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2022 Compliatric Continuous Compliance Series - Chapter 5.pdf

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2022 Compliatric Continuous Compliance Series - Chapter 5.pdf

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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 5: Clinical Staffing

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

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 5: Clinical Staffing

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 5.pdf

  1. 1. www.compliantfqhc.com Continuous Compliance Series- It’s not JUST an OSV Prep COMPLIATRIC WEBINAR SERIES Presented by: Michelle Layton BSN, MBA marketing@fqhcwebinar.com
  2. 2. Chapter 5 – Clinical Staffing
  3. 3. Disclaimers  This presentation is not endorsed by Management Strategists Consulting Group (MSCG)  This presentation is not endorsed by Health Resources Services Administration (HRSA) or the Bureau of Primary Health Care (BPHC).  Not employed by MSCG or BPHC  Independent Consultant who is contracted to conduct Operational Site Visits (OSV), provide Technical Assistance and assist health centers with preparation for their OSV  This information should not be considered legal advice Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be reproduced or disclosed under any circumstances without the express written permission of the aforementioned party.
  4. 4. Purpose of the Compliatric Series  HRSA’s evaluation of compliance during COVID-19 continues via Virtual Operational Site Visits (vOSV)  Provides an overview of the health center program requirements  Provides updates to the Site Visit Protocol and vOSV Process  Provides tips on “What to Expect”  Provides tips on “How to Prepare”  Provides a reviewer perspective
  5. 5. Purpose of the Compliatric Series  Compliance maintains HRSA funding ◦ Non-compliance can impact other Federal Programs (i.e., FTCA)  Continuous Compliance supports high performing health centers ◦ Eliminates the chaos of having to “prepare” ◦ Develops practices for operational excellence for the health center
  6. 6. Agenda  Back to Basics - Credentialing and Privileging  What has Changed?  Requirements for Compliance  Evaluation of Compliance  Maintaining Continuous Compliance – Factors to Consider  Question and Answer Session
  7. 7. Back to Basics
  8. 8. Back to Basics Credentialing and privileging… Oh… I thought they were the same thing?
  9. 9. Definitions Credentialing The process of assessing and confirming the qualifications of a clinical staff member Privileging/Competency The process of authorizing a clinical staff member’s specific scope and content of patient care services
  10. 10. Definitions Licensed Independent Practitioner (LIP) Physician, Dentist, Nurse Practitioner and Nurse Midwife, or “ any other individual permitted by law and the organization to provide care and services without supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges
  11. 11. Definitions Other Licensed or Certified Health Care Practitioner (OLCP) An individual who is licensed, registered or certified but is not permitted by law to provide patient care services without direction or supervision. Examples include: • Laboratory Technicians • Medical Assistants • Registered Nurses • Dental Hygienists
  12. 12. Definitions Other Clinical Staff A clinical staff member that performs services in a state, territory or other jurisdiction that does not require licensure or certification. Examples include: • Medical Assistants • Dental Assistants • Community Health Workers
  13. 13. Definitions Primary Source Verification Verification by the original source of a specific credential to determine the accuracy of a qualification reported by a clinical staff member. Examples include: • Internet verification (i.e., state database) • Direct correspondence • Reports from Credentials Verification Organization
  14. 14. Definitions Primary Source Verification Possible sources for PSV of education and residency for physicians include: • American Medical Association (AMA) Masterfile • American Board of Medical Specialties • American Osteopathic Association Physician Profiles • Education Commission for Foreign Medical Graduates (ECFMG) – International graduates licensed after 1986
  15. 15. Definitions Primary Source Verification Possible sources for PSV of certifications for other LIPs (i.e., PA, NP, etc.) include: • American Nurses Credentialing Center • American Midwifery Certifying Board • National Commission on Certification of Physician Assistants
  16. 16. Definitions Secondary Source Verification Methods of verifying a credential that are not considered an acceptable form of primary source verification. Examples include: • Notarized copy of the credential • Copy of the credential that is made from an original by approved staff
  17. 17. Definitions Reappointment The process of verifying expired credentials and re- privileging of a clinical staff member on a recurring basis
  18. 18. Credentialing and Privileging Activities Credentialing and Recredentialing activities for LIPs include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary source • Verification of education and training – Primary source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration • Verification of basic life support training
  19. 19. Credentialing and Privileging Activities Privileging and Reprivileging activities for LIPs include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Initial – Verification via training, education, reference reviews • Renewal – Verification via peer review, performance improvement activities
  20. 20. Credentialing and Privileging Activities Credentialing and Recredentialing activities for OLCPs and OCS include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary Source (OLCPs only) • Verification of education and training – Primary or Secondary Source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration (if applicable) • Verification of basic life support training
  21. 21. Credentialing and Privileging Activities Privileging and Reprivileging activities for OLCPs and OCS include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Based on Supervisory evaluation of clinical competence per the job description
  22. 22. Temporary Privileges • Privileges SHOULD: • Be granted in accordance with FTCA Guidelines • Be approved by the CEO upon the recommendation of appropriate department head • Privileges SHOULD NOT: • Exceed more than 90 days • Be renewed • Be granted in lieu of expired credentials
  23. 23. Credentialing and Privileging Activities Initial Privileging and Reappointment  Privileging is completed after the health center has verified all necessary credentials for a clinical staff member  Re-appointment is completed on a recurring basis (i.e., every two years), as determined by the health center  Re-appointment involves the verification of expired credentials and re-privileging/competency of clinical staff  The health center determines who has approval authority for credentialing and privileging
  24. 24. Credentialing and Privileging Activities Delineation of Privileges (Clinical Services) • Subsequent to credentials verification, the clinical staff member submits a request for clinical privileges, which includes completion of a Delineation of Clinical Services Form. • The Delineation of Clinical Services Form: • Includes only services and sites listed in the health center’s approved scope of project • Is specific to each specialty within the health center (i.e., Dental, Behavioral Health, Family Practice, Obstetrics) • Outlines Requested Services, Non-Requested Services, Approved Services and Non-Approved Services
  25. 25. What has Changed?
  26. 26. What has Changed? 2021 and 2022  The HRSA Health Center Compliance Manual has NOT changed  The HRSA Site Visit Protocol HAS changed (specific chapters as of 5/26/2022)  The HRSA Summary of Updates includes: ◦ 2021 updates made to increase effectiveness, clarify, consistency and transparency ◦ 2022 updates made to improve consistency with numbering formatting and grammar ◦ Other minor changes to include additional examples
  27. 27. What has Changed? 2021 and 2022  Element C – Review of Credentials ◦ Added notes to define the term “clinical staff” (2021)  Element D – Review of Privileges ◦ Added notes to define the term “clinical staff” (2021) ◦ Added a question requiring the reviewer to explain how Fitness for Duty is verified to ensure all clinical staff have the “physical and cognitive” ability to safely perform their responsibilities (2021)
  28. 28. What has Changed? 2021 and 2022  Element F – Credentialing and Privileging of Contracted or Referral Providers ◦ Clarified the methodology and questions by including examples of how the health center can assess contracts and referral arrangements to evaluate compliance with credentialing and privileging requirements. (2021)  Credentialing and Privileging File Review Resource ◦ Now titled “Examples of Credentialing and Privileging Documentation” ◦ The example used to verify Fitness for Duty now states an attestation can be confirmed by a licensed “provider” vs. a licensed physician designated by the health center. (2022)
  29. 29. Requirements for Compliance
  30. 30. Requirements for Compliance Element a: Staffing to Provide Scope of Services The health center has adequate clinical staffing, either directly or through formal written contracts or formal written referral arrangements, to carry out all required and additional services included in the HRSA approved scope of project.
  31. 31. Requirements for Compliance Element b: Staffing to Provide Reasonable Patient Access The health center has considered the size, demographics and health needs (i.e., large number of children served, high prevalence of diabetes) of the patient population in determining the number and mix of clinical staff necessary to ensure reasonable access to health center services.
  32. 32. Requirements for Compliance Element c: Procedures for Review of Credentials The health center has operating procedures for the initial and recurring review (i.e., every two years) of credentials for all clinical staff members (Licensed Independent Practitioners, Other Licensed or Certified Practitioners and Other Clinical Staff) providing clinical services on behalf of the health center who are health center employees, individual contractors, or volunteers.
  33. 33. Requirements for Compliance Element d: Procedures for Review of Privileges The health center has operating procedures for the initial granting and renewal (i.e., every two years) of privileges for all clinical staff members (Licensed Independent Practitioners, Other Licensed or Certified Practitioners and Other Clinical Staff) providing clinical services on behalf of the health center who are health center employees, individual contractors, or volunteers.
  34. 34. Requirements for Compliance Element e: Credentialing and Privileging Records The health center maintains files or records for its clinical staff (employees, individual contractors, and volunteers) that contain documentation of licensure, credentialing verification, and applicable privileges, consistent with operating procedures.
  35. 35. Requirements for Compliance Element f: Credentialing and Privileging of Contracted or Referral Providers If the health center has contracts with provider organizations or formal written referral arrangements for services provided in scope, the health center ensures providers are:  Licensed, certified or registered as verified through a credentialing process; and  Competent and fit to perform the contracted or referred services, as assessed through a privileging process.
  36. 36. Evaluation of Compliance
  37. 37. Evaluation of Compliance  Review of Documentation ◦ Policy/procedures for credentialing and privileging of LIPs, OLCPs and if applicable, other clinical staff ◦ Website URL ◦ Current staffing profile with name, position, hire date, FTE status, credential, provider type, specialty and translation capability (spreadsheet) ◦ Sample credentialing and privileging files (SVP, page 19) ◦ Credentials Verification Organization (CVO) contract (if applicable) ◦ Sample of the formal contracts/referral arrangements reviewed under Required and Additional Health Services ◦ Needs Assessment
  38. 38. Evaluation of Compliance Sub-Sample of Contracts for Column II and Column III services: • Column II – No more than three contracts with provider organizations. Prioritize contracts for clinical services offered only in Column II. • Column III – No more than three written referral arrangements. Prioritize agreements for clinical services offered only in Column III. • Do not select contracts/referral arrangements for enabling services (i.e., transportation, translation, etc.) as HRSA recognizes many of these will not include language to support appropriate credentialing and privileging.
  39. 39. Evaluation of Compliance  Staff Interviews ◦ Verification of process with Clinical Leadership and staff responsible for credentialing and privileging  Site Tours ◦ Tour of two sites, one where the majority of services are provided ◦ If a Column I service can not be observed during a site tour, documentation of the service in the patient’s medical record must be provided (Refer to Chapter 4 - Required and Additional Health Services)
  40. 40. Maintaining Continuous Compliance – Factors to Consider
  41. 41. Factors to Consider  The Credentialing and Privileging Policy does NOT require board approval – Best Practice? No  Credentialing and privileging of clinical staff (including LIPs) does not require board approval – Best Practice? No  The health center determines who has approval authority for credentialing and privileging  If the health center does not have OCS, they do not need to be included in the procedures  The health center must have a process for modification/revocation of privileges based on performance
  42. 42. Factors to Consider  The Compliance Manual is the minimum standard for credentialing and privileging of clinical staff  Federal Tort Claims Act (FTCA) regulations are the highest standard for credentialing and privileging of clinical staff  Follow the guidelines and examples for primary and secondary source verification outlined in the “HRSA Examples of Credentialing and Privileging Documentation”  An NPDB Query is required for ALL categories of clinical staff – No longer “as reportable”  Fitness for Duty must verify the “physical and cognitive” ability of the clinical staff member
  43. 43. Factors to Consider Examples of demonstrating compliance with credentialing and privileging requirements for contracted or referral providers include: ◦ Contracts/referral arrangements with provisions to support credentialing and privileging of the contracted/referral providers ◦ The contracted organization’s credentialing and privileging process ◦ The contracted organization’s documentation from a nationally recognized organization ◦ The contracted laboratory’s documentation of CLIA compliance
  44. 44. Resources
  45. 45. Additional Resources Compliatric https://www.compliatric.com/ HRSA Health Center Compliance Manual Health Center Program Compliance Manual | Bureau of Primary Health Care (hrsa.gov) HRSA SiteVisit Protocol Health Center Program SiteVisit Protocol | Bureau of Primary Health Care (hrsa.gov) HRSA Examples of Credentialing and Privileging Documentation Health Center Program SiteVisit Protocol: Examples of Credentialing and Privileging Documentation | Bureau of Primary Health Care (hrsa.gov) HRSA 2021 and 2022 Summary of Updates 2021 and 2022 SiteVisit Protocol: Summary of Updates | Bureau of Primary Health Care (hrsa.gov)
  46. 46. Questions & Answers
  47. 47. Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC marketing@fqhcwebinar.com

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