Please Note: This training is limited to community health centers and look-alikes. If you are not affiliated with a health center and would like to attend, please contact us.

HRSA’s compliance assessment efforts for Federally Qualified Health Centers (FQHCs) are a “mainstay” of the Health Center Program (HCP).  Conducted at least once per project period, all health centers are subject to an Operational Site Visit (OSV) to determine their ongoing compliance with the HCP Requirements that establish the foundation and framework of every health center’s particular project. In addition to the traditional 3-day OSV, HRSA has begun a limited roll-out of the Compliance & Engagement Operational Site Visit (CE-OSV), which combines aspects of the “live” (virtual or in-person) OSV with substantial desk audits. The CE-OSV process streamlines the assessment process, striving for both compliance and operational excellence by blending together pre-site visit technical assistance sessions on the HCP Requirements and the Site Visit Protocol (SVP), document review including health center-self assessments based on the SVP, and traditional interviews for the most common areas of non-compliance.   

Whether your assessment follows the new CE-OSV process or the traditional 3-day OSV, compliance with HCP Requirements in both documentation and practice is a vital component of a health center’s daily operations … and non-compliance findings may result in legal consequences that significantly impact operations and your ability to serve your patient populations and your community at large.

All compliance assessments – OSVs, CE-OSVs and FQHC Look-Alike certification site visits – focus on the HCP Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance. The Manual incorporates an “ongoing compliance” approach by addressing each requirement’s statutory and regulatory bases, the key elements of compliance that collectively form the framework of every health center’s project, and areas for which health centers maintain discretion.

Similarly, all assessment processes are guided by the SVP, which aligns with the HCP Compliance Manual and forms the basis for review under all compliance assessments.  The SVP reflects an objective assessment tool that clarifies many of the documentation requirements and assessment methodologies used by HRSA to verify compliance.

Regardless of any changes to the assessment process, HRSA maintains an expectation of 100% ongoing compliance with the HCP Requirements – both in your documentation and your daily operations. Is your health center prepared to meet this challenge? Have you reviewed the most recent HRSA guidance and assessment processes with an eye toward shoring up your own operations and establishing your HRSA compliance work plan? For example,

• Is your Form 5A up to date, based on HRSA’s definitions for services and modes of delivery?
• Do you have written contracts and referral agreements in place for services listed in columns II and III of Form 5A, and do they include all required provisions, including sliding fee discounts and provisions under 45 CFR Part 75?
• Are members of your clinical staff (including staff members such as dental assistants, medical assistants, and community health workers) appropriately credentialed and privileged?
• Does your quality improvement system meet all current standards?
• Do you have systems in place to assess all patients for income and family size? Does your sliding fee discount schedule apply to all in-scope services and have you implemented mechanisms to ensure input from your Board members when establishing the sliding fee discount schedule and nominal fee, and when conducting an effectiveness evaluation of the program overall?
• Do you have billing and collection policies that address the waiver / reduction of payments and other processes that help strike the balance between maximizing reimbursement and maintaining optimum access?
• Is your financial management system, including but not limited to your procurement processes, sufficient for purposes of federal accountability and good stewardship of public funds?
• Is your budget constructed to account for all expenses and revenues?
• Is your Board of Directors independently exercising all required authorities, without limitation, and do you have documentation to verify compliance?

Join us for this training exploring:

• The distinctions and similarities between the traditional 3-day OSV and the CE-OSV process;
• How to use the Compliance Manual, the SVP, and other HRSA-issued compliance guidance to prepare for your compliance assessment, including discussion of the elements of the HCP Requirements, the documentation and assessment methodologies required to verify compliance with each, and where health centers retain explicit discretion and flexibility;
• How the legal requirements intersect with the reviewers’ interpretations;
• Key high-risk areas from recent compliance reviews; and
• Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during, and after their OSVs.