HRSA Requirements Education & Training 2016

I. Program Expectations for 330 Community Health Centers II. Role of the Board of Directors

I. Program Expectations for 330 Community Health Centers Need Services Management & Finance Governance

Need Needs Assessment: Demonstrates and documents the needs of their target population, including updating their service area, when appropriate. (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act)

Need Medically Underserved Area (MUA)/Medically Underserved Population (MUP) Designation: Serves, in whole or in part, a designated MUA/MUP. (Section 330(a) of the PHS Act) (Requested, not required for HCH, PHPC or MHC applicants).

Services Required and Additional Services: 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 per program requirements. (Section 330(a) of the PHS Act) Note: Organizations receiving 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)

Services Staffing Requirement: 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. (Section 330(a)(1) and (b)(1), (2) of the PHS Act)

Services Accessible Hours of Operation/ Locations: 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)

Services After Hours Coverage: Provides professional coverage during hours when the center is closed. (Section 330(k)(3)(A) of the PHS Act)

Services Hospital Admitting Privileges and Continuum of Care: 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, organization must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act)

Services Sliding Fee Discounts: 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 the 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 percent of the Federal poverty level. (Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f))

Services Quality Improvement/Assurance Plan: 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 focus of responsibility 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 applicant; and Such assessments shall: be conducted by physicians or by other licensed health professionals under the supervision of physicians; be based on the systematic collection and evaluation of patient records; and identify and document the necessity for change in the provision of services by the applicant and result in the institution of such change, where indicated. (Section 330(k)(3)(C) of the PHS Act and 42 CFR 51c.303(c)(1-2))

Management & Finance Collaborative Relationships: Makes effort to establish and maintain collaborative relationships with other health care providers, including other health centers, in the service area of the center. Secures a letter of support from the existing health centers in the service area or provides an explanation for why such a letter of support cannot be obtained (Section 330(k)(3)(B) of the PHS Act)

Management & Finance Contractual/Affiliation Agreements: Exercises appropriate oversight and authority over all contracted services. (Section 330(k)(3)(I)(ii) and 42 CFR Part 51c.303(n), (t))

Management & Finance Key Management Staff: Maintains a fully staffed health center management team as appropriate for the size and needs of the center. Prior review of final candidates for Project Director/Executive Director/CEO position is required. (Section 330(k)(3)(H)(ii) of the PHS Act and 45 CFR Part 74.25 (c)(2), (3))

Management & Finance Financial Management and Control Policies: Has 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. Assures that an annual independent financial audit is performed in accordance with Federal audit requirements, addressing all reportable/material weaknesses in the Audit Report. (Section 330(k)(3)(D), Section 330(q) of the PHS Act and 45 CFR Part 74.21)

Management & Finance Program Data Reporting Systems: Maintains 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)

Management & Finance Billing and Collections: 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).

Management & Finance Budget: Has developed a budget that reflects the costs of operations, expenses, and revenues (including the Federal grant) necessary to accomplish the service delivery plan. (Section 330(k)(3)(D), Section 330(k)(3)(I)(i), and 45 CFR Part 74.25)

Management & Finance Service Level: Maintains their funded scope of project (i.e., projected number of patients to be served, including any increases based on recent New Access Point/Expanded Medical Capacity awards). (45 CFR Part 74.25)

Governance Board Authority: Governing board maintains appropriate authority to oversee the operations of the center, including: Holding monthly meetings, Approval of the health center’s grant application and budget, Selection/dismissal and performance evaluation of the CEO, Selection of services to be provided & the hours of operations, Establishment of general policies for the health center. Note: Some fiscal and personnel policies may be retained in the case of public centers (also referred to as “public entities”). (Section 330(k)(3)(H) of the PHS Act)

Governance Conflict of Interest Policy: Bylaws or written corporate board-approved policy include provisions that prohibit conflict of interest or the appearance of 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 an ex-officio member of the board. (45 CFR Part 74.42 and 42 CFR Part 51c.304(b), when applicable)

Governance Board Composition: Governing board must be composed of individuals, a majority of whom are being served by the center and, who as a group, represent the individuals being served by the center. Organizations that receive/request targeted funding to serve migrant and seasonal farmworkers, individuals experiencing homelessness and/or residents of public housing, must have appropriate representation on the board from these populations. (Section 330(k)(3)(H) of the PHS Act)

Governance Waiver of Board Requirements: Upon a showing of good cause the Secretary shall waive, for the length of the project period, all or part of the requirements of this subparagraph in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p). Such eligible applicants may request a waiver of the Board Composition and/or Monthly Meeting requirements. (Section 330(k)(3)(H) of the PHS Act)

Governance Board Size (for CHC and MHC applicants only): Governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization. (42 CFR Part 51c.304)

Governance Board Expertise (for CHC and MHC applicants only): The remaining members of the board shall be representative of the community in which the center's catchment 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. (42 CFR Part 51c.304)

Governance Non-Consumer Board Member Income (for CHC and MHC applicants only): 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. (42 CFR Part 51c.304)

II. Role of the Board of Directors

HEALTH CENTER BOARD MEMBER LEGAL AND PROGRAM RESPONSIBILITIES Responsibility Primarily that of the Board of Staff Shared Develops and amends the mission statement   Selects board members who will meet the duties of care, loyalty and obedience! Hires and evaluates key leadership staff, including the CEO, CFO and CMO Sets the strategic direction for the organization Implements the strategic plan Keeps track of “lobbying” expenditures Ensures that there is no conflict of interest when board members make a decision Establishes and approves financial policies Accepts the annual audit report

HEALTH CENTER BOARD MEMBER LEGAL AND PROGRAM RESPONSIBILITIES Responsibility Primarily that of the Board of Staff Shared Develops the annual operating budget   Approves the federal grant budget Reviews the general ledger for accuracy Reviews personnel records to ensure that policies are being followed Approves health care policies, procedures and protocols Receives VIP treatment when seen by a provider Ensures compliance with all applicable federal, state, and local law, regulation and policy Plans for the annual party!

Principles of Good Governance The organization should clearly understand and publicly express its mission. The organization's board should be engaged, informed, and independent. The board should have real responsibility and authority, including implementing the rules against inurement and self-dealing. The organization should ensure proper use and safeguarding of assets.

Principles of Good Governance The organization should implement policies and practices that address executive compensation, protect against conflicts of interest, and support independent financial reviews. Relationships and decision making should be transparent—board decisions should be reflected in minutes, and whistleblowers should be protected. The organization should develop a system of internal controls that is appropriate to the organization itself.

Mission The BPHC encourages Organizations to establish and review regularly the organization’s mission. A clearly articulated mission, adopted by the board of directors, serves to explain and popularize the charity’s purpose and guide its work. It also addresses why the organization exists, what it hopes to accomplish, and what activities it will undertake, where, and for whom.

Conflicts of interest The directors of a non-profit organization owe it a duty of loyalty. The duty of loyalty requires a director to act in the interest of the organization rather than in the personal interest of the director or some other person or organization. In particular, the duty of loyalty requires a director to avoid conflicts of interest that are detrimental to the charity. Many organizations have adopted a written conflict of interest policy to address potential conflicts of interest involving their directors, trustees, officers, and other employees.

Conflicts of interest The BPHC encourages an organization’s board of directors to adopt and regularly evaluate a written conflict of interest policy that requires directors and staff to act solely in the interests of the organization without regard for personal interests; includes written procedures for determining whether a relationship, financial interest, or business affiliation results in a conflict of interest; and prescribes a course of action in the event a conflict of interest is identified.

Conflicts of interest The BPHC encourages organizations to require its directors, trustees, officers and others covered by the policy to disclose, in writing, on a periodic basis any known financial interest that the individual, or a member of the individual’s family, has in any business entity that transacts business with the charity. The organization should regularly and consistently monitor and enforce compliance with the conflict of interest policy.

Fundraising Charitable fundraising is an important source of financial support for many FQHC’s. The BPHC encourages organizations to adopt and monitor policies to ensure that fundraising solicitations meet federal and state law requirements and solicitation materials are accurate, truthful, and candid. Charities are encouraged to keep their fundraising costs reasonable and to provide information about fundraising costs and practices to donors and the public.

Governing Body Minutes & Records The BPHC encourages the governing bodies and authorized sub-committees to take steps to ensure that minutes of their meetings, and actions taken by written action or outside of meetings, are contemporaneously documented.

Transparency and Accountability By making full and accurate information about its mission, activities, finance, and governance publicly available, an organization encourages transparency and accountability to its constituents.

Financial Statements Many organizations (FQHC) that receive federal funds are required to undergo one or more audits as set forth in the Single Audit Act and OMB Circular A-133.

Corporate Compliance The entire organization “must” be engaged in promoting an atmosphere of corporate compliance. Corporate Culture to Ensure: Ethical Behavior Adherence to Applicable Laws Commitment of Resources To Whom Does It Apply? - Everyone

As a board member, if you can only ask eight questions….ask these What is your strategic plan and what progress has been made? What is the one-year operational plan and what progress has been made? What is the current financial position? Total margin Days cash on hand Days in A/R Days in A/P Current ratio

As a board member, if you can only ask eight questions….ask these What mechanisms are in place to ensure compliance with: 330 requirements; state and federal laws and regulations; Medicaid and Medicare requirements? Is your staff satisfied? How do you know? Are your patients satisfied? How do you know? What goals have been set in the QA/QI Plan and have they been met? What is the need in the community - # of services and type of services? How well are you doing in meeting this need?

Thank You For Serving

Questions?