Watch the Webinar Here: https://compliatric.com/continuous-compliance-chapters-18-20/ 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 18: Program Monitoring Chapter 20: Board Composition 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

3. Presentation not endorsed by Management Strategist Consulting Group
(MSCG)
Presentation not endorsed by Health Resources Services Administration
(HRSA) or Bureau of Primary Health Care (BPHC)
Not employed by MSCG or HRSA/BPHC
Independent Consultant contracted to completed Operational Site Visits
(OSV)s and Technical Assistance (TA)
Presentation not intended to provide legal advice
For specific questions, please contact your HRSA Point of Contact

5. Updates to the Site Visit
Protocol (SVP)
Methods to maintain
continuous compliance
Requirements are the foundation,
not the ceiling
Using the requirements in
everyday practice
“Good to Great” to improve
excellence

7. Program Monitoring and Data
Reporting Systems

8.  Compliance:
◦ Element A:
Ensuring systems are in place to oversee operations of the
federal award supported activities and to monitor
performance

9. Considerations for Element A:
Timely submission of UDS reporting
Timely submission of other HHS or HRSA request
Data systems a health center utilizes
•Health Records
•Practice Management Systems
Has your health center changed health
records?

10.  Compliance:

11.  Considerations:
◦ Collecting data and putting it in a format that staff
and board can understand to make informed
decisions
◦ Reports must support decision making in the
following:
 Patient service utilization
 Trends and patterns in the patient population
 Overall health center clinical, financial or operational
performance

12.  Considerations:
◦ Patient Service Utilization Reports
 Number of patients, number of no shows, departmental
trends
 Covid-19 vaccination rates, testing rates
 Integration rates by service lines
◦ Trends and Patterns in the Patient Population
 Patient Surveys
 Special population data-homeless, migrant and seasonal
agricultural workers, public housing
 Tele-health vs. in-person visits
 Changes in your zip codes

13.  Considerations:
◦ Overall Clinical, Financial and Operational Performance:
 Clinical quality metrics
 UDS data
 PCMH measures
 Financial measures required by grant funding
 Days in Accounts Payable
 Days in Accounts Receivable
 Medical cost per medical patient compared to grant cost
 Days cash on hand
 Liquidation of assets
 Chart closure times

14.  How to keep this requirement compliant
◦ Analyze systems to ensure that you can get data out
 How many systems do you use to get an answer for one
piece of data?
◦ Ensure that reports used can “tell you something”
 If they don’t, re-evaluate what you’re using
◦ Data reports support changes within your health center
◦ Meet as a team to review reports for internal decision
making

15.  Visual reports are easier to read
 “Does the board receive appropriate data to make a
decision?”
 “Is it too much data or too little?”
◦ Let reports speak for themselves

18. Source: Instagram

19. Board Composition

20.  Compliance:
◦ Element A: Board Member Selection and Removal
Process

21.  Compliance:
◦ Element B: Required Board Composition

22.  Compliance:
◦ Element C/D: Current Board Composition &
Prohibited Board Members
 Does the Board of Directors represent patients served?
 Health Centers that have special populations funding
must ensure:
 1 or more board members that serves as a representative
of the population served
 Ex. If you are funded for 2 special populations, then you
must have 2 board representatives for those patient
populations
 Immediate family members (spouses, children,
parents, siblings through blood, adoption or marriage)
can’t be board members

23.  Compliance:
◦ Element C: Current Board Composition
 Clarification:

24.  Compliance:
◦ Things to consider:
 Health Centers that ONLY receive special populations
funding may have a “waiver” for the 51% board
composition
 Demonstrate, collect and document input
 Examples of how the special population impacts board
decision responsibilities (Board Authority, Element C)

25.  Things to consider:
 Health Care Industry Sample:
◦ Health care industry is defined as "hospitals and other
healthcare institutions, nurses, dentists and other licensed
healthcare professionals whose primary responsibility is
providing primary preventative and therapeutic healthcare
services".

26.  Things to consider:
◦ Board Characteristics (Form 6) reflective of current
board not just during the site visit
 Comparison of health center website Board of
Directors’ list versus documentation provided
 Update information
◦ Board Matrix
 Can provide direction on board member recruitment
 What skillsets are needed?
 Always recruiting for board members

28.  Things to consider:
◦ Prohibited Board Members
 How do we know? How does a health center ensure?
 Can ask in the board application
 Can ask in the annual Conflict of Interest
 “The Health Center verifies periodically…”

29.  Board Recruitment
◦ Industry standard is NOT 9 board members
 The number of board members is up to the health
center (as long as between 9-25 and 51% patients)
◦ How to find board members?
 ALWAYS RECRUIT
 Staff are key= know the patients
 Individuals sitting on committees
 When there is an opening, they can join the board

31. All Program Requirements have been covered
Series has been recorded with access to samples and
templates
Questions received during webinars have been answered
What’s next:
Feedback from participants for variety of topics
Exciting new topics for 2023

32.  https://bphc.hrsa.gov/programrequirements/compliancemanual/in
dex.html
 https://bphc.hrsa.gov/programrequirements/svprotocol