Deciphering the Operational Site Visit: Legal Requirements and Practical Tips for a Successful OSV

June 23, 2021 to June 25, 2021

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.


As a result of the COVID-19 pandemic, HRSA has transitioned and re-focused its compliance efforts for Federally Qualified Health Centers (FQHCs) to a virtual compliance assessment process.  As of April 2021, HRSA has indicated that the virtual Operational Site Visit (OSV) will be in place for the foreseeable future.  Despite this change to a virtual platform, the review process itself strives to mirror the onsite process. As such, compliance with health center program requirements is still a vital component of a health center’s daily operations.

Whether conducted virtually or on-site, the OSV revolves around the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance, and the Site Visit Protocol, a “hands-on” compliance assessment tool that is a “living document” continually modified by HRSA to reflect updated practices and feedback from the field. The most recent update of the Protocol (the 2021 Site Visit Protocol) a summary of which was published in April 2021, will be effective for all OSVs that start after May 28, 2021.

The Manual incorporates a new approach to “everyday compliance” by addressing each requirement’s statutory and regulatory basis, the key elements of compliance that collectively form the framework of every health center’s project, and areas for which health centers maintain discretion.  Aligning with and complementing the Manual, the Protocol reflects an objective review guidance used by HRSA reviewers and health centers alike.

While the Protocol strives to clarify the documentation requirements and assessment methodologies used by HRSA to verify compliance, confusion regarding review-related processes still exists. Further, as in the past, there is an expectation of 100% ongoing compliance with the Health Center Program Requirements. 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 service definitions and correct 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, such as 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? Have you implemented mechanisms to inform patients about the sliding fee discount program and to conduct an effectiveness evaluation of the program?
  • 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 sufficient for federal accountability purposes?
  • Is your Board of Directors independently exercising all required authorities, and do you have documentation to verify compliance?

Join FTLF for this training exploring:

  • The key challenges of the virtual OSV process and how they differ from (and are the same as) the onsite process;
  • How to use the Compliance Manual, the new 2021 Site Visit Protocol and other HRSA-issued compliance guidance to prepare for your OSV, including discussion of the elements of the programmatic requirements and the documentation and assessment methodologies required to verify compliance with each, as well as areas 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; 
  • A concentrated examination of credentialing and privileging, governance, contracts and referral agreements, sliding fee discount program, and financial management in a choice of breakout sessions; and 
  • Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during, and after their OSVs.

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
  • Other Staff assisting with HRSA compliance and/or OSV preparation

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

Learning Objectives

After this training, you will be able to:

  • Identify the key elements of the HRSA program requirements addressed in the Manual and the Protocol.
  • Describe the specific documentation and assessment processes 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.
Course summary
Available credit: 
  • 12.00 Certificate of Attendance
Course opens: 
12/23/2020
Course expires: 
01/10/2022
Event starts: 
06/23/2021 11:00am EDT
Event ends: 
06/25/2021 4:00pm EDT
Cost:
$1,495.00
FTLF Virtual Classroom
Wednesday, June 23, 2021 - Friday, June 25, 2021

*Agenda times are all ET*

NOTE: The two sessions listed below will NOT be addressed in the workshop and will be provided via pre-recorded webinar prior to the on-site training. Please review the webinars prior to arrival and come prepared with your questions! The webinars can be accessed by clicking the gray "Take Course" button on either the "Overview" or "Register" tab once you have registered for the course.

  • Introduction to the Health Center Program Compliance Manual and HRSA Review Process
  • Working within the “Box”: Key Elements and Requirements of Scope of Project

Day 1

Wednesday, June 23, 2021
11:00 am - 4:30 pm ET
11:00 am - 11:30 amIntroduction to the Training
11:30 am - 12:45 pm
The "Community" in Community Health Center: The Governing Board of Directors
  • Chapter 19: Board Authority
  • Chapter 20: Board Composition
12:45 pm - 1:15 pmBreak
1:15 pm - 2:45 pm
The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part I
  • Chapter 4: Required & Additional Health Services
  • Chapter 7: Coverage for Medical Emergencies During and After-Hours
  • Chapter 8: Continuity of Care & Hospital Admitting
2:45 pm - 3:00 pmBreak
3:00 pm - 3:45 pmBreakout Sessions
  • Governance
  • Form 5a, Contracts, and Referral Agreements
3:45 pm - 4:00 pmBreak
4:00 pm - 4:30 pm
The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part 2
  • Chapter 3: Needs Assessment
  • Chapter 6: Accessible Locations and Hours of Operation
  • Chapter 14: Collaborative Relationships
 

Day 2

Thursday, June 24, 2021
11:00 am - 4:30 pm ET
11:00 am - 12:15 pm
Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 1
  • Chapter 16: Billing and Collection
  • Chapter 9: The Sliding Fee Discount Program
12:15 pm - 12:30 pmBreak
12:30 pm - 1:30 pm
Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 2
1:30 pm - 2:00 pmBreak
2:00 pm - 3:15 pm
Personnel Dynamics - Ensuring Appropriate Management and Staff
  • Chapter 11: Key Management Staff
  • Chapter 5: Clinical Staffing
3:15 pm - 3:30 pmBreak
3:30 pm - 4:30 pm
Quality is Key
  • Chapter 10: Quality Improvement/Assurance

Day 3

Friday, June 25, 2021
11:00 am - 4:00 pm ET
11:00 am - 12:15 pm
Internal Controls and Ensuring Fiscal Viability - Part 1
  • Chapter 15: Financial Management & Accounting Systems
  • Chapter 17: Budget
  • Chapter 12: Contracts and Sub-awards
  • Chapter 13: Conflict of Interest Policy
12:15 pm - 12:30 pm
Break
12:30 pm - 2:00 pmInternal Controls and Ensuring Fiscal Viability - Part 2
2:00 pm - 2:30 pmBreak
2:30 pm - 2:45 pm
It's All About the Data
  • Chapter 18: Program Monitoring and Data Reporting Systems
2:30 pm - 3:45 pmBreakouts
  • Credentialing and Privileging
  • Financial Controls
  • Sliding Fee Discount Program
3:45 pm - 4:00 pmQuestions 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 learning@ftlf.com or 1-855-200-3822.

MOLLY EVANS  

A Partner in the firm’s health law practice group, Molly 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]

TED WATERS

Serving as Managing Partner of the firm since 2003, and 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 and the never-ending list of grant administration matters. Ted’s expertise in financial, cost reporting, reimbursement, and administrative issues is widely recognized and he routinely handles government audits, internal investigations, and litigation. [Full Bio]

MARCIE ZAKHEIM

A Partner at the firm, Marcie specializes 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]

Conference participants can earn up to 14.40 CPE credits in Specialized Knowledge and Applications.

ADDITIONAL INFORMATION

  • Prerequisites: None 
  • Target Audience: Health Center Executive Staff, Clinical Leadership, Quality and Credentialing/Privileging Staff, Financial Leadership and Staff, Compliance Officers, Board members, 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).

Available Credit

  • 12.00 Certificate of Attendance

Price

Cost:
$1,495.00
Please login or register to take this course.

REGISTRATION FEES:

EARLY REGISTRATION
(THROUGH May 15)
REGULAR REGISTRATION
(May 16 OR LATER) 
$1,495$1,595

GROUP DISCOUNTS

Bring your team! Discounts are available for groups of three (3) or more individuals from the same organization. Please contact us to process your registration.

GROUPS OF 3 - 6
GROUPS OF 7 - 10
GROUPS OF 11 - 15
OVER 15 ATTENDEES
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  • For yourself: login to your account and register with your personal information
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  • 30 or more days prior to the event, requests for a full refund or a transfer without a fee will be granted.
  • Between 11 to 29 days prior to the event, requests for cancellations will be granted a 50% refund and requests for transfers will be granted, space permitting and subject to a transfer fee.
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