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.
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
(OSV)s and Technical Assistance (TA)
Not intended to provide legal advice
For specific questions, please consult your HRSA Point of Contact

3.
Updates to the Site Visit
Protocol (SVP)
Review clarification to the
elements
Methods to maintain
continuous compliance
Requirements are the foundation
not the ceiling
Best practices for health centers
Improving excellence
Using the requirements in every
day practice

4.
Contracts and Subawards

5.
 Please do the following:
◦ Review the Compliance Manual (Chapter 12
Contracts/Subawards) and footnotes
 https://bphc.hrsa.gov/compliance/compliance-manual/chapter12
 Definition of “simplified acquisition threshold” [small
purchase methods] and what those thresholds are based on
48 CFR subpart 2.1 and 41 U.S.C. 1907
◦ FQHC Look-Alikes:
 Does not apply BUT if received any HRSA funding during the
pandemic this may apply (Covid Cares $$). This includes
Chapter 13- Conflict of Interest
 If you’re having a site visit, please check with HRSA Point of
Contact
◦ Review the HRSA Sampling Guide
 https://bphc.hrsa.gov/programrequirements/svprotocol/resource-guide

6.
 Element A: Procurement Procedures
◦ Are they written?
 Describe how a health center makes purchases of
supplies, equipment, etc.
 Any procurement directly attributed to the federal
award conducted in a manner providing full and open
competition, consistent with federal cost principles
 45 CFR Part 75, Subpart E: Cost Principles
Also includes non-
competitive
proposals including
sole source
(45 CFR 75.329(f))

7.
 Element B: Records of Procurement Actions
◦ Review of (5) five contracts AND supporting
documentation that use federal award funds
https://bphc.hrsa.gov/compliance/site-visits/sampling-review#contracts

8.
 Element B: Records of Procurement Actions
◦ Based on documentation:
 Rationale for procurement method
 Selection of contract type (sole source, competition, etc.)
 Contractor selection or rejection
 Basis for contract price
◦ Comply with 45 CFR 75.328
 Open and fair competition and if not:
 Item is only available from a single source
 Public Emergency
 Non-competitive is authorized by HRSA
 Competition is determined to be inadequate after getting a few sources

9.
 Element C: Retention of Final Contracts
◦ Is the health center able to provide the final
executed contract?
 Retain financial records, supporting documents,
statistical records, and all other records pertinent to
the Health Center Program for a period of three years
from the date of the submission of the final
expenditures report to HHS
 Element D: Contractor Reporting
◦ How do you oversee contractor performance?
 Examples: Performance goals, invoices/payments
reconciled, UDS submission

10.
 Element F: Required Contract Provisions
◦ Contracts that support HRSA approved scope of
project
 Includes Form 5A, Column II contracts

11.
Element E: HRSA Approval for
Contracting Substantive
Programmatic Work
•HRSA approved (it will be in
Notice of Funding Award
[NOFA])
•A single entity for the majority
of health care providers
•Ex. Pass through entity, all
employees are leased except
for the CEO
Elements G-J: Subrecipient
Monitoring
•Subrecipient supports the
Health Center’s scope of
project
•Must comply with ALL HRSA
Program Requirements
•Health Center must monitor
the subrecipient and keep
records

12.
 Contracts (based on the HRSA requirements)
✓List of the entities involved
 Who is the contract with?
✓List of services to be provided
 Description of services
✓How will the health center pay for the services
 Invoiced monthly, quarterly, etc.
✓How will the service be documented in the patient
record?
 Will the contractor send a treatment plan? Will it be
documented in the health center’s health record?

13.
✓Assurances of Credentialing and Privileging
 “Provider agrees to provide Health Center with assurances that,
during the term of this contract agreement, it, and as
applicable, its individual healthcare practitioners furnishing the
services to health center patients are and will remain: 1) duly
licensed, certified and/or otherwise qualified to provide services
hereunder, with appropriate training, education and experience
in their particular field; 2) appropriately credentialed and
privileged; and 3) eligible to participate in federal health care
programs including Medicaid and Medicare”
✓Sliding Fee Discount Program (SFDP)
 “Discounts are provided in a manner that meets all Health
Center Program requirements, ex. health center applies its own
sliding fee discount to amounts owed by eligible patients;
contract contains specific sliding fee provisions; contracted
services are provided by another health center which applies a
sliding fee discount that meets structural requirements”

14.
✓Monitoring contract performance
 Ensuring that the contract is being carried out
 What documents will be requested?
 What happens if there is an issue with the service provided?
✓Data reporting expectations and intervals
 Will data will be provided to know the contract is going well?
Are you going to use invoices and cross reference payment
as a reporting expectation? What about treatment plans
received back in a certain period?
✓Provisions for record retention and access, audit and
property management
 Who owns the record? How long do you keep medical
records? What about audits and access to records?

15.
 How to keep this requirement compliant
◦ Create a checklist of HRSA requirements for
contracts
 Paper or electronic tracking of all contracts
 Ensure contracts are not expired, or monitor expiry
date by using a system or a platform
◦ Use the HRSA Center Self-Assessment Worksheet
for Form 5A: Services Provided
◦ https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/scope/fo
rm-5a-self-assessment-review.pdf
◦

16.
 How to keep this requirement compliant
◦ Work with legal counsel for standard contract
templates to ensure other contractual language
◦ Create addendums, if needed, for contracts (Quest,
LabCorp, etc.)
 If addendums are added, provide the entire contract
and addendums for review during site visits
◦ Keep contracts in one place

17.
Contracts help health centers provide services we may
not be able to offer in house
Ensure they protect the health center and provide
clarity to roles and responsibilities
Can help to avoid expensive and potential risk and
disputes

18.
 Source: Instagram

19.
Conflict of Interest

20.
 Element A: Standards of Conduct
◦ Do WRITTEN standards of conduct apply for the
selection, award and administration of contracts
that at a minimum apply to its procurement paid for
in whole or in part by the federal award?

21.
 Element A: Standards of Conduct

22.
 Element B: Standards for Organizational
Conflicts of Interests
◦ Do the standards prevent or mitigate any identified
or perceived conflicts of interest?
◦ Does a health center’s audit (A133) identify any
perceived or identified conflict of interest?
 (Review the two (2) most recent audits and
management letters)

23.
 Element C: Dissemination of Standards of
Conduct
◦ How does your health center inform employees,
officers, board members and agents of the conflict-
of-interest standards?

24.
 Element D: Adherence to Standards of
Conduct
◦ Reviewing of contracts from Chapter 12 (Contracts)
on procurement process
◦ Reading Board of Directors meeting minutes
◦ Is there documentation of a perceived or apparent
conflict in the past three (3) years?
 If so, what were the steps and what do the disclosures
state?

25.
 Considerations:
◦ Polices/Standard of Conduct must be reflective of
current operational practices
◦ If your bylaws only address Conflict of Interest for board
and officers, ensure that documentation is also provided
for employees and agents of the health center
◦ A conflict of interest does not mean that a health center
is out of compliance
 Follow the policies and procedures that your health center
has
 Declare and document the conflict

26.
 Be mindful of conflicts in the organization
◦ Sometimes it’s difficult in smaller rural areas
◦ Certain companies may have an
expertise/equipment that a health center needs
◦ Have employees sign conflict of interest statements
 Keep in Human Resource (HR) files
 A133 annual audits require Conflict of
Interest Statements signed by the Board and
Senior Team

27.
 https://bphc.hrsa.gov/programrequirements/compliancemanual/index.
html
 Health Center Self-Assessment Worksheet for Form 5A: Services
Provided (hrsa.gov)
 https://www.healthcenterinfo.org/
 https://bphc.hrsa.gov/programrequirements/svprotocol
 MOU-vs-Contracts_FINAL_20120117.pdf (changelabsolutions.org)

28.
 Jennifer Genua-McDaniel, BA (Hons), CHCEF
◦ Genua Consulting, LLC
◦ jgenua@genuaconsulting.com