1. Compliance and the Board Casie Pauley, MPA Program Coordinator Health Center Operations, CPCA 1

2. 19 Key Health Center Program Requirements Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. §254b) 2

3. 3 Role of a Compliance Program

4. 4 Seven Core Elements of an Effective Compliance Program 1. Written policies, procedures and standards of conduct 2. Compliance program oversight 3. Training & Education 4. Opening the lines of communi- cation 5. Auditing & Monitoring 6. Consistent discipline 7. Corrective actions

5. Why do we need Compliance? Health Care is one of the most regulated industries Rising health care costs results in increased governmental scrutiny Government is the biggest payer It’s required by governmental agencies Risks of non-compliance are great! 5

6. What does it mean to be a Health Center Board Member? Fiduciary Duties Duty of Care Duty of Loyalty Duty of Obedience Board of Directors Functions and Responsibilities Where do you start learning about compliance? 6

7. Governing Board Handbook HRSA’s Governing Board Handbook BPHC designed this handbook as an orientation tool to assist new members in understanding the structure and responsibilities of a governing board. 7 http://bphc.hrsa.gov/technicalassistance/TAResources.a spx?Mode=SubTopicSubResource&STopic=Governance# Governance/Board

8. Program Requirement 17: Board Authority Policy making and monitoring Policies reviewed… When and how often? Has the Board signed off on the revisions? 8

9. Policy Making Process 9 Board Considers New Policy Is this policy in keeping with the mission statement No Is this policy or action necessary and appropriate? Yes No Sufficient to warrant amending mission statement Yes No Board does not make this policy Yes Board makes this policy

10. Who’s Responsible? Long-term goalsDay-to day operations Short-term goals (monitor)Short-term goals (execute) Personnel policiesStaff development Org. chartStaff hiring CEO/Director evaluation onlyStaff evaluations Staff salaries (budget line item)Staff salary approval Budget (approves)Budget (develops) Capitol purchasesMaintenance Major repairsMinor & Emergency repairs Fees & collections (approves)Fees & Collections (develops) 10

11. Who’s Responsible? Board OversightAdministrator Long-term goalsDay-to day operations Short-term goals (monitor)Short-term goals (execute) Personnel policiesStaff development Org. chartStaff hiring CEO/Director evaluation onlyStaff evaluations Staff salaries (budget line item)Staff salary approval Budget (approves)Budget (develops) Capitol purchasesMaintenance Major repairsMinor & Emergency repairs Fees & collections (approves)Fees & Collections (develops) 11

12. Your Health Center Bylaws Should include: Term limits How and when board meetings will be conducted How board members and officers will be selected Duties of corporate officers/executive committee Committee Structure Description of the board’s relationship with the center’s CEO and staff 12

13. The Board’s Role in Strategic Planning 13

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15. Program Requirement 17: Board Authority Cont’d Establishment of general policies for the health center Holding monthly meetings Selection/dismissal and performance evaluation of the health center CEO Measuring and evaluating the organization’s progress in meeting its annual and long-term programmatic and financial goals and developing plans for long-range viability of the organization 15

16. Does your board approve the applications related to the health center project, including grants applications and other HRSA requests regarding scope of project? Does your board approve the annual health center budget and audit? Are these reviews and approvals being documented in the board meeting minutes? 16 Questions for the Board: Requirement 17

17. Additional Questions: Requirement 17 Does the board select the services (beyond those required in law, i.e., “Required Services”) to be provided by the health center, as well as the location and mode of delivery of those services? Does the board determine the hours during which services are provided at health center sites, ensuring that these are appropriate and responsive to the community’s needs? Are these reviews and approvals documented in the board minutes? 17

18. Quality as Compliance Where to Start 1.Create the Basic Structures 2.Evaluate & Determine Priorities 3.Select Performance Measures 4.Collect Data/Determine a Baseline 5.Analyze Data/Evaluate Performance 6.Plan & Implement Changes for Improvement 7.Monitor Performance Over Time 18

19. QI Committee QI Plan & Health care plan QI calendar Clinical practice guidelines Policies & procedures Peer review Chart audits Patient satisfaction surveys & employee surveys Tracking systems Credentialing and privileging Data sources 19 Create the Basic Structures

20. Internal Monitoring Major Risk Areas False Claims Act HIPAA and HITECH Act Grant Requirements Anti-Kickback Act Stark Act Workplace Safety Laws Employment Laws 20

21. External Monitoring Who Investigates? OIG - Office of the Inspector General OCR – Office for Civil Rights HRSA/BPHC – Health Resources and Services Administration/Bureau of Primary Health Care State Privacy CDPH – licensed clinics and facilities Licensing boards – licensed professionals CA Attorney – unlicensed individuals (e.g., MAs) District Attorney Federal Tort Claims Act (FTCA) 21

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23. Program Requirement 18: Board Composition 51% of Board members must be consumers Must be representative of the individuals being served by the health center Must have between 9 and 25 members Bylaws must specify a range or specific number Non-consumer board members must be representative of the community in which the health center’s service area is located 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 23

24. Program Requirement 19: Conflict of Interest Bylaws should include provisions that prohibit conflict of interest. Written standards of conduct Board and Employee conflicts Gratuities Disciplinary Actions Family Members CEO/ED not a voting member 24

25. What should the board do? Ask Questions How is your compliance program structured? Who is responsible? Does the compliance committee report to the board? How frequently? What are the goals of the compliance program? How are compliance risks determined? How are compliance risks reported to the board? Is there a code of conduct for the organization? What compliance related training and education is provided? 25

26. Additional Questions the Board Should be Asking Is your budget in line for this period? Where are you on your strategic plan? Do you receive Board packets and meeting minutes? Do you see the Quality Meeting minutes? Do you receive data on patient complaints? Do you see productivity data? Are you documenting major actions and decisions made by the board? 26

27. Policy Information Notice (PIN) 2014-01 Health Center Program Governance PIN Key clarity points Structure and functioning of boards Requirements for public centers under co-applicant arrangements Waiver for the 51% patient majority for eligible 330 grantees and lookalikes Elimination of the waiver consideration for monthly meeting requirement 27

28. Resources New Governance PIN 2014-01 http://bphc.hrsa.gov/policiesregulations/policies/pin201 401.pdf Governance Overview http://bphc.hrsa.gov/policiesregulations/governance/in dex.html Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors https://oig.hhs.gov/fraud/docs/complianceguidance/Cor porateResponsibilityFinal%209-4-07.pdf 28

29. CPCA Health Center Board Peer Network The CPCA Health Center Board Peer Network provides an opportunity for Community Clinic and Health Center board members to be more involved in the organizations for which they govern. Stay up to date on issues impacting health center governance, state-wide policy issues and facilitate sharing with your peers across the state. http://www.cpca.org/index.cfm/health-center- resources/peer-networks-workgroups/health-center- board-peer-network/ http://www.cpca.org/index.cfm/health-center- resources/peer-networks-workgroups/health-center- board-peer-network/ 29

30. Questions? Contact Casie Pauley cpauley@cpca.org 30