Webinar Here: https://compliatric.com/continuous-compliance-its-not-just-an-osv-prep-chapters-3-6/ Starting off 2022 means preparing for Operational Site Visits! Compliatric is excited to restart 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.

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. Needs Assessment and
Accessible Locations and Hours of Operations

4. 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

5. Continuous Compliance
Monthly focus on various HRSA
Compliance Chapters
Provide additional resources to include
best practices for preparation of the
OSV
What are the requirements?
Use compliance to be a generative
health center (higher functioning)
Visit Virtual visits will continue to be the primary mode of assessing
compliance for the foreseeable future
365 site visits are planned for 2022

6. UNDERSTANDING OF THE
PROGRAM REQUIREMENTS WHICH
INCLUDES UPDATES TO THE SITE
VISIT PROTOCOL (SVP)
MAINTAINING CONTINUOUS
COMPLIANCE NOT BASED ON A
SITE VISIT
IMPROVING OPERATIONAL
EXCELLENCE FOR YOUR HEALTH
CENTER

7. Needs Assessment

8.  Element A (updated):
◦ Comparison of Form 5B zip codes and most recent zip
codes provided in most recent UDS
 Where are your patients coming from?
 Does your Form 5B reflect updated zip codes?

9.  Element B:
◦ Updated at least once every 3 years?
 UDS data updated yearly
 What are the changes?
◦ Based on available data
 Local, state, federal information
 Most readily available information

10.  Element B:
◦ Needs Assessment Addresses:
 Healthcare Utilization
 Who are your patients? Where do they work? What do they do?
How do they get to your health center? What language do they
speak? What is their highest level of education?
 Significant Causes of Morbidity and Mortality
 Diabetes, high blood pressure, cancer, low birth weight babies,
behavioral health, health disparities-housing, racial injustice
 Unique Healthcare Needs
 Cultural/ethnic factors, physical environment, language needs;
pandemic
 Special Population Funding
 Must address the above

11.  Standardize when the data is updated and
evaluated
 UDS data must be submitted
 Federal Poverty Levels (FPL) updated
 Annual BPR update
 During your competing grant application
 Ensure data is up to date (census data, local data)
 Analyze the data to determine whether patients
are moving in and out of your service area
◦ Determination of additional services, change of location
may be warranted

12.  Documentation in files
◦ Board meeting minutes
◦ Committee meeting minutes
 Patient Surveys=Answers!
◦ Can provide valuable information
◦ Adapt questions to your community
◦ Provide open ended questions
◦ Analyze the trends
◦ Keep up to date on local news and information
 Significant workforce challenges due to Covid-19

13.  Keeping the pulse on your service area:
◦ Real Example:
 Local developer has started purchasing property and homes
around your service area
 The city and developer agreed to remove low income
housing and build a highway and shopping center
 Residents are moving out of the area (zip codes)
 Residents are living in an area that is not included in your
service area (do not have the zip code listed on your Form 5B
and not in UDS

14.  Needs assessment = basis for the strategic
plan
◦ Ask the questions to get honest feedback
◦ Foundation to expand services, locations, sites
◦ Able to understand the challenges and
opportunities
 Telehealth and COVID-19
 Workforce challenges

15.  Provides insights that you may not have
thought about
◦ Other lines of business
◦ Expansion of services (acupuncture, chiropractic,
etc.)
 May provide the foundation to determine if
there is a duplication of services in the
community

16.  Source: Instagram

17. Accessible Locations and
Hours of Operations

18. Element A:
• Accessible service sites
based on:
• Access barriers
• Distance and time for
patients to travel in-
between sites
• How does a health
center’s special
population access
locations?
Element B:
• Hours of Operations
based on:
• Patient needs
• Most requested
appointment times?
• Tele-health, on-site,
hybrid model?

19.  Element C (updated):

20.  Relates to Chapter 3-Needs Assessment
 If the needs of the service area require additional hours;
evaluate the data and need, then an adjustment should be
made
 Requires board approval and approval from HRSA
 Completed through a Change in Scope
 COVID-19 adjustments: https://bphc.hrsa.gov/emergency-
response/coronavirus-frequently-asked-
questions?field_faq_category_tid=289&combine=
◦ Review any publications and social media hours and locations
 Compare it with Form 5B

21.  Patient Surveys
◦ Can determine data and information required for this
requirement
◦ Examples:
 “Tele-health visits help me keep my appointments”
 “Do the current hours the clinic is open help me keep my
appointment?”
 “What hours of operation would be easier for your family?”
 What questions do your health center use on
their patient surveys?

22.  Documentation of review of patient
satisfaction surveys
◦ Through the QI Committee and then to the full
governing board
◦ Aggregate data
 “Did my health center change/add/improve
practices because of a patient suggestion?”
◦ Additional hours, transportation, etc.?

23. ****NEW***
HRSA-Form 5B Scope of Accuracy
Worksheet
•https://bphc.hrsa.gov/sites/defaul
t/files/bphc/programrequirements
/scope/form5b-accuracy-
worksheet.pdf
Potential increased revenue
Increase service lines/other lines of
business
Organization reputation
Community “team player”
“Online presence” can make or
break an organization
“Today’s patient
experience=tomorrow’s reputation”

24. HRSA Health Center
Compliance Manual
https://bphc.hrsa.gov/pro
gramrequirements/compli
ancemanual/index.html
HRSA Health Center
Site Visit Protocol
https://bphc.hrsa.gov/pro
gramrequirements/site-
visit-protocol
HRSA Scope of
Project (Form 5B
Worksheet)
https://bphc.hrsa.gov/pro
gramrequirements/scope/
documenting
NACHC-Health
Center Resource
Clearinghouse
https://www.healthcenteri
nfo.org/

25.  Jennifer Genua-McDaniel, BA (Hons), CHCEF
Genua Consulting, LLC
 Questions?
marketing@fqhcwebinar.com