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.
Board Authority (Chapter 19)

3.
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

4.
 Updates to Site Visit Protocol (SVP) for Board
Authority
 Understand the requirements and why they are
important
 Methods to maintain continuous compliance
◦ Requirements are the “floor not the ceiling”
 How to use the requirements in everyday practice
◦ “Good to Great” to improve excellence

5.
 OSVs transitioned from in-person to virtual
during the Covid-19 pandemic
◦ Site visits will continue to be the primary mode of
assessing compliance
◦ HRSA has started reassessing and phasing back into
in-person visits (late summer/1st quarter FY 2023)
Number of Operational Site Visits Completed
Completed in 2021 October 2021-June 2022
569 308

6.
 Compliance:
◦ Elements A & B are related to official documents of the health
center
 Bylaws, Articles of Incorporation, other relevant corporate
documents, etc.
(Board Authority, Element A #2)
◦ Public Agencies (Co-Applicant Boards) ensure that the co-
applicant agreement has the required language needed
 Delegation of duties, role and responsibilities delineation

7.
 Compliance:
◦ Board Authority, Element B:

8.
 Compliance:
◦ Board Authority, Elements C, D, E

9.
 Compliance:
◦ Board Authority, Elements D, E
 In the last 3 years, adopted, evaluated the following policies:
 Sliding Fee Discount Program
 Quality Improvement/Quality Assurance Program
 Billing and Collections
 INCLUDING a policy for waiving or reducing patient fees
 IF APPLICABLE: Refusal to Pay policy
 Financial Management and Accounting Systems
 Personnel
**Health Centers that are Public Entity, Co-Applicant Model, Fiscal and
Personnel can be N/A if it’s stated in the co-applicant agreement and bylaws
that Public Entity will oversee**

10.
• In the past 12 months,
how has the board
demonstrated their
required oversite?
• Keep a checklist of
completed duties
• Oversite may be
on-going (ex.
Updates of a
renovation or new
service line)
• Document, Document,
Document
• Discussion reflected
in meeting minutes

11.
 Project Objectives:
◦ Goals that you have
written within your HRSA
grant
◦ Funding you have
received:
 Covid Cares Funds
 School Based Health Centers
 2022 HRSA ARP-UDS Awards
◦ Completion of various
projects
◦ Strategic Plan

12.
 Service Utilization
Patterns:
◦ Number of patients
◦ Number of no shows
◦ Departmental trends
◦ Integration of service
lines
◦ Telehealth vs In-person

13.
 Quality of Care
◦ Clinical Measures for
various service lines
◦ Other quality measures
◦ Any other data that
measures quality
 Social determinants of
health
 Chart closure times
 Open referrals vs closed
referrals

14.
 Efficiency and
Effectiveness of the
Health Center
◦ Financial Data
◦ Fiscal Measures
 Grant Cost per Total Patient
(330 funded)
 Total Cost per Total Patient
 Medical Cost per Medical
Visit
◦ Time Studies
◦ Strategic Plan updates

15.
 Patient
Satisfaction/Grievances
◦ Feedback on telehealth
◦ Any additional
services/locations
◦ How do they feel about
the care they get?
◦ What can your health
center improve on?
 Call back from back office
 Test results
 Wait times
BEST PRACTICE:
Report results to
the board
quarterly

16.
 Within the last 3 years, has the
board adopted and evaluated the
following:
◦ Sliding Fee Discount Program
◦ Quality Improvement/Assurance
◦ Billing and Collections
 Policy for waiving or reducing patient
fees
 Refusal to pay (IF APPLICABLE)
◦ Financial Management and Accounting
Systems**
◦ Personnel**
**Health Centers where the Public Entity retains authority, Financial Management and Accounting Systems and
Personnel are “N/A”**

17.
 Spend time with the Board of Directors:
◦ How the board oversees the health center program
◦ Do they understand their roles and responsibilities?
◦ Is the data provided easy to understand, in their
preferred language, so they are able to make decisions?
◦ How is clinical and financial data provided?
◦ If the health center has special populations, how are
those populations represented on the board?

18.
 Source: Instagram

19.
 How to keep this requirement compliant:
◦ Keep a calendar or schedule to ensure governance
requirements are completed
◦ Meeting minutes are key!
 Consistent documentation to capture board discussion
 Use Roberts Rules of Order
 HRSA required approvals should not be in a consent
agenda
 Business conducted is reflective of current process

20.
• “Hi Jenn… my name is… do I have to do…. even though HRSA
doesn’t say I have to?”
• “Hi Jenn… HRSA says I have to do…. But it’s too much… how do I
get around it?”
Requirements are the floor not the ceiling
• Does it affect my federal funds?
• Does it affect my HRSA designation?
• What impact does meeting the bare minimum have?
• If my health center meets the bare minimum, what does it say about
my organization and the culture within my health center?
• Did my health center review my state non-profit laws?
Questions to consider:

21.
 Example #1
◦ Question: Do policies need to be signed by the
Board Chair or the Board?
◦ Answer:
 It’s not a HRSA requirement (Compliance Manual,
Protocol)
 FTCA Applications in the past-required signed policies
by the Board Chair
 What do bylaws and governance policies say?
 Board Chair and/or designee
 Are there other state/federal grants that require it?
 A health center would also want to look at
parliamentarian procedures (Roberts Rule of Order)

22.
Ensure work is reflective of
current practice
•Change policies or
workflows to match current
health center practices
•Update bylaws
•Officers and Committees of
the board
Work towards generative
thinking boards
•Visionary boards asking the
tough questions
•Focusing on the bigger
picture
•“Why” doesn’t matter-it’s the
meaning behind it
•Ex. What is the meaning
behind the increase of
diabetes in our community

23.
https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html
https://www.healthcenterinfo.org/
https://bphc.hrsa.gov/programrequirements/svprotocol

24.
 Jennifer Genua-McDaniel, BA (Hons), CHCEF
◦ Genua Consulting, LLC
◦ marketing@compliatric.com