Condensed overview of the HRSA 19 Requirements as found in the HRSA Site Visit Guide, November 2014.

1. HRSA Requirements
Jean Maki, CHC, MBA

2. 19 REQUIREMENTS
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3. For each requirement consider….
Board/Committee Oversight
Accountability
Operational Implementation
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4. Section I & Requirement 1: Needs
Needs
Assessment
Service
Area
SAC
UDS
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5. Section II: Services
Requirement 2: Required & Additional Services
Directly Contracted Referred Out
FORM 5A
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6. Requirement 3: Staffing
•Each site•Primary Source
•Secondary
Source
•Licenses
•Contracts
•Agreements
•Subrecipient
•Clinical
•Non-clinical
Staffing
Profile
Provider
Privileging
Lists
Credentialing
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7. Requirement 4: Accessible Hours of
Operation/Locations
Hours of Operations
Form 5B: Service Site
Form 5C: Other Activities/Locations
Service Area Map (UDS)
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8. Requirement 5: After Hours Coverage
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9. Requirement 6: Hospital Admitting Privileges and
Continuum of Care
Continuity
of Care
ER
Referrals
Discharge
Patient
Tracking
Admitting
Privileges
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10. Requirement 7: Sliding Fee Discounts
Fee Schedule(s)
Policies
Operating Procedures
Signage
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11. Requirement 8: Quality
Improvement/Assurance Plan
QI Plan
Incident Reporting
Peer Review
Risk Management
Safety
Clinical Directors
Job Description
Clinical Degree
HIPAA
Patient Confidentiality
Release of Information
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12. Requirement 9: Key Management Staff
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13. Requirement 10: Contractual/Affiliation
Agreements
Contracted Services
Contracts
Monitoring
Evaluation
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14. Requirement 11: Collaborative
Relationships
Letters of Support
MOUs
Collaboration!
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15. Requirement 12: Financial Management
and Control Policies
GAAP
CAP
Annual
Audit
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16. Requirement 13: Billing and Collections
Policies and Procedures
3rd Party
Payor
Contracts
Collections
Billing
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17. Requirement 14: Budget
Expenses
•Costs of
Operation
Revenues
•Grants
Patients
•Service
Deliver
Plan
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18. Requirement 15: Program Data Reporting
Systems
Decision
Making
Data
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19. Requirement 16: Scope of Project
Sites
Services
Service Area
Target
Population
Providers
Form 5A and Form 5B
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20. Requirement 17: Board Authority
Policy Oversight
Approves Grant Application and Budget
Measuring and Evaluating the Organization’s Progress
Selection of CEO
Services and Hours of Operations
Monthly Meetings
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21. Requirement 18: Board Composition
13, 52%
2, 8%
2, 8%
2, 8%
2, 8%
4, 16%
Board Members
Patients Finance Local Gov Commercial Legal Social Serviceswww.jeanemaki.com

22. Requirement 19: Conflict of Interest
Policy
Standards of
Conduct
Prohibit
conflict of
Interest
Board Member
is not an
employee
CEO is a non-
voting
member of
the Board
Bylaws
And
Policy
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