Staying on Top of HRSA Program Requirements – Don’t Wait for the Operational Site Visit

HRSA program requirements

Health center program grantees and health center look-alikes are supposed to receive routine operational site visits (OSVs) conducted by the Health Resources and Services Administration (HRSA) every three years. The main purpose of the OSV is to verify the status of each health center program participant’s compliance with the 19 Health Center Program Requirements (PRs).

Most health centers delay preparing for the site visit until they receive a notice about a pending OSV, putting them at risk for findings of noncompliance which can threaten their funding. Why not make 2017 the year you get proactive about program compliance and build a work plan for your board that ensures your ability to demonstrate compliance?

The calendar below provides a road map for demonstrating program compliance. In addition to complying with all 19 PRs, documenting these activities in your board meeting minutes is a fail safe way to demonstrate compliance with “PR #17 Board Authority”.

Staying on top of HRSA program requirements through the year

January – Need Assessment Update (PR #1 Need)

Update and present needs assessment data to your management team and your board that includes service area population demographics, uninsured rate, the percentage of population living below 200 percent Federal Poverty Level (FPL), provider to population ratios, health disparities, and any changes in your health care environment. Summarize and share other local needs assessments with your board when they are available. Document the discussion of community need in the meeting minutes.

February – Scope of Project Approval or Amendment (PR #2 Required and Additional Services, PR #3 Staffing Requirements, PR #4 Accessible Hours of Operations/Locations, PR # 16 Scope of Project)

Review your current scope forms found in the Electronic Hand Book (EHB) – Form 5A: Services, Form 5B: Sites, and Form 5C: Other Activities – with your board.  Are the services listed accurate? Are the columns marked correctly on 5A? Do you employ or contract with the appropriate clinicians and enabling staff to provide the services listed on 5A and 5C? Compare the zip codes listed on Form 5B with the patient origin data from your UDS Report (Table I). Are the zip codes where 75 percent of your patients reside listed on Form 5B? Do the total hours listed for each site reflect the actual hours of operation? Document the discussion about hours of operation – do they meet the patient needs? What are your after-hour arrangements? Have the board affirm or amend Form 5B to accurately reflect zip codes and hours.

March – Update the Sliding Fee (PR #7 Sliding Fee Discount Program, PR #13 Billing and Collections)

The Federal Poverty Guidelines are generally published by February; many electronic practice management systems and billing systems automatically update your system with this information, but all changes to your scale require board approval. Take this opportunity to review your sliding fee program with the board. Document patient board members’ opinions and discussion about nominal fees. Does your nominal fee present a barrier to care? How would the board know? Document any changes in the collections policy.

April – UDS Report Presentation (PR#1 Needs, PR# 15 Program Data Reporting Systems, and PR# 8 Quality Improvement/Assurance Plan)

Review your UDS Report results with the board. How are you progressing on your clinical and financial performance goals? Do the goals need to be updated? Are you meeting your target goals for un-duplicated patients and patient visits? Do the numbers reflect changes in the health care environment (i.e., target population needs)?

May, June, July – Policy Updates (PR #5 After Hours Coverage, #6 Hospital Admitting Privileges and Continuum of Care, PR 12 Financial Management and Control Policies, and PR #13 Billing and Collections)

Board committees should review and recommend affirming or amending policies to the entire board. Key policies should be reviewed at least every three years and include financial policies, clinical policies, billing and collections, personnel policies, credentialing/privileging, procurement and HIPAA. Sliding fee and conflict of interest policies should be reviewed annually.

August – Strategic Planning (PR# 1 Needs, PR# 17 Board Authority)

The board is responsible for strategic planning which should include updated needs assessment data (see January).

September – Governance Check (PR # 18 Board Composition, PR# 19 Conflict of Interest)

The majority of the board members should be patients of the health center at all times. In preparation for the annual meeting when board members are typically elected, the board should complete a board self-evaluation to identify gaps in representation, plan for board elections, new member orientation and on-going training needs. This is also a great time to review the conflict of interest policy.

October – CEO/Executive Director Evaluation

The board is responsible for completing an annual evaluation of the executive director/CEO.

November – Approval of Health Center Grant and Budget (PR #14 Budget)

The annual 330 grant submission (service area competition or budget prior progress report) or look-alike submission (renewal designation or re-certification) and accompanying budget must be approved by the board.

December – Celebrate!

Though it may be tempting to take the month off for year-end holidays and skip a board meeting, health center boards are required to meet monthly. Take this opportunity to reflect on your health center’s successes over the past year and celebrate all you do for your community.

Each of the monthly activities listed above should be performed in time to meet your annual grant or renewal submission deadline. Ideally, the scope of project activities noted in February will be completed (or repeated) two months before your annual grant or look-alike submission. The budget and submission approval will likely occur within the month of those submissions.

Planning ahead and creating an annual work plan or calendar for how you will address each of the items your board is required to perform under “PR #17 Board Authority” will make it easy for you to demonstrate compliance with most of the 19 Program Requirements. Make sure the activities are clearly recorded in your monthly board meeting minutes, and your OSV reviewers will have the documentation they need to report your health center’s compliance.

Health Center Solutions’ dedicated professionals are focused on providing outcome-focused, customer-driven solutions. To schedule a meeting, or to request more information about program compliance, please contact us today!

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