as possible with hospitals to detail out follow up and revise as needed.

• Reviewer:• Are hospital agreements/MOUs up-to-date and signed? (FTCA)

Requirement #7- Sliding Fee Discounts• Health Center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patients

ability to pay.

• Health Center:• Test your own policy, pretend you are a patient and make sure application makes sense. Add additional information to the sliding fee

packet- reduced lab costs, payment plan options, any other relevant information to help patients.• How did you determine your nominal fee? Is it Board approved and documented in minutes?• Are your charges high enough to offset sliding fee adjustments? Do you know the cost per visit?• Do you have a separate sliding fee schedule for dental, medical, behavioral and/or pharmacy? Are you testing it to make sure it is

properly being recorded in billing system?

• Reviewer:• Is there a written Sliding Fee Policy?• Is Health Center following the policy?• Is signage readily visible in the Health Center that services are provided without regard to the patient’s ability to pay?• Will meet with Registration staff to walk through the sliding fee determination process.• Is the Sliding Fee available for all services provided under arrangement?• Discounts are not offered to patients above 200% of Federal Poverty Guidelines (“FPG”)• Full discounts are offered to patients below 100% of FPG.

Requirement #7- Sliding Fee Discounts- continued• Nominal Fees are in place and consistent• Are the most recent FPGs being utilized?• Are different sliding fees used for the different services provided (medical,

dental, lab, etc.)?

Requirement #8- Quality Improvement/Quality Assessment Plan• Health Center has an ongoing QI/QA Program that includes clinical services and management and that

monitors the confidentiality of patient records.• Health Center:

• Is their representation from each department at the QI/QA Meeting? Do you have subgroups?• Does the CMD/CDO report updates on HRSA clinical benchmarks to the Board and Staff on a continuous basis? (FTCA)• Is the Medical Records space locked with limited staff having access?• How is the Health Center doing peer reviews? Is there an approved policy in place?• Is there a standard method in place to assist staff in identifying problems- PDSA cycles? (FTCA)• Does the Board/Staff receive an annual QI/QA Plan of results to help prepare objectives for the following year?

• Reviewer:• Is the Chief Medical Officer/Medical Director/Clinical Director (“CMO”) an integral part of the Plan? (FTCA)• Are all components of the Health Center represented in the QI/QA process?• Is QI/QA a clear component of the CMO’s Job Description?• Has the QI/QA Plan been reviewed/approved/signed by the Board within the last 3 years? (FTCA)• Are QI/QA audit results reported to the Board? (FTCA)• Does the Health Center have appropriate professional liability coverage in place?

Requirement #9- Key Management Staff• Health Center maintains a fully staffed Health Center Management Team as appropriate for the size and needs

of the center.• Health Center:

• Is the key management involved in strategic planning?• Are strategic planning goals incorporated into key management’s performance evaluations?• Does the CMO/CDO operate their departments? Do they understand budgeted goals and expectations?• Does the Health Center permit time for training key management and staff?• Is there ownership by the employees?

• Reviewer:• Who makes up the Management Team?• Are all Management Team members full-time?• Are any Management Team members shared with other organizations?• What is the Chief Financial Officer’s background?• If Chief Executive Officer is a clinician, how many hours per week are devoted to administration vs. clinical?• Is the communication between Management Team and Board appropriate?

Requirement #10- Contractual/Affiliation Agreements• Health Center exercises appropriate oversight and authority over all contracted

services, including assuring that any sub-recipients meet Health Center Program Requirements.• Health Center:

• How often do you review contracts for expirations and term changes?• Do you have material contracts approved by the Board?• Are you making sure all vendors are not on the OIG exclusion list?• Are contracts assigned to key management staff to ensure compliance?

• Reviewer:• Are all contracts up-to-date and signed?• Do contracts appropriately protect the Health Center?• Are all contracted services covered under written agreement?

Requirement #11- Collaborative Relationships• Health Center makes effort to establish and maintain collaborative relationships

with the other health care providers, including other Health Centers in the service area of the center. The Health Center receives support from existing Health Centers in the service area.

• Health Center:• Does the Health Center have collaborative relationships that support emergency

preparedness and management plan/activities?• Does the Health Center attempt to reach out to other existing FQHC’s in the service area?

• Reviewer:• Are collaborative agreements up-to-date and signed?

Requirement #12- Financial Management and Control Policies• Health Center maintains accounting and internal control systems appropriate to the size and complexity of the organization

reflecting Generally Accepted Accounting Principles “(GAAP”) and support functions appropriate to the organizational size to safeguard assets and maintains financial stability.

• Health Center:• Do you have a cash budget? • Does Finance Committee have members who understand financials and are there training plans in place?• Are HRSA benchmarks being reviewed monthly with financials and are the benchmarks well defined so people understand?• Does the Board understand a balance sheet and are they being trained to ask the right questions?• Does the staff know how many medical, dental, etc. visits are expected each day by each Provider?• Is someone watching the cancellations/missed appts. and is the Health Center scheduling patients to compensate for lost appointments?

• Reviewer:• Are monthly financial statements prepared in accordance with GAAP?• Are staff functions appropriately segregated to avoid the appearance of internal control concerns?• Did the most recent Financial Audit identify Material Weaknesses or Internal Control Deficiencies?• Have such comments been addressed appropriately?• Is the Financial Audit in compliance with A-133?• Is the Health Center demonstrating financial stability?• Does the Health Center track all key financial ratios and present to the Finance Committee and Board on a regular basis?• What is the make-up of the Finance Committee?

Requirement #12- Financial Management and Internal Control Polices- continued

• Is Chart of Accounts adequate?• Does the Health Center provide monthly financial statements with comparison to budget

and prior year activity?• Do the monthly financial statements provide encounter data?• Can the Health Center appropriately report encounters, revenue, payments and

contractual allowances by payor?• Does the Health Center know the breakeven point for services?• Does the Health Center participate with all available Medical Assistance Managed Care

Plans?• Is the Line of Credit adequate?• Who has signatory authority?

Requirement #13- Billing & Collections• Health Center has systems in place to maximize collection and reimbursement for its costs in providing health services,

including written billing, credit and collection polices and procedures.• Health Center:

• Are you offering payment plans to patients- especially for dental services?• Are sliding fee adjustments higher than bad debt adjustments?• Is the staff collecting copays and if so, is the Health Center sharing how they are doing?• Phressia tablets, self checks in, patient portals are other opportunities for Health Centers to collect money• Health Centers are not free clinics- it is a business and it is okay to make money!• Does the billing office provide denial reports to Providers on a regular basis?• Does the billing office provide an unpaid claims report to key management?• Are securities in place so charges can not be “written off”

• Reviewer:• Are there written billing and collection polices and procedures in place?• Does the Health Center adjust accounts at time of billing or at time of payment?• Are Accounts appropriately written off in a timely manner?• Does the Health Center utilize a Collection Agency?• Does the Health Center bill for all services provided directly or thru written agreement- and for which Health Center pays for the

delivery of such service?

Requirement #14- Budget• Health Center has developed a budget that reflects the costs of operations, expenses and revenues,

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

• Health Center:• Does the budget track programs? • Is there a capital budget and a plan on how to fund it?• When does the budget need revision?• Are budget variance reports completed by Key management?

• Reviewer:• Is the budget prepared in accordance with GAAP?• Has the Budget been approved by the Board?• Does the Health Center compare the monthly financial statements to budget?• Is the Operating Budget the same as the Federal Grant Budget?

Requirement #15- Program Data Reporting Systems• Health Center has systems which accurately collect and organize data for program reporting and which support management decision

making.

• Health Center:• How are referral tracking reports? (FTCA)• Who is responsible for creating and analyzing reports?• Is data shared with employees? Both good & bad?• Is there a process in place to develop a workplan to improve data and decision making?• Is the data going in correct and is it coming out meaningful?• Does the Health Center have an emergency plan to recover if EMR goes down? Can the Health Center “drop” to paper?• Are IT systems secure and protected?

• Reviewer:• What systems are used for:

• Patient Revenue• Billing• Payroll• Financial Statements• Accounts Payable• Purchasing• UDS• EMR

Requirement #15- Program Data Reporting Systems- continued• Are there appropriate interfaces that allow for communication between

systems?• Does the EMR System produce the UDS Report?• Has the Health Center been timely in meeting Reporting deadlines, including

UDS, FFR and other such documents?• Does the Health Center have an up-to-date Strategic Plan?• Has the Strategic Plan been approved by the Board?• Does the Health Center monitor all performance measures on a timely basis?• Are back-up systems in place?• Are systems adequate in providing information?

Requirement #16- Scope of Project• Health Center maintains its funded scope of project (sites, services, service area, target population

and providers).• Health Center:

• How often is the scope of project compared to what is going on at Health Center?• How often is Form 5 reviewed for accuracy especially if Health Center is covered by FTCA?• Does the Board and key management evaluate scope of project for changes needed?• Does the Health Center know the point of full capacity?• Is there a marketing/outreach plan?

• Reviewer:• How do the projected patients and patient encounters compare to actual?• Has there been any change in number of Providers?• Has there been any new BPHC funding?• Has there been any significant change in operations?• How are actual encounters compared to capacity?• Are there any out-of-scope services?

Requirement #17- Board Authority• Health Center Governing Board maintains appropriate authority to oversee the operations of

the Center.• Health Center:

• Does the Board have a self-review process?• Does the Board approve the annual budget and utilize a annual board work plan to help Board members

understand important due dates and responsibilities?• Does the Board have a committee to keep track of Board terms?• Do the Board members have job descriptions and understand their role?

• Reviewer:• Does the Board meet monthly?• Does the Board approve the HRSA Grant application and Budget?• Does the Board approve all services?• Is the Board engaged in Strategic Planning?• Is there a Succession Plan in place?

Requirement #18- Board Composition• The Health Center Governing Board is composed of individuals, a majority of whom are being served by the Center and

this majority as a group, represents the individuals being served by the Center in terms of demographic factors, such as: race, ethnicity and sex.

• Health Center:• Does the Board review patient Board members to make sure they are “users” of the Health Center?• Is there a process for recruiting new board members and a plan to retain board members?• Is Board training offered on a recurring basis?• Does the board understand the bylaws and is the board in compliance with its composition?• Does the Board understand the 19 requirements?

• Reviewer:• How large is the Board?• What is the race, ethnicity and sex of each Board member and how does it compare to the target area?• Does the Board meet the 51% majority rule?• Has each identified patient Board member had a Health Center visit within the last 2 years?• Is Board composition in compliance with the Health Center Bylaws?• Does the Board have the appropriate expertise?• Do more than 50% of the non-patient Board members derive more than 10% of their annual income from the Healthcare industry?

Requirement #19- Conflict of Interest Policy• Health Center Bylaws or written corporate Board approved policy includes provisions that prohibit conflict of

interest by Board members, employees, consultants and those who furnish goods or services to the Health Center.

• Health Center:• Are all employees required to sign a new conflict of interest statement each year and is the entire policy filed in the employees

HR file?• Does the Health Center have a standard code of conduct in place for employees and Board members?• How often are bylaws reviewed for changes?• Are procurement policies and procedures in place and audited for compliance?• Does the Health Center track board members hours of service provided to the health center?

• Reviewer:• Do the Bylaws prohibit conflict of interest?• Do the Bylaws state that no Board member shall be an employee of the Health Center or an immediate family member of an

employee?• Do the Bylaws state that the CEO is a non-voting member of the Board?• Are conflict of interest statements obtained on a annual basis?• Are all conflict of interest statements up-to-date?

Contact Information

• Bridgette Madden, MBA: bmadden@ch-dc.org

• Jim Kelly, James P. Kelly, LLC: jpkelly179@aol.com