As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level. This month’s webinar will focus on the following chapters: Chapter 11: Key Management Staff Chapter 14: Collaborative Relationships Webinar attendee takeaways will include: · Understanding the requirements and why they are important · Methods to maintain continuous compliance (without addressing it last minute or only during an OSV) · How to use the requirement in everyday practice to improve your Community Health Center

1. www.compliantfqhc.com
Continuous Compliance Series- It’s not JUST an OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Jennifer Genua-McDaniel
jgenua@genuaconsulting.com

2. Key Management Staff and
Collaborative Relationships

4.  This presentation is not endorsed by Management
Strategists Consulting Group (MSCG)
 This presentation is not endorsed by Health
Resources Services Administration (HRSA) or Bureau
of Primary Health Care (BPHC)
 Not employed by MSCG or BPHC
 Independent Consultant who is contracted to do
Operational Site Visits (OSVs) and Technical
Assistance (TA)
 Not intended to provide legal advice

5.  Continuous Compliance = HRSA funding
◦ Monthly focus on various HRSA Compliance Chapters
 Do something different than just “plain, old,
boring Operational Site Visit preparation”
◦ Generative approach
 What are the requirements?
 Do we understand them?
 Can we take it to the next level and use compliance for
excellence?
 Virtual OSVs continue

6.  Understand the requirements and why they are
important
◦ Every month HRSA Compliance chapter requirements
presented
 Methods to maintain continuous compliance
◦ Without doing it at the last minute or when told, “hey
we’re having an OSV in 3 months”
 How to use the requirement in everyday practice
◦ Make your Community Health Center awesome!

7.  Compliance:
◦ Composition and Functions of Key Management Staff
 Functions and allocation of time for each key management position
sufficient to carry out the scope of project
◦ Documentation of Key Management Staff Positions
 Determined by HRSA, NOT during the site visit
◦ Process for Filling Key Management Vacancies
 If any positions are open, how will the health center fill those positions?
◦ CEO Responsibilities
 Directly employed by the health center
 Oversee the key management staff in day-to-day activities of the health
center
◦ HRSA Approval for Project Director/CEO Changes
 If the health center has had a change (during the start of the project),
did HRSA approve it?

8.  Key Management Take-Aways:
◦ Appropriate oversight of the health center program
 Based on size and complexity of the organization
 If you have part-time senior staff that oversee the program,
are they able to provide appropriate oversite?
 The health center decides what key management and
responsibilities look like

9.  Key Management Take-Aways:
◦ Vacant key management positions happen!
 Ensure there is a plan/process in place to fill the position
 No warm body hires (intentional hiring)
◦ Having a key position vacant doesn’t mean an area of
non-compliance during a site visit

10.  Key Management Take-Aways:
◦ CEO/Project Director
 Sometimes is NOT the same person
 Public Entities (funded as co-applicant health centers) may
have a different model. The Project Director/CEO may be
directly employed by the public entity (designee of record)
 To assess compliance, the Project Director/CEO should
demonstrate employment with a W-2 or paystub
 An Interim CEO must still be employed by the health center

11.  How to keep this requirement compliant
◦ Evaluate your organizational chart and add the number
of “FTEs” to determine oversight
◦ Keep job descriptions current especially during growth
 Can become outdated
 Not reflective of current practice
 Difficult for accountability
◦ Notify HRSA if the CEO/Project Director changes
 Done through a prior approval with EHB
 Resume, Board of Director meeting minutes approval of new
CEO/Project Director
 Will receive a new Notice of Funding Award when approved

12.  How can a Gap Analysis Help My Community
Health Center?

13.  Provides insights regarding growth of an
organization
◦ Adding staff, streamlining services
◦ Brick and mortar vs working from home
 Provides insight on the structure of the
organization
◦ Other lines of business
◦ Reporting relationships

14.  Source: Instagram

15.  Compliance:
◦ Documentation of established collaboration with
other providers and organizations in the service
area
 Local hospitals, providers, social service organizations,
specialty providers
◦ Documentation of coordination efforts with other
federally-funded, state, and local health services
 Includes efforts to work with other health centers in
the service area

16.  Collaborative Relationships Take-Away:

17.  Collaborative Relationships Take-Away:
◦ Determination of collaborations is up to the
health center
 Can be through MOAs, letters, minutes of coalition
meetings, emails, etc.
 Can be letters of support between health centers
 Can be shared referral arrangements
◦ What if you don’t have a health center in your
service area?

18.  How to keep this requirement compliant
◦ Relates to various requirements (Required and Additional
Services & Form 5A)
 Evaluate what agencies/resources your community has
 Keep a list of entities/individual providers you
collaborate with, OR
 Determine any that you’re not collaborating with and
reach out
◦ Able to decrease duplication within the service area
◦ Able to provide services that your health center may
be unable to provide

19.  Best Practice:
https://compliatric.com/

20.  Part of various certifications
◦ NCQA (PCMH), JACHO, HRSA, etc.
 Organization reputation
◦ Community “team player”
◦ “Today’s patient experience=tomorrow’s
reputation”
◦ Patient centered and focused on social
determinants of health

21.  https://bphc.hrsa.gov/programrequirements/compliancemanual/in
dex.html
 https://www.healthcenterinfo.org/

22.  Jennifer Genua-McDaniel, BA (Hons), CHCEF
◦ Genua Consulting, LLC
◦ jgenua@genuaconsulting.com