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

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

3. Key Management Staff and
Collaborative Relationships

5.  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………………………………….

7.  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

8. 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!

9. Key Management Staff

10.  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?

11.  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

12.  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

13.  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

14.  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

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

16. 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

18. Collaborative Relationships

19.  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

20.  Collaborative Relationships Take-Aways:

21.  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?

22.  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?”

23.  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”)

24. 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

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

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