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

Alexandria, VA US
September 7, 2022 to September 8, 2022

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 efforts for Federally Qualified Health Centers (FQHCs) from an on-site compliance assessment to a virtual process that mirrors the in-person reviews.  Using lessons learned from the virtual Operational Site Visit (OSV), HRSA is currently “pilot testing” a new approach that strives for both compliance and excellence by combining aspects of the virtual process with desk audits and pre-OSV support through technical assistance sessions on the Health Center Program Requirements.  Regardless of the specific process used for your OSV, compliance with health center program requirements is still a vital component of a health center’s daily operations. . .and non-compliance findings may result in legal consequences impacting such operations and your ability to serve your patient populations and your community at large.

Whether virtual or on-site, the OSV process revolves around the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance. The Manual, which supersedes most (but not all) prior guidance, 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 assist in conducting a “hands-on” compliance assessment, HRSA reviewers utilize the Site Visit Protocol, which aligns with the Manual and reflects a more objective assessment tool than prior review guides. HRSA’s most recent Protocol, which is effective for both the virtual OSVs and the new pilot program, clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance.

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, 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 conducting 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, without limitation, and do you have documentation to verify compliance?

Join FTLF for this training exploring:

  • The virtual OSV process and how it differs from (and is the same as) the onsite process;
  • How to use the Compliance Manual, the most recent 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; 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 elements of the HRSA program requirements addressed in the Manual and the Protocol.
  • Describe the specific documentation requirements and assessment methodologies, and the distinctive procedural processes, necessary to demonstrate compliance
  • Describe the areas where health centers retain discretion in implementing compliance.
  • 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
Course opens: 
05/16/2022
Course expires: 
03/30/2023
Event starts: 
09/07/2022 - 10:00am EDT
Event ends: 
09/08/2022 - 5:00pm EDT

Agenda

FTLF Virtual Classroom or Washington, DC
Wednesday, September 7, 2022 - Thursday, September 8, 2022

*All specific agenda times are ET and subject to change*

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, September 7, 2022       
10:00 am - 5:30 pm ET
10:00 am - 10:15 amIntroduction to the Training
10:15 am - 11:30 am
The "Community" in Community Health Center: The Governing Board of Directors
  • Chapter 19: Board Authority
  • Chapter 20: Board Composition
11:30 am - 11:45 amBreak
11:45 am - 1:00 pm
The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part I
  • Chapter 3: Needs Assessment
  • Chapter 4: Required & Additional Health Services
  • Chapter 6: Accessible Locations and Hours of Operation
  • Chapter 7: Coverage for Medical Emergencies During and After-Hours
  • Chapter 8: Continuity of Care & Hospital Admitting
  • Chapter 14: Collaborative Relationships
1:00 pm - 2:00 pmBreak
2:00 pm - 3:00 pm
The Heart of Your Health Center Project: Need, Services & Continuity of Care - Part 2
3:00 pm - 4:00 pm
Quality is Key
  • Chapter 10: Quality Improvement/Assurance
4:00 pm - 4:15 pmBreak
4:15 pm - 5:30 pm
Personnel Dynamics - Ensuring Appropriate Management and Staff
  • Chapter 11: Key Management Staff
  • Chapter 5: Clinical Staffing

Day 2

Thursday, September 8, 2022       
10:00 am - 5:15 pm ET
10:00 am - 11:30 am
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
11:30 am - 11:45 amBreak
11:45 am - 1:00 pmInternal Controls and Ensuring Fiscal Viability - Part 2
1:00 pm - 2:00 pmBreak
2:00 pm - 3:30 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
3:30 pm - 3:45 pmBreak
3:45 pm - 4:45 pm
Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement - Part 2
4:45 pm - 5:00 pm
It's All Up with Data 
  • Chapter 18: Program Monitoring and Data Reporting Systems
5:00 pm - 5:15 pm Questions & Wrap-Up
The Westin Alexandria Old Town
400 Courthouse Square
Alexandria, VA 22314
United States
+1 (703) 253-8600

IN-PERSON VENUE INFORMATION

FTLF has negotiated a discount rate of $199 per night. You can make your reservations by clicking here. The discounted rate expires August 16, 2022. FTLF cannot guarantee the availability of a hotel room after the August 16 cut-off date or after the specially rated FTLF block has been filled. 

 

VIRTUAL VENUE INFORMATION

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]

Participants can earn up to 12.00 CPE credits in Specialized Knowledge and Applications upon completion of all course requirements.

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).

 
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TRAINING IS RECORDED

This training will be recorded for later viewing, and attendees will receive a copy of the recording after the event.


Registration Fees:

In-Person Registration
Early Registration
(Through May 31)
Discounted Registration
(June 1 - August 9)
Regular Registration
(August 10 - September 7)
$1,695$1,795$1,895
Virtual Registration
Early Registration
(Through May 31)
Discounted Registration
(June 1 - August 9)
Regular Registration
(August 10 - September 7)
$1,595$1,695$1,795

Registration Instructions

Each registration must be in the name of the individual(s) who will attend. This allows FTLF to communicate important course information to the actual attendee(s), add training materials and handouts to the right account, and properly assign certificates of attendance or CPE credits. 

To register for this training:

  • For yourself: login to your account and register with your personal information
  • For someone else: login with the ATTENDEE’S login information or create an account for the ATTENDEE and register from the ATTENDEE's account
  • For a group: email Learning@ftlf.com to complete group registration

If you encounter problems or have questions Contact us.


Payment

We accept payment by PayPal, credit card, and check. Payment for any live training is due upon registration. If payment is not received in full prior to the start of the event, FTLF reserves the right to cancel your order and deny you entrance to the training.


Cancellation/Transfer Policy

All cancellation or transfer requests must be received in writing at learning@ftlf.com. Requests for refunds or transfers for in-person events will be granted according to the following schedule:

  • 30 or more days prior to the event, requests for a full refund or a transfer, minus a $75 administrative 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.
  • Within 10 days of the event start date, no requests for refunds or credits will be granted. At FTLF's discretion, late transfers may be granted, space permitting and subject to a transfer fee.

If there are extenuating circumstances regarding your cancellation, please reach out to the FTLF Training Team directly at learning@ftlf.com.


CAN I TRANSFER FROM IN-PERSON TO THE VIRTUAL CLASSROOM? 

Yes, you can transfer from attending in-person to virtually.  Please note that no refunds of the price difference, if any, will be given.  All transfer requests must be submitted in writing.

CAN I TRANSFER FROM THE VIRTUAL CLASSROOM TO ATTEND IN-PERSON?

Yes, you can transfer to attend in-person, providing there is an open seat.  Any additional registration cost is due at the time of transfer.  All transfer requests must be submitted in writing.

If there are extenuating circumstances regarding your cancellation, please reach out to the FTLF Training Team directly at learning@ftlf.com.

Required Hardware/software

In-Person

No hardware required


Virtual

Google Chrome or Mozilla Firefox are the preferred browsers.