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

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 (OSVs) and Technical
Assistance (TA)
 Not intended to provide legal advice

4.
 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

5.
 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!

6.
 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?

7.
 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

8.
 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

9.
 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

10.
 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

11.
 How can a Gap Analysis Help My Community
Health Center?

12.
 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

13.
 Source: Instagram

14.
 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

15.
 Collaborative Relationships Take-Away:

16.
 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?

17.
 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

18.
 Best Practice:
https://compliatric.com/

19.
 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

20.
 https://bphc.hrsa.gov/programrequirements/compliancemanual/in
dex.html
 https://www.healthcenterinfo.org/

21.
 Jennifer Genua-McDaniel, BA (Hons), CHCEF
◦ Genua Consulting, LLC
◦ jgenua@genuaconsulting.com