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

At the start of the COVID-19 pandemic, HRSA transitioned and re-focused its compliance assessment efforts for Federally Qualified Health Centers (FQHCs) to a virtual process that mirrored the in-person reviews.  Almost three years later, HRSA is transitioning the Operational Site Visit (OSV) process once again, testing a new Compliance Engagement (CE) Site Visit that strives for both compliance and excellence by combining aspects of the “live” (virtual or in-person) process with desk audits and pre-CE technical assistance sessions on the Health Center Program Requirements.  Regardless of the specific process used for your assessment, compliance with health center program 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 revolve around the Health Center Program 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.

To conduct a “hands-on” compliance assessment, HRSA reviewers utilize the Site Visit Protocol, which aligns with the Manual and reflects an objective assessment tool. HRSA’s most recent Protocol, which is effective for OSVs, CE assessments and Look-Alike certification site visits, clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance.

As in the past, HRSA maintains an expectation of 100% ongoing compliance with the Health Center Program 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 towards 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 FTLF for this training exploring:

• How to use the Compliance Manual, the most recent Site Visit Protocol, and other HRSA-issued compliance guidance to prepare for your OSV/CE, including discussion of the elements of the programmatic 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.