(Recorded Webinar) Part III: Ensuring Effective Governance and Management
On Part III of the De-Mystifying the Compliance Manual webinar series, we will explore the health center program requirements related to both the “heart and soul” of the health center program – the community-based Board of Directors that sets the priorities and direction for the health center – and the management team that implements the Board’s directives. FTLF attorneys will discuss the Board’s numerous composition requirements and required responsibilities, and what it means to be compliant with those requirements both “on paper” and “in practice.” In addition, we will also discuss the most recent Chief Executive Officer (CEO) requirements and the composition of the key management team.
This webinar will focus on topics from the following chapters of the Compliance Manual:
- Chapter 19: Board Authority
- Chapter 20: Board Composition
- Chapter 11: Key Management Staff
In the past few years, HRSA has transitioned its compliance efforts from requiring FQHCS to utilize multiple guidance documents to ensure adherence to health center program requirements to issuing the Health Center Program Compliance Manual (the Manual), a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance. The Manual, which supersedes most (but not all) prior guidance, incorporates a new approach to everyday compliance.
To assist in conducting a “hands-on” compliance evaluation, HRSA issued a Site Visit Protocol (the SVP), which aligns with the Manual and reflects a more objective assessment tool than prior review guides. The current SVP (issued in April 2019), includes additional clarification on documentation requirements and assessment methodologies.
Together, the Manual and the SVP are the main tools used by HRSA for both on-site reviews of grantees and FQHC look-alike entities (Operational Site Visits - OSVs) and “desk audits” of project and designation renewal applications, by addressing:
- Each requirement’s statutory and regulatory basis
- Key elements of compliance that form the framework of every health center’s project
- Documentation necessary to verify compliance (both on paper and in practice)
- Areas where health centers maintain discretion
There is an expectation of 100% ongoing compliance with the Health Center Program Requirements. Is your health center prepared to meet this challenge? Given the possible consequences of non-compliance, including 1-year project periods for non-compliance with a single element and potential loss of 330-grant funds, it is critical that every health center be and remain vigilant, whether you are expecting an OSV, submitting a grant or look-alike designation application, or looking to bolster current operations and establish your HRSA compliance workplan as part of ongoing compliance efforts.
- Health Center Executive Staff
- Financial Leadership and Staff
- Administrative/Operations Leadership and Staff
- Compliance Officers
- Board members
- Other Staff assisting with HRSA compliance and/or OSV preparation
After this webinar series, you will be able to:
- Discuss the elements of and nuances related to the required Board authorities and the means to demonstrate that the Board fully exercises its responsibilities.
- Describe the elements of and nuances related to the required Board composition requirements and the means to demonstrate compliance.
- Assess whether your key management team is appropriate for the size and complexity of your organization and meets HRSA requirements.
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]
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