This is a private virtual training developed for and hosted by the Montana Primary Care Association (MTPCA) as a benefit for their members.

If you are not a member but interested in training on the Compliance Manual, please review our HRSA Program Requirements page or Contact Us.

In the past few years, HRSA has transitioned its compliance efforts for Federally Qualified Health Centers (FQHCs) from multiple policy guidance documents to 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 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.

To assist in evaluating compliance, HRSA issued a Site Visit Protocol, which aligns with the Manual and reflects a more objective assessment tool than prior review guides. HRSA’s most recent Protocol clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance during both on-site reviews (Operational Site Visits - OSVs) and “desk audits” of applications for grant project period and FQHC look-alike designation renewals.

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 like 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 exercising all required authorities, and do you have documentation to verify compliance?

Join FTLF for this hands-on training covering:

• The Compliance Manual and Site Visit Protocol, including the elements of each programmatic requirement, the documentation required to verify compliance, assessment methodologies designed for various elements, and 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;
• Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during and after their OSVs; and
• Guidance on responding to preliminary findings during HRSA’s Compliance Resolution Opportunity to avoid grant conditions.