Deciphering the Operational Site Visit: Legal Requirements and Practical Tips for a Successful Compliance Assessment
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.
- Health Center Executive Staff
- Clinical Leadership
- Quality and Credentialing/Privileging Staff
- Financial Leadership and Staff
- Compliance Officers
- Administrative / Operations Leadership and Staff
- Board members
- Other Staff assisting with HRSA compliance and/or OSV preparation
After this training, you will be able to:
- Identify the elements of the HRSA program requirements addressed in the Manual and the Protocol.
- Describe the specific documentation and assessment process necessary to demonstrate compliance and areas where health centers retain discretion.
- Discuss the newest compliance tips for all phases of the HRSA compliance review (before, during, and after) and use such tips to establish your health center’s HRSA compliance workplan.
Wednesday, May 3, 2023
11:00 a.m. - 4:30 p.m. ET
|11:00 - 11:30 a.m.||Welcome and Overview|
|11:30 a.m. - 12:45 p.m.||The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part I|
|12:45 - 1:15 p.m.||Break|
|1:15 - 2:00 p.m.||The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part 2|
|2:00 - 3:15 p.m.||Personnel Dynamics - Ensuring Appropriate Management and Staff|
|3:15 - 3:30 p.m.||Break|
|3:30 - 4:15 p.m.||Breakout Sessions|
|4:15 - 4:30 p.m.||Wrap-up of Day 1 and Preview of Day 2|
Thursday, May 4, 2023
11:00 a.m. - 4:30 p.m. ET
|11:00 a.m. – 12:00 p.m.|
Building Blocks of Fiscal Viability and Internal Controls – Part I
|12:00 - 12:45 p.m.|
Quality is Key
|12:45 - 1:15 p.m.||Break|
|1:15 - 1:45 p.m.|
Building Blocks of Fiscal Viability and Internal Controls – Part I (continued)
|1:45 - 2:45 p.m.|
Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 1
|2:45 - 3:00 p.m.||Break|
|3:00 - 4:30 p.m.|
Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement – Part 2
Friday, May 5, 2023
11:00 a.m. - 4:00 p.m. ET
|11:00 a.m. – 12:30 p.m.||Building Blocks of Fiscal Viability and Internal Controls: Part II |
|12:30 - 1:00 p.m.||Break|
|1:00 - 2:30 p.m.||The "Community" in Community Health Center: The Governing Board of Directors|
|2:30 - 2:45 p.m.||Break|
|2:45 - 3:00 p.m.||It's All About the Data|
|3:00 - 3:45 p.m.||Breakouts|
|3:45 - 4:00 p.m.||Questions and Wrap-Up|
FTLF'S VIRTUAL CLASSROOM
This live, interactive training will take place in FTLF's Virtual Classroom, hosted by Zoom. Should you have any technical questions or would like more information, please contact us at firstname.lastname@example.org or 1-855-200-3822.
Molly Evans is a Partner in the firm’s health law practice group. She advises health centers on the management of clinical, employment and workforce related risks, with a particular focus on professional liability, Federal Tort Claims Act, and HIPAA matters. From her experience as both a private attorney and in-house counsel, Molly knows the importance of managing liability and risk issues in mission-driven organizations. [Full Bio]
Carrie Riley is a Partner in the health law, non-profit and corporate law, and federal grants law practice groups. She counsels a wide variety of health care clients, including Title X grantees and subrecipients, and other private and public health care providers, on contracting, regulatory compliance, fraud and abuse, and reimbursement matters. Carrie also provides counsel on transactional matters, including formation and agreements for multi-provider affiliations/joint ventures, general contracting, and residency training arrangements. [Full Bio]
Ted Waters has served as Managing Partner of the firm since 2003, and as a member of the Health Law and Federal Grants practices since 1992. Ted is a national authority in the area of federal grants, particularly in the health and community service spheres. He advises clients on all aspects of program requirements, including issues such as cost-based reimbursement, governance, grant administration, cost reporting, and administrative issues and routinely handles challenging issues such as government audits, internal investigations, and litigation. His priority is to help each organization carry out its mission by offering practical, down-to-earth counsel and to ensure that legal challenges do not distract from that focus. [Full Bio]
Marcie Zakheim is a Partner at the firm specializing in health care law, particularly in the areas of federal grants, grant-related requirements and grants management related to the federal health center program. Health centers turn to Marcie as a resource for knowing not only the letter of the law, but also the likely interpretation of requirements by federal policymakers, including the Health Resources and Services Administration (HRSA). [Full Bio]
Participants can earn up to 11.50 CPE credits in Specialized Knowledge and Applications upon completion of all course requirements.
- Prerequisites: None
- Target Audience: Health Center Executive Staff; Clinical Leadership; Quality and Credentialing/Privileging Staff; Financial Leadership and Staff; Compliance Officers; Administrative / Operations Leadership and Staff; Board members; and Other Staff assisting with HRSA compliance and/or OSV preparation
- Advanced Preparation: None
- Program Level: All
- Delivery Method: Group Internet Based
Feldesman Tucker Leifer Fidell LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website www.nasbaregistry.org (formerly www.learningmarket.org).
- 13.75 Certificate of Attendance
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.
TRAINING IS NOT RECORDED
This training will not be recorded for later viewing, as we would like attendees to be comfortable and candid, sharing their experiences and asking scenario-based questions. The discourse between the attorneys and participants is a valued part of each training.
(THROUGH MARCH 15)
(MARCH 16 OR LATER)
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