As Operational Site Visits (OSVs) continue virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level. This month’s webinar will focus on the following chapters: Chapter 18: Program Monitoring and Data Reporting Systems Chapter 20: Board Composition Webinar attendee takeaways will include: · Understanding the requirements and why they are important · Methods to maintain continuous compliance (without addressing it last minute or only during an OSV) · How to use the requirement in everyday practice to improve 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. Program Monitoring/Data Reporting (Chapter 18)
and
Board Composition (Chapter 20)

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 =
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 continuing

6.  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 requirements in everyday practice
◦ Make your Community Health Center awesome!

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

8.  Compliance:
◦ Element B:
Data based reports as necessary to inform and support
internal decision making and oversight by the health
center’s key management staff and governing board
◦ Patient Service Utilization
◦ Trends and Patterns in the patient population
◦ Overall health center clinical, financial or operational
performance

9.  Compliance:

10.  Compliance:
◦ 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

11.  Compliance:
◦ 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

12.  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 to 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

13.  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

15. Source: Instagram

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

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

18.  Compliance:
◦ Element C/D: Current Board Composition &
Prohibited Board Members
 Does the Board of Directors represent patient 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

19.  Compliance:
◦ Element C: Current Board Composition
 UPDATED:

20.  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)

21.  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".

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

23.  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…”

24.  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% users)
◦ 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

25. 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
Restart the series in the 2022

26. NACHC CHI EXPO ORLANDO
BOOTH #514
or Visit Compliatric.com for more
information

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

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