BUREAU OF PRIMARY HEALTH CARE SITE VISIT REPORT Consolidated Team Report template updated October 2012

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1 The purpose of the site visit is to provide direct support to grantees on key health center program requirement(s) and to identify any area(s) for potential performance or operational improvements. Attached are the preliminary findings and recommendations from the site visit team that have been identified by the consultants as a result of the site visit process. This report is not exhaustive, but identifies any key program requirement findings/recommendation(s) as well as any recommended area(s) for performance or operational improvement. Task Order: Grantee Information: Part One Type of Visit: Purpose of Visit: Date(s) of Visit: Consultant(s): Overview of Grantee Organization: Site Visit Participants: Name & Title of Participant Interviewed (Y/N) Entrance (Y/N) Exit (Y/N) List of Documents Reviewed: List of Documents Left With Grantee: Primary Compliance Issues, Concerns, and/or Performance Improvement Opportunities Addressed During Visit: Specific Actions Taken During Site Visit: Innovation/Best Practices: This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 1 of 72

2 Part Two SECTION 1: Need Program Requirements Program Requirement #1 Needs Assessment: Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate. (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act) Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 2 of 72

3 SECTION 2: Services Program Requirements Program Requirement #2 Required and Additional Services: Health center provides all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. (Section 330(a) of the PHS Act) Note: Health centers requesting funding to serve homeless individuals and their families must provide substance abuse services among their required services. (Section 330(h)(2) of the PHS Act) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #3 Staffing Requirement: Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed, and privileged. (Section 330(a)(1), (b)(1)-(2), (k)(3)(c), and (k)(3)(i) of the PHS Act) Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 3 of 72

4 Program Requirements Program Requirement #4 Accessible Hours of Operation/Locations: Health center provides services at times and locations that assure accessibility and meet the needs of the population to be served. (Section 330(k)(3)(A) of the PHS Act) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #5 After-Hours Coverage: Health center provides professional coverage for medical emergencies during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act and 42 CFR Part 51c.102(h)(4)) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #6 Hospital Admitting Privileges and Continuum of Care: Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act) This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 4 of 72

5 Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #7 Sliding Fee Discounts: Health center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient s ability to pay. This system must provide a full discount to individuals and families with annual incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* No discounts may be provided to patients with incomes over 200% of the Federal poverty guidelines.* No patient will be denied health care services by the health center due to an individual s inability to pay for such services, assuring that any fees or payments required by the center for such services will be reduced or waived. (Section 330(k)(3)(G) of the PHS Act, 42 CFR Part 51c.303(f)), and 42 CFR Part 51c.303(u)) Note: Portions of program requirements notated by an asterisk (*) indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs. Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 5 of 72

6 Program Requirements Program Requirement #8 Quality Improvement/Assurance Plan: Health center has an ongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinical services and management, and that maintains the confidentiality of patient records. The QI/QA program must include: a clinical director whose focus of responsibility is to support the quality improvement/assurance program and the provision of high quality patient care;* periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center; and such assessments shall:* o be conducted by physicians or by other licensed health professionals under the supervision of physicians;* o be based on the systematic collection and evaluation of patient records;* and o identify and document the necessity for change in the provision of services by the health center and result in the institution of such change, where indicated.* (Section 330(k)(3)(C) of the PHS Act, 45 CFR Part (c)(2), (3) and 42 CFR Part 51c.303(c)(1-2)) Note: Portions of program requirements noted by an asterisk indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs. Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 6 of 72

7 SECTION 3: Management and Finance Program Requirements Program Requirement #9 Key Management Staff: Health center maintains a fully staffed health center management team as appropriate for the size and needs of the center. Prior approval by HRSA of a change in the Project Director/Executive Director/CEO position is required. (Section 330(k)(3)(I) of the PHS Act, 42 CFR Part 51c.303(p) and 45 CFR Part 74.25(c)(2),(3)) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #10 Contractual/Affiliation Agreements: Health center exercises appropriate oversight and authority over all contracted services, including assuring that any subrecipient(s) meets Health Center program requirements. (Section 330(k)(3)(I)(ii), 42 CFR Part 51c.303(n), (t)), Section 1861(aa)(4) and Section 1905(l)(2)(B) of the Social Security Act, and 45 CFR Part 74.1(a) (2)) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #11 Collaborative Relationships: Health center makes efforts to establish and maintain collaborative relationships This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 7 of 72

8 with other health care providers, including other health centers, in the service area of the center. The health center secures letter(s) of support from existing health centers (Section 330 grantees and FQHC Look-Alikes) in the service area or provides an explanation for why such letter(s) of support cannot be obtained. (Section 330(k)(3)(B) of the PHS Act and 42 CFR Part 51c.303(n)) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #12 Financial Management and Control Policies: Health center maintains accounting and internal control systems appropriate to the size and complexity of the organization reflecting Generally Accepted Accounting Principles (GAAP) and separates functions appropriate to organizational size to safeguard assets and maintain financial stability. Health center assures an annual independent financial audit is performed in accordance with Federal audit requirements, including submission of a corrective action plan addressing all findings, questioned costs, reportable conditions, and material weaknesses cited in the Audit Report. (Section 330(k)(3)(D), Section 330(q) of the PHS Act and 45 CFR Parts 74.14, and 74.26) Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 8 of 72

9 Program Requirements Program Requirement #13 Billing and Collections: Health center has systems in place to maximize collections and reimbursement for its costs in providing health services, including written billing, credit, and collection policies and procedures. (Section 330(k)(3)(F) and (G) of the PHS Act) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #14 Budget: Health center has developed a budget that reflects the costs of operations, expenses, and revenues (including the Federal grant) necessary to accomplish the service delivery plan, including the number of patients to be served. (Section 330(k)(3)(D), Section 330(k)(3)(I)(i), and 45 CFR Part 74.25) Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #15 Program Data Reporting Systems: Health center has systems which accurately collect and organize data for program reporting and which support management decision making. (Section 330(k)(3)(I)(ii) of the PHS Act) This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 9 of 72

10 Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #16 Scope of Project: Health center maintains its funded scope of project (sites, services, service area, target population, and providers), including any increases based on recent grant awards. (45 CFR Part 74.25) Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 10 of 72

11 SECTION 4: Governance Program Requirements Program Requirement #17 Board Authority: Health center governing board maintains appropriate authority to oversee the operations of the center, including: holding monthly meetings; approval of the health center grant application and budget; selection/dismissal and performance evaluation of the health center CEO; selection of services to be provided and the health center hours of operations; measuring and evaluating the organization s progress in meeting its annual and long-term programmatic and financial goals and developing plans for the long-range viability of the organization by engaging in strategic planning, ongoing review of the organization s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance;* and establishment of general policies for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) Note: In the case of public centers (also referred to as public entities) with co-applicant governing boards, the public center is permitted to retain authority for establishing general policies (fiscal and personnel policies) for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304(d)(iii) and (iv)) Note: Upon a showing of good cause the Secretary may waive, for the length of the project period, the monthly meeting requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p)(section 330(k)(3)(H) of the PHS Act) Note: Portions of program requirements noted by an asterisk * indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs. Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 11 of 72

12 Program Requirements Program Requirement #18 Board Composition: The health center governing board is composed of individuals, a majority of whom are being served by the center and, this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex. Specifically: governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.* the remaining non-consumer members of the board shall be representative of the community in which the center s service area is located and shall be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.* no more than one half (50%) of the non-consumer board members may derive more than 10% of their annual income from the health care industry.* Note: Upon a showing of good cause, the Secretary may waive, for the length of the project period, the patient majority requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p) (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) Note: Portions of program requirements notated by an asterisk (*) indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs. Performance Improvement Area: Areas for Performance Improvement Program Requirements Program Requirement #19 Conflict of Interest Policy: Health center bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the health center. This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 12 of 72

13 No board member shall be an employee of the health center or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board.* (45 CFR Part and 42 CFR Part 51c.304(b)) Note: Portions of program requirements notated by an asterisk (*) indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section 330(i)) Programs. Performance Improvement Area: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 13 of 72

14 SECTION 5: Clinical Performance Measures (see Appendix C of Health Center Site Visit Guide for additional information on required measures) Areas for Performance Improvement Selected Performance Measure #1: Selected Performance Measure #2: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 14 of 72

15 SECTION 6: Financial Performance Measures (see Appendix C of Health Center Site Visit Guide for additional information on required measures) Areas for Performance Improvement Selected Performance Measure #1: Selected Performance Measure #2: Areas for Performance Improvement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 15 of 72

16 SECTION 7: Capital and Other Grant Progress Review (see Appendix D of Health Center Site Visit Guide for information on reviewing progress on grant awards under the American Recovery and Reinvestment Act (ARRA) and Affordable Care Act (ACA)) ARRA IDS and NAP Review Summary of Progress on IDS and NAP ARRA Awards: TA Recommendations (if applicable): Capital Grant Progress Review (ARRA and ACA Awards: C81 Capital Improvement Program (CIP), C80 Facility Investment Program (FIP), C8A Capital Development (CD), and C12 School-based Health Center Capital (SBHCC) grants. Also includes one-time funding for minor construction activities included within New Access Point (NAP) grants) Summary of Progress on Capital Grant Awards: Findings/Factors (attach facility photos if taken): TA Recommendations (if applicable): This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 16 of 72

17 Summary of Key Health Center Program Requirements Health centers are non-profit private or public entities that serve designated medically underserved populations/areas or special medically underserved populations comprised of migrant and seasonal farmworkers, the homeless or residents of public housing. A summary of the key health center program requirements is provided below. For additional information on these requirements, please review: Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. 254b) Program Regulations (42 CFR Part 51c and 42 CFR Parts for Community and Migrant Health Centers) Grants Regulations (45 CFR Part 74) NEED Needs Assessment: Health center demonstrates and documents the needs of its target population, updating its service area, when appropriate. (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act) SERVICES Required and Additional Services: Health center provides all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established written arrangements and referrals. (Section 330(a) of the PHS Act) Note: Health centers requesting funding to serve homeless individuals and their families must provide substance abuse services among their required services. (Section 330(h)(2) of the PHS Act) Staffing Requirement: Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. (Section 330(a)(1), (b)(1)-(2), (k)(3)(c), and (k)(3)(i) of the PHS Act) Accessible Hours of Operation/Locations: Health center provides services at times and locations that assure accessibility and meet the needs of the population to be served. (Section 330(k)(3)(A) of the PHS Act) After-Hours Coverage: Health center provides professional coverage during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act) Hospital Admitting Privileges and Continuum of Care: Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act) Sliding Fee Discounts: Health center has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient s ability to pay. This system must provide a full discount to individuals and families with annual incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income.* No discounts may be provided to patients with incomes over 200% of the Federal poverty guidelines.* This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 17 of 72

18 No patient will be denied health care services by the health center due to an individual s inability This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 18 of 72

19 This report has been prepared to pay for the such exclusive services, use of the assuring Health Resources that any and fees Services or payments Administration, required Bureau of by Primary the center Health Care for (HRSA/BPHC) such 19 of 72

20 This report has been prepared services for will the exclusive be reduced use of the or Health waived. Resources (Section and Services 330(k)(3)(G) Administration, of the Bureau PHS of Act, Primary 42 Health CFR Care Part (HRSA/BPHC) 20 of 72

21 This report has been prepared 51c.303(f)), for the exclusive and 42 use CFR of the Part Health 51c.303(u)) Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 21 of 72

22 This report has Note: been Portions prepared for of the program exclusive requirements use of the Health Resources notated and by an Services asterisk Administration, (*) indicate Bureau regulatory of Primary Health requirements Care (HRSA/BPHC) that 22 of 72

23 This report has are been recommended prepared for the but exclusive not required use of the for Health grantees Resources that and receive Services Administration, funds solely Bureau for Health of Primary Care Health for Care the (HRSA/BPHC) 23 of 72

24 This report has Homeless been prepared (Section for the 330(h)) exclusive use and/or of the the Health Public Resources Housing and Services Primary Administration, Care (Section Bureau of 330(i)) Primary Health Programs. Care (HRSA/BPHC) 24 of 72

25 This 8. report has Quality been prepared Improvement/Assurance for the exclusive use of the Health Plan: Resources Health and center Services has Administration, an ongoing Bureau Quality of Primary Improvement/Quality Health Care (HRSA/BPHC) 25 of 72

26 This report has Assurance been prepared (QI/QA) for the exclusive program use that of the includes Health Resources clinical and services Services Administration, and management, Bureau of and Primary that Health maintains Care (HRSA/BPHC) the 26 of 72

27 This report has confidentiality been prepared for of the patient exclusive records. use of the The Health QI/QA Resources program and Services must Administration, include: Bureau of Primary Health Care (HRSA/BPHC) 27 of 72

28 a clinical director whose focus of responsibility is to support the quality improvement/assurance This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 28 of 72

29 This report has been prepared program for the and exclusive the provision use of the of Health high Resources quality and patient Services care;* Administration, Bureau of Primary Health Care (HRSA/BPHC) 29 of 72

30 periodic assessment of the appropriateness of the utilization of services and the quality of This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 30 of 72

31 This report has been prepared services for provided the exclusive or use proposed of the Health to Resources be provided and Services to individuals Administration, served Bureau by of Primary the health Health center; Care (HRSA/BPHC) and such 31 of 72

32 This report has been prepared assessments for the exclusive shall:* use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 32 of 72

33 This report has been prepared o for be the conducted exclusive use by of the physicians Health Resources or by and other Services licensed Administration, health Bureau professionals Primary Health under Care the (HRSA/BPHC) 33 of 72

34 This report has been prepared for supervision the exclusive use of of physicians;* the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 34 of 72

35 This report has been prepared o for be the based exclusive on use the of the systematic Health Resources collection and Services and evaluation Administration, of Bureau patient of Primary records;* Health and Care (HRSA/BPHC) 35 of 72

36 This report has been prepared o for identify the exclusive and use document of the Health the Resources necessity and Services for change Administration, in the provision Bureau of Primary of services Health Care by (HRSA/BPHC) the 36 of 72

37 This report has been prepared for health the exclusive center use and of the result Health in Resources the institution and Services of Administration, such change, Bureau where of Primary indicated.* Health Care (HRSA/BPHC) 37 of 72

38 This report has (Section been prepared 330(k)(3)(C) for the exclusive of the use PHS of the Act, Health 45 Resources CFR Part and Services (c)(2), Administration, (3) and Bureau 42 CFR of Primary Part Health 51c.303(c)(1-2)) Care (HRSA/BPHC) 38 of 72

39 MANAGEMENT AND FINANCE This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 39 of 72

40 This 9. report has Key been Management prepared for the Staff: exclusive Health use of the center Health maintains Resources and a fully Services staffed Administration, health Bureau center of Primary management Health Care team (HRSA/BPHC) as 40 of 72

41 This report has appropriate been prepared for for the the size exclusive and use needs of the of Health the center. Resources Prior and Services approval Administration, by HRSA Bureau of a of change Primary Health in the Care Project (HRSA/BPHC) 41 of 72

42 This report has Director/Executive been prepared for the Director/CEO exclusive use of the position Health Resources is required. and Services (Section Administration, 330(k)(3)(I) Bureau of Primary the PHS Health Act, Care 42 (HRSA/BPHC) CFR 42 of 72

43 This report has Part been 51c.303(p) prepared for and the exclusive 45 CFR use Part of the 74.25(c)(2),(3)) Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 43 of 72

44 10. Contractual/Affiliation Agreements: Health center exercises appropriate oversight and authority over This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 44 of 72

45 This report has all been contracted prepared services, for the exclusive including use of the assuring Health Resources that any and subrecipient(s) Services Administration, meets Bureau Health of Primary Center Health program Care (HRSA/BPHC) 45 of 72

46 This report has requirements. been prepared (Section for the exclusive 330(k)(3)(I)(ii), use of the Health 42 Resources CFR Part and Services 51c.303(n), Administration, (t)), Section Bureau of 1861(aa)(4) Primary Health Care and (HRSA/BPHC) Section 46 of 72

47 This report has 1905(l)(2)(B) been prepared of for the exclusive Social use Security of the Health Act, Resources and 45 CFR and Services Part 74.1(a) Administration, (2)) Bureau of Primary Health Care (HRSA/BPHC) 47 of 72

48 11. Collaborative Relationships: Health center makes efforts to establish and maintain collaborative This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 48 of 72

49 This report has relationships been prepared with for the other exclusive health use of care the Health providers, Resources including and Services other Administration, health centers, Bureau of in Primary the service Health Care area (HRSA/BPHC) of the 49 of 72

50 This report has center. been prepared The health for the center exclusive secures use of the letter(s) Health Resources of support and Services from existing Administration, health Bureau centers of Primary (Section Health Care 330 (HRSA/BPHC) grantees 50 of 72

51 This report has and been FQHC prepared Look-Alikes) for the exclusive in use the of service the Health area Resources or provides and Services an Administration, explanation Bureau for why of Primary such Health letter(s) Care of (HRSA/BPHC) support 51 of 72

52 This report has cannot been prepared be obtained. for the exclusive (Section use 330(k)(3)(B) of the Health Resources of the and PHS Services Act and Administration, 42 CFR Bureau Part 51c.303(n)) of Primary Health Care (HRSA/BPHC) 52 of 72

53 12. Financial Management and Control Policies: Health center maintains accounting and internal control This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 53 of 72

54 This report has systems been prepared appropriate for the exclusive to the size use of and the Health complexity Resources of and the Services organization Administration, reflecting Bureau of Generally Primary Health Accepted Care (HRSA/BPHC) 54 of 72

55 This report has Accounting been prepared Principles for the exclusive (GAAP) use of and the Health separates Resources functions and Services appropriate Administration, to organizational Bureau of Primary Health size Care to safeguard (HRSA/BPHC) 55 of 72

56 This report has assets been and prepared maintain for the financial exclusive use stability. of the Health Health Resources center and Services assures Administration, an annual Bureau independent of Primary financial Health Care audit (HRSA/BPHC) is 56 of 72

57 This report has performed been prepared in accordance for the exclusive with use of Federal the Health audit Resources requirements, and Services including Administration, submission Bureau of Primary of a Health corrective Care (HRSA/BPHC) action 57 of 72

58 This report has plan been addressing prepared for all the findings, exclusive use questioned of the Health costs, Resources reportable and Services conditions, Administration, and Bureau material of Primary weaknesses Health Care (HRSA/BPHC) cited in 58 of 72

59 This report has the been Audit prepared Report. for the (Section exclusive use 330(k)(3)(D), of the Health Resources Section and 330(q) Services of Administration, the PHS Act Bureau and of 45 Primary CFR Health Parts Care 74.14, (HRSA/BPHC) of 72

60 This report has and been 74.26) prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 60 of 72

61 13. Billing and Collections: Health center has systems in place to maximize collections and reimbursement This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 61 of 72

62 This report has for been its costs prepared in providing for the exclusive health use of services, the Health Resources including and written Services billing, Administration, credit, Bureau and of collection Primary Health policies Care (HRSA/BPHC) and 62 of 72

63 This report has procedures. been prepared (Section for the exclusive 330(k)(3)(F) use of the and Health (G) Resources of the and PHS Services Act) Administration, Bureau of Primary Health Care (HRSA/BPHC) 63 of 72

64 14. Budget: Health center has developed a budget that reflects the costs of operations, expenses, and This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 64 of 72

65 This report has revenues been prepared (including for the exclusive the Federal use of grant) the Health necessary Resources and to accomplish Services Administration, the service Bureau delivery of Primary plan, Health including Care (HRSA/BPHC) the 65 of 72

66 This report has number been prepared of patients for the to exclusive be served. use of the (Section Health Resources 330(k)(3)(D), and Services Section Administration, 330(k)(3)(I)(i), Bureau of Primary and 45 Health CFR Care Part (HRSA/BPHC) 74.25) 66 of 72

67 This 15. report has Program been prepared Data for Reporting the exclusive Systems: use of the Health Health Resources center and has Services systems Administration, which Bureau accurately of Primary collect Health and Care organize (HRSA/BPHC) 67 of 72

68 This report has data been for prepared program for the reporting exclusive and use of which the Health support Resources management and Services Administration, decision making. Bureau of (Section Primary Health 330(k)(3)(I)(ii) Care (HRSA/BPHC) of 68 of 72

69 This report has the been PHS prepared Act) for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 69 of 72

70 This 16. report has Scope been of prepared Project: for the Health exclusive center use of the maintains Health Resources its funded and Services scope Administration, of project (sites, Bureau of services, Primary Health service Care area, (HRSA/BPHC) target 70 of 72

71 This report has population, been prepared and for providers), the exclusive use including of the Health any Resources increases and based Services on Administration, recent grant Bureau awards. of Primary (45 Health CFR Care Part (HRSA/BPHC) 74.25) 71 of 72

72 GOVERNANCE Board Authority: Health center governing board maintains appropriate authority to oversee the operations of the center, including: holding monthly meetings; approval of the health center grant application and budget; selection/dismissal and performance evaluation of the health center CEO; selection of services to be provided and the health center hours of operations; measuring and evaluating the organization s progress in meeting its annual and long-term programmatic and financial goals and developing plans for the long-range viability of the organization by engaging in strategic planning, ongoing review of the organization s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance;* and establishment of general policies for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) Note: In the case of public centers (also referred to as public entities) with co-applicant governing boards, the public center is permitted to retain authority for establishing general policies (fiscal and personnel policies) for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304(d)(iii) and (iv)) Note: Upon a showing of good cause, the Secretary may waive, for the length of the project period, the monthly meeting requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p) (Section 330(k)(3)(H) of the PHS Act) Board Composition: The health center governing board is composed of individuals, a majority of whom are being served by the center and, this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex. Specifically: governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.* the remaining non-consumer members of the board shall be representative of the community in which the center s service area is located and shall be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.* no more than one half (50%) of the non-consumer board members may derive more than 10% of their annual income from the health care industry.* Note: Upon a showing of good cause, the Secretary may waive, for the length of the project period, the patient majority requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p) (Section 330(k)(3)(H) of the PHS Act and 42 CFR Part 51c.304) Conflict of Interest Policy: Health center bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the health center. No board member shall be an employee of the health center or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board.* (45 CFR Part and 42 CFR Part 51c.304(b)) NOTE: Portions of program requirements notated by an asterisk (*) indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (section 330(i)) Programs. This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC) 72 of 72