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
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
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
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
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
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 74.25 (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
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
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, 74.21 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
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
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
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
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
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 74.42 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
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
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
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
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 56.201-56.604 for Community and Migrant Health Centers) Grants Regulations (45 CFR Part 74) 1. 2. 3. 4. 5. 6. 7. 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
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
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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
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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
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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
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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
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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
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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
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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
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
17. 18. 19. 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 74.42 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