Board-Approved Policies Needed to Demonstrate Health Center Program Compliance

Health Center Program

Board members of Health Center Program participants play a big role in the success of the health center by providing leadership and oversight to ensure that underserved community members have access to health care services. Challenges and opportunities are addressed while meeting the HRSA health center program requirements for health centers. One of the ways that board members meet HRSA requirements is by approving board policies that demonstrate compliance with the health center program.

Board-approved policies needed to demonstrate Health Center Program compliance

  1. Sliding Fee Discount Policy

Compliant health centers are required to provide basic health care services to community members on a sliding fee discount so that they never turn patients away for inability to pay. The sliding fee discount policy must be evaluated every three years to show how the health center’s sliding fee discount schedule(s) (SFDS(s)) will be structured in order to ensure that patient charges are adjusted based on ability to pay (income) and family size. The evaluation process includes input from existing health center patients assesses how well the SFDS has provided access to care. Where barriers to care are indicated, adjustments should be considered.

  1. QI/QA Program or Plan

The Quality Improvement/Quality Assurance (QI/QI) program or plan is established by board-approved policies to assess the quality and use of health center services. Assessment tools include patient satisfaction surveys, patient grievances, patient safety reports, including adverse events and patient health data. It also evaluates adherence to current evidence-based clinical guidelines, standards of care, and standards of practice in the provision of health center services. The health center assigns a person to oversee the program. This person must provide QI/QA assessments which should be reported to the board on at least a quarterly basis in order to improve the way health center services are provided, as needed. Reports are provided after each assessment via the board QI committee.

  1. Peer Review Policy

As part of QI/QA compliance the health center’s physicians or other licensed health care professionals conduct peer assessments on at least a quarterly basis, using data gathered from patient records. The purpose of the peer review policy is to ensure health provider competency, and adherence to current evidence-based clinical guidelines, standards of care, and standards of practice in the provision of health center services.  The policy then addresses relevant follow-up actions to address the way care is provided and to improve patient safety.

  1. Purchasing & Procurement Policy/Contracting and Contract Management

The health center creates and implements written standards of conduct for all purchases using federal funds. It is recommended that a health center apply the same standards for all purchasing however. The policy must also address conflict of interest for board members, officers and employees.  Written disclosure of any conflicts of interest must be included in the written policy. The policy must restrict anyone involved in the selection of contractors from receiving or soliciting gifts or favors with monetary value and enforce disciplinary action on anyone who breaks the policy. This policy must be reviewed and evaluated at least every three years. It is recommended that the board members review potential conflicts of interest and sign disclosure forms annually. This process should be documented in board meeting minutes.

  1. Financial Management & Internal Controls

The health center must have and use a financial management and internal control system that uses Generally Accepted Accounting Principles (GAAP) for private non- profit health centers or Government Accounting Standards Board (GASB) principles for public agency health centers. The system must be able to track the financial performance of the health center and account for all Federal awards. It must also show that the health center’s expenditures are consistent with the HRSA-approved total budget and that assets are being used solely for authorized purposes in accordance with the terms and conditions of the Health Center Program award/designation.

  1. Billing & Collection Policy

The billing and collection policy outlines how bills are created and sent to patients. The collection policy outlines how outstanding bills will be collected including Refusal to Pay Policy, if applicable.

  1. Refusal to Pay Policy

If a health center chooses to limit or deny services based on a patient’s refusal to pay, the health center will have a board-approved policy that distinguishes between refusal to pay and inability to pay. “Ability to pay” is determined by a patient’s placement on the federal poverty scale based on income and family size.  “Refusal to pay” is indicated when a patient simply does not pay their bill, regardless of sliding fee discount eligibility. The policy needs to explain how patients will be notified of amounts owed and the timeframe allowed for payments, collection efforts and how services will be limited or denied in the future.

  1. Personnel Policies

At least every three years board members must review the health center personnel policies to ensure that they are working to provide the best possible health care services to the health care patients under the requirements of the Health Center Program. The board is also responsible for approving the pay scale for staff positions.

  1. Bylaws

Bylaws must demonstrate compliance with the health center program governance requirements. This includes describing the organization’s independent governing board and how it retains (i.e. does not delegate) the required unrestricted authorities, functions, and responsibilities. Additionally, they must be signed and dated by the appropriate individual indicating review and approval by the governing board. The bylaws should be reviewed at least every three years.

  1. Risk Management Policies

The health center must have a board approved policy that shows the existence and implementation of a current health care risk management program to reduce the risk of adverse outcomes that could result in medical malpractice or other health or health-related litigation. The personnel in charge of risk management policy must produce a quarterly risk management assessment and annual reporting to the health center board.

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