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2022 Compliatric Continuous Compliance Series - Chapter 11 and 14.pdf

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2022 Compliatric Continuous Compliance Series - Chapter 11 and 14.pdf

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Watch The Webinar Here: https://compliatric.com/continuous-compliance-2022-its-not-just-an-osv-prep-chapters-11-14/

Compliatric is excited to continue their “Continuous Compliance" Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.

This month’s webinar will focus on the following chapters:

Chapter 11: Key Management Staff
Chapter 14: Collaborative Relationships

Webinar attendee takeaways will include:

· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance - not only based on a site visit
· Improving operational excellence for your Community Health Center

Watch The Webinar Here: https://compliatric.com/continuous-compliance-2022-its-not-just-an-osv-prep-chapters-11-14/

Compliatric is excited to continue their “Continuous Compliance" Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.

This month’s webinar will focus on the following chapters:

Chapter 11: Key Management Staff
Chapter 14: Collaborative Relationships

Webinar attendee takeaways will include:

· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance - not only based on a site visit
· Improving operational excellence for your Community Health Center

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2022 Compliatric Continuous Compliance Series - Chapter 11 and 14.pdf

  1. 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. 2. 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
  3. 3. Key Management Staff and Collaborative Relationships
  4. 4.  Do something different than just “plain, old, boring Operational Site Visit preparation” ◦ Generative approach  What are the requirements?  Do we understand them?  What’s next? How to achieve operational excellence  Virtual OSVs continue until end of FY 2022  AND………………………………….
  5. 5.  NO changes to the Compliance Manual  Update to the Site Visit Protocol to reflect: ◦ Methodologies and refined questions ◦ Grammar, numbering, formatting  On or after May 26, 2022, will be released on the HRSA website  Health centers with site visits after May 26, 2022, should receive a zip file with new documents ◦ Usually, a month before your virtual site visit
  6. 6. Review the program requirements May 2022: Key Management and Collaborative Relationships Best practices to maintain continuous compliance How to use the requirement in everyday practice Make your Community Health Center awesome!
  7. 7. Key Management Staff
  8. 8.  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 virtual operational 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 through W-2, paystub, employment agreement, or other documentation  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?
  9. 9.  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 oversight?  The health center decides what key management and responsibilities look like
  10. 10.  Key Management Take-Aways: ◦ Vacant key management positions happen!  Health Center decides what a “key management position“ is  Ensure there is a plan/process in place to fill the position  No warm body hires (intentional hiring) ◦ Having a key position vacancy doesn’t mean an area of non-compliance during a site visit
  11. 11.  Key Management Take-Aways: ◦ CEO/Project Director  Sometimes this 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 be directly employed by the health center through W-2, paystub, employment agreement or other documentation  An Interim CEO must still be employed by the health center
  12. 12.  Best Practices: ◦ 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  Using systems to operationalize Human Resources? ◦ 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
  13. 13.  How can a Gap Analysis Help My Community Health Center?
  14. 14. Provides insights regarding growth of an organization •Adding staff, streamlining services •Brick and mortar vs tele-working Provides insight on the structure of the organization •Other lines of business •Reporting relationships
  15. 15. Collaborative Relationships
  16. 16.  Compliance: ◦ Coordination and Integration of Activities  Local hospitals, providers, social service organizations, specialty providers ◦ Collaboration with Other Primary Care Providers  Includes efforts to work with other health centers in the service area  Coordinate/integrate activities with other federally-funded, state and local health services delivery projects ◦ Expansion of HRSA Approved Scope of Project  Not assessed on a site visit
  17. 17.  Collaborative Relationships Take-Aways:
  18. 18.  Collaborative Relationships Take-Aways: ◦ 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?
  19. 19.  Collaborative Relationships Take-Aways: ◦ Health Centers that have special populations funding:  Homelessness  Public Housing  Migrant and Seasonal Agricultural Worker (MSAW) ◦ “How does your health center work with special populations?”
  20. 20.  Best Practices for this program requirement: ◦ 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 ◦ Goal: To decrease duplication within the service area  Able to provide services that your health center may be unable to provide (“can’t be all things to all people”)
  21. 21. 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
  22. 22.  https://bphc.hrsa.gov/programrequirements/compliancemanual/in dex.html  https://www.healthcenterinfo.org/
  23. 23.  Jennifer Genua-McDaniel, BA (Hons), CHCEF ◦ Genua Consulting, LLC ◦ marketing@fqhcwebinar.com

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