BPHC Site Visit Report: Consolidated Team Reportfiles.sj-r.com/media/news/HRSAreport.pdfBUREAU OF PRIMARY HEALTH CARE SITE VISIT REPORT Consolidated Team Report template updated September

BUREAU OF PRIMARY HEALTH CARE SITE VISIT REPORT

Consolidated Team Report template updated September 2013

This report has been prepared for the exclusive use of the Health Resources and Services Administration, Bureau of Primary Health Care

(HRSA/BPHC) to assist in providing guidance and oversight of the HRSA/BPHC grantee. Information provided in this report is restricted to

HRSA/BPHC use and cannot be distributed, copied, shared, and/or transmitted without written permission from HRSA/BPHC and the

Review Team.

Page 1 of 42

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.

TA Request: TA000286

Part One

Grantee Information: Central Counties Health Centers, Inc.

2239 East Cook Street

Springfield, Illinois 62703

Contact: Barbara Dunn, Interim CEO

E-mail: [email protected]

Type of Visit: Operational Site Visit (OSV)

Purpose of Visit: The Project Officer requests a standard, comprehensive, Operational Site Visit

(OSV) to assess the grantee’s compliance with meeting the 19 Key Health Center Program

Requirements. The site visit should also evaluate and provide recommendations for Performance

Improvement in all areas of governance, administrative, clinical, and fiscal operations.

The goal of the OSV is to strengthen the organization’s ability to carry out their mission and that

of HRSA’s Health Center Program to provide access to culturally competent, quality health care

services to communities in need. In addition, the OSV is to identify the Program Requirements

where the grantee is out of compliance and provide an explanation to the grantee, while on-site,

on how to come into compliance. The desired outcome of the OSV is a Site Visit Report

describing the Program Requirements as Met or Not Met, in sufficient detail, along with

recommendations for performance improvement.

Dates of Visit: January 22 – 24, 2014

Consultants: Administrative/Governance/Team Leader

(b) (5)

(b) (5)

mailto:[email protected]






Review Team.

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Finance

Clinical

Overview of Grantee Organization: Central Counties Health Centers (CCHC) is located in

Springfield, Sangamon County, IL. CCHC has been HRSA-funded since 1999 and moved to

their current location on East Cook Street in 2005. The target service area for this project

includes the medically underserved population of Springfield. Other than services provided by

CCHC there are no other affordable, accessible primary care options for service area residents.

CCHC also receives Section 330(h) funding to provide care to those residents experiencing

homelessness. The most recent data shows that the annual homeless population of the city is

approximately 4,000 persons. Through the assistance of a formerly homeless individual who

now serves on the CCHC Board of Directors, CCHC conducts periodic health care needs surveys

of the homeless population. The surveys are conducted on unduplicated individuals at three

locations in the Springfield area, are completely voluntary, and have a response rate of over 90%

of those actually taking part in the survey.

A dynamic and involved Board of Directors governs CCHC. The Board is currently conducting

a search for a regular President/CEO, and has engaged the services of a well-qualified interim to

lead the Key Management Staff during the process.

CCHC experienced significant operating losses in fiscal 2012 and 2013 of ( ) and

( ) respectively. Despite these losses, CCHC has a strong financial position with no

long term debt, in investments, and in cash on hand (2013 audited results).

These losses were in large part created by changes in the Illinois State Medicaid program in

relation to dental services. During 2012, dental services for adult Medicaid recipients were

terminated. CCHC’s dental practice had a large adult Medicaid population that was suddenly no

longer covered for services, thereby creating a significant reduction in Medicaid revenues and a

related increase in uninsured dental care.

In response to these losses, CCHC made overall adjustments in available capacity and reduced

personnel costs. Six months into the current fiscal year that ends June 30, 2014, CCHC’s interim

financial statements show year-to-date revenues of $249,763 with $4,199,804 remaining in

investments and zero long-term debt.

(b) (5)

(b) (5)

(b) (5)

(b) (5)

(b) (4)(b) (4)

(b) (4)(b) (4)






Review Team.

Page 3 of 42

CCHC provides primary medical and dental care to residents of the East Springfield Community

as well as to the homeless population found in that area. Care is provided by family, internal

medicine, and pediatric providers. CCHC provides care to the homeless community not only at

the main site, but also at two shelters for 32 hours weekly.

The Center’s medical and dental programs work in close concert with an excellent referral

system, especially for both the homeless and pediatric populations. The dental department sees

pediatric patients beginning at age one. The dental department is also a member of the Miles of

Smiles team in which Illinois school children in Kindergarten, First, and Sixth grades are given

dental exams. As part of that team, CCHC proactively appoints children and notifies parents

when further work is needed. This brings new patients not only into dental but into medical as

well.

The Center has close ties to the two nearby community hospitals that continue to support the

organization in their efforts to improve the health of the community. Both hospitals provide

significant discounts for laboratory and radiology services as well as when hospitalization is

needed. In addition, the sub-specialists in the community offer either free or highly discounted

care for CCHC patients.

Site Visit Participants:

Name & Title of Participant Interviewed Entrance Exit

Barbara Dunn, Interim CEO

Y

Y

Y

Dr. Dora Ramos, CMO Y Y Y

Brad Buzzard, CFO/COO Y Y Y

Scott Parks, Human Resources Director Y Y Y

DDS, CDO Y N N

DDS Y N N

NP Y N N

LPN Y N N

Julie Janssen, Board Chair Y Y Y

Donald Waters, Vice Chair Y Y Y

Dawn Melcher, Board Member Y Y Y

Ida Jackson, Board Member Y Y Y

Michael Nyles, Board Member N Y Y

Sam Gaines, Board Member Y Y N

Geraldine Johnson, Board Member Y Y N

James Greenwald, DDS, Board Secretary Y N Y

David Mytar, Board Member N N Y

(b) (4)

(b) (4)(b) (4)

(b) (4)






Review Team.

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Other Attendees: Susan Gaines, Illinois Primary Health Care Association

HRSA Representative: Joanne Thompson, CPA, Federal Project Officer

Contact: [email protected]

(Telephonically attended Entrance and Exit Conferences and

available to the consultants throughout the OSV)

List of Documents Reviewed:

2013 BPR Submission

Needs Assessment (being updated 1/2014)

Binder with Various County Health Rankings, Health Surveys, and Data Dashboards

http://hpsafind.hrsa.gov/HPSASearch.aspx

http://bhpr.hrsa.gov/shortage/hpsas/primarycareoffices.html#il

Board Minutes, Past 12 Months

Board List and Committee Assignments – 1/2014

Bylaws – 11/2013

Employee Handbook – 10/2010

Other Representative General Personnel Policies including

o Personal Protective Equipment – 3/2013

o Emergency Evacuation Plan – 2/2013

Representative Personnel Files

Annual Employee Evaluation Tool

Staff Satisfaction Survey Tool and Results – 2013

Job Description File

I-9 Folder

Organizational Chart – 1/2014

Minutes of the Board dated 12/10/2013 appointing an Interim President/CEO

Minutes of the Board dated 12/20/2013 establishing a Search Committee for a regular

President/CEO

Job Description: Interim CEO – 1/2014

Employment Agreement with Interim President/CEO – 1/2014

Various Documents Supporting the President/CEO Search Committee, namely:

o Search Committee Timeline

o CEO Competencies and Success Factors



http://bhpr.hrsa.gov/shortage/hpsas/primarycareoffices.html#il






Review Team.

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o Position Posting for Local and National Media

o Draft Succession Policy

o List of Search Committee Members

New Board Member Packet

Electronic Billing Records of Consumer Board Members

Patient Bill of Rights – undated

Mission Statement

CCHC Strategic Plan: 2012

Staffing List

Audited Financial Statements for June 30, 2013

Auditors Communication with those Charged with Governance June 30, 2013

Audited Financial Statements for June 30, 2012

Finance Committee Minutes January 2013 – November 2013

Interim Financial Statements July 2013 – December 2013

2012 UDS

2011 UDS

2010 UDS

FY 2014 Budget

2014 Form 2 Staffing profile

Financial Policies including Billing Policies

Chart of Accounts

NOA 01/08/2014

NOA 12/09/2013

NOA 09/12/2013

NOA 05/05/2013

NOA 02/24/2013

Fee Schedule

A/R Aging December 31, 2013

A/P Aging December 31, 2013

2012 federal Form 990

Bank Reconciliation October – December 2013

Check Register for December 2013






Review Team.

Page 6 of 42

Form 941 for October 31, 2013

Form 941 for December 31, 2013

Medicare Cost Report June 30, 2013

Central Counties Patient Brochure

Central Counties Dental Brochure

Board List (Form 6A)

Roster of staff by position/job title

UDS Trend Reports

Peer Review process/forms

MOUs

QM Plan

Credentialing policy

Credentialing and privileging files

Provider contracts

Current Staffing List/Position Descriptions/Bios

Hours of Operation

Clinical Policies and procedures

Signs posted in the clinic

Patient records

Meeting minutes including QI and clinical meetings

Patient satisfaction surveys

Chart reviews

List of Documents Left With Grantee:

NACHC Governance Bulletin Succession Planning

Sample Succession Planning Manual

Sample Succession Planning Policy

Sample Succession Planning Work Plan

Credentialing checklists for LIPs and other providers






Review Team.

Page 7 of 42

Primary Compliance Issues, Concerns, and/or Performance Improvement Opportunities

Addressed During Visit: The following table summarizes the Program Requirements

determined to be not met, which require CCHC to remedy the deficiency, along with significant

Program Requirements where the site visit team provides recommendations for Performance

Improvement (PI).

Program Requirement

Not

Met PI Program Requirement

Not

Met PI

1 – Needs Assessment X 11 – Collaborative Relationships X

2 – Required/Additional Services

12 – Financial Management &

Control Policies

3 – Staffing Requirement X 13 – Billing and Collections

4 – Accessible Hours/Locations 14 – Budget

5 – After Hours Coverage 15 – Program Data Reporting

Systems

X

6 – Hospital Admitting Privileges

and CC

16 – Scope of Project X X

7 – Sliding Fee Discount X 17 – Board Authority X X

8 – QI/QA Plan 18 – Board Composition X X

9 – Key Management Staff X 19 – Conflict of Interest Policy

10 – Contractual/Affiliation

Agreements X

Program Requirements Not Met:

Administration & Governance

(b) (6)

(b) (6)






Review Team.

Page 8 of 42

Clinical

None Noted.

Financial

None Noted.

Significant Concerns/Performance Improvement Opportunities and Recommendations:

Administrative/Governance

CCHC should contact the Illinois Primary Care Office (PCO) to request assistance and

clarification of their current primary care HPSA score.

CCHC should undertake a process wherein job descriptions are annually updated.

CCHC should review all network and linkage agreements for accuracy and relevancy.

CCHC should reevaluate and reconsider adding form 5C to the scope of project.

CCHC should consider scheduling and convening a strategic planning process in

conjunction with their successful President/CEO recruitment process.

CCHC should consider increasing the number of voting Board members.

Financial

CCHC should use a cost benefit analysis to evaluate the benefits of converting sliding

scale structure from a percentage of charges to graduated flat fees.

Clinical

CCHC should consider changing their organizational chart to have the nurse manager

(and her subordinates) report to the CMO.

Specific Actions Taken During Site Visit:

Participated in site visit planning and coordination prior to the site visit, including a

conference call with the Project Officer and site visit team, followed by a conference call

with CCHC’s management team to discuss the objectives of the site visit, the document

request, initiate planning of the agenda, and other logistics. A document request was

submitted for information needed in advance of the site visit. The team leader developed

an agenda to guide the site visit.

Reviewed documents provided by CCHC and the BPHC Project Officer prior to the

arrival for the site visit, as well as documents provided while on-site.






Review Team.

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Held brief meetings during the course of the site visit with CCHC to discuss observations

and strategies for performance improvement, with a recap and review of the team’s

findings and recommendations.

Participated in an Entrance Conference with the Project Officer (via telephone), Key

Management Staff, and Board members. The meeting included review of the site visit

objectives, an overview of CCHC’s operations, and site visit logistics.

Site visit team members met with Senior Management Staff, Board members, and other

staff in accordance with the agenda and as determined throughout the site visit. These

meetings served to aid site visit team members in gathering specific information

regarding their respective areas of review for the 19 Program Requirements as further

delineated in the HRSA Site Visit Guide.

Members of the site visit team toured CCHC’s clinical/administrative site on East Cook

Street.

Members of the site visit team participated in a closed (no staff present) session with

seven (of ten) Board members. The vision, level of understanding of an FQHC Board’s

responsibilities, and knowledge of strategic planning, human resources, finance, and

quality improvement of the Board members were ascertained.

Site visit team members reviewed documents, sampled records, and completed analysis

of information to assess compliance with Program Requirements.

Site visit team members left vetted documents and examples behind as delineated above

in this section.

Site visit team members participated in an Exit Conference with Senior Management

Staff, Board members, and Project Officer (via telephone) to review the site visit

findings, observations, recommendations, and next steps.

Additionally, the clinical consultant toured the HCH program site at the Salvation Army

Shelter.

Additional Technical Assistance Recommended: None recommended.

Innovation/Best Practices: CCHC has instituted a unique and excellent process where the

employee is actually present while the supervisor is completing the evaluation form, and

discourse about each grading criteria occurs between the two. This process eliminates

misunderstanding by the employee as to why a certain grade is assigned.






Review Team.

Page 10 of 42

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)

Findings/Factors: Met.

CCHC has a well-documented Needs Assessment that is being updated as of the time of this site

visit. Their service area includes eight census tracts within Springfield and parts of two zip

codes. The City of Springfield is classified as a “small metro area.” The assessment describes

the residents of the service area in significant detail and documents that about 15.5% of residents

are “Non-Hispanic Black,” 79.4% are “Non-Hispanic White,” and about 1.9% are reported as

“Hispanic.” About 14% of residents are uninsured (the impact of the Affordable Care Act

(ACA) in numbers of insured residents is not yet able to be reflected in this number).

The Needs Assessment cites Malignant Neoplasm, Heart Disease, Cerebrovascular Disease,

Lower Respiratory Disease, Death by Firearms, and Homicide as the leading causes of mortality

in the service area.

CCHC’s HPSA scores (per http://hpsafind.hrsa.gov/) are as follows:

CCHC *

Primary Care 8

Dental 11

Mental Health 14

* Listed as “Central Counties Health Centers”

Note: Satellite sites of Comprehensive Health Centers automatically assume the HPSA score of

the affiliated grantee. They are not listed separately.

The HPSA score for Primary Care is not sufficiently high to enable participation in such programs

as loan repayment or placement of NHSC Scholars. CCHC reports that they have not attempted to

access these programs in recent years. CCHC employs physicians, mid-level providers, dentists,

and dental hygienists.

Recommendations: None for this program requirement.

http://hpsafind.hrsa.gov/






Review Team.

Page 11 of 42

Areas for Performance Improvement

Performance Improvement Area: HPSA Scores

Findings/Factors: CCHC’s Primary Care HPSA score listed at hpsafind.hrsa.gov is not

sufficiently high to facilitate placement of NHSC scholars, and may not accurately reflect the

actual shortages and subsequent need for providers within the service area.

Recommendations: CCHC should contact the Illinois Primary Care Office (PCO) to request

assistance and clarification of their current score. (Note: During the Exit Conference, the PCA

representative informed all attendees that in Illinois, the PCA takes responsibility for HPSA

score determination). The PCO contact information is as follows:

Center for Rural Health

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL 62761

Phone: (217) 782-1624

Fax: (217) 782-2547

PCO Director: Julie Casper – (217) 782-1624

HPSA & NHSC Contact: Dianne Roberts – (217) 782-1624


Performance Improvement Area: Using the Needs Assessment for Patient-Centered

Medical Home (PCMH)

Findings/Factors: CCHC’s Needs Assessment can contribute to their System Accountability by

improving Patient Centeredness.

Recommendations: In future and ongoing updates of their Needs Assessment, CCHC should

address the following questions in the interest of improving Patient Centeredness:

Does the needs assessment provide an analysis of key important conditions and risky

behaviors for the population? Are these prioritized?

Does the needs assessment include a language and cultural analysis?

Does the needs assessment fully analyze health disparities and gaps across the

service area?


http://www.idph.state.il.us/








Review Team.

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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)


The Center provides all required services. Pre- and post-natal care is delivered on-site by

arrangement with the Springfield Family Medicine Residency Program Physicians who also

deliver these patients. There is a formal agreement for these services. Center physicians care for

the infants, and both mothers and infants return to the CHC.

Mental Health and Substance Abuse services are provided for the homeless population at the

shelters where the Center has clinical sites. Non-homeless clients in need of these services are

referred to the local mental health agency for care. There is a formal agreement for the provision

of these services.



Performance Improvement Area: None for this program requirement.

Findings/Factors: N/A

Recommendations: N/A






Review Team.

Page 13 of 42

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)


The Center has appropriately credentialed and privileged physicians, dentists and mid-level

providers.

provide primary care services to center patients at the main clinic as well as at

two nearby shelter locations.

CCHC’s administration of human resources is excellent and performed under the direction of the

Human Resources Director. The HR Director has access to a corporate attorney for questions and to

request policy review. The Personnel Policies have been Board approved and also serve as the

Employee Handbook. The Employee Handbook was last reviewed and Board approved in 2010 and

is scheduled for review and possible update. The new edition will be presented to the Board via the

Operations and Development Committee for review and approval. Employees are provided with the

Manual in paper format, acknowledge receipt of the latest revision to the Policy upon hire and

changes are distributed by e-mail, and later explained at the quarterly ‘Town Hall’ (all-staff)

meetings with standard agendas and minutes taken. Job descriptions are complete and signed by

employees however, there is no process for annually updating them. New employees are formally

and thoroughly oriented using a standard check-off list. Employees are further indoctrinated at their

divisional level, including clinical competencies where appropriate.

Employee evaluations are scheduled annually and accomplished using a standard tool that

incorporates elements of individual job descriptions into the evaluation process. CCHC has

instituted a unique and excellent process where the employee is actually present while the supervisor

is completing the evaluation form and discourse about each grading criteria occurs between the two

(see Best Practices above in Section I). This process eliminates any misunderstanding by the

employee as to why a certain grade is assigned. Employees can appeal comments concerning their

evaluation to their supervisor and ultimately the CEO, using a special form.

A formal staff satisfaction survey is conducted annually in paper format. The results are

consolidated and shared with the Key Management Staff. To date, the survey results have not

been trended from year to year. The HR Director attends monthly Board meetings.


(b) (4)






Review Team.

Page 14 of 42


Performance Improvement Area: Staffing

Findings/Factors: The current organizational chart has the RN nurse manager reporting to the

COO/CFO. This is an inappropriate line of authority, as a clinically licensed person must report

to a superior who holds either the same or a greater license. Additionally, the CMO should have

authority over all clinical areas.

Recommendations: The organization chart should be changed to have the nurse manager (and

her subordinates) report to the CMO. If desired, there could be a dotted line to the COO.


Performance Improvement Area: Periodic Review and Updating of Job Descriptions

Findings/Factors: CCHC’s job descriptions are not periodically reviewed and updated, and

some are several years old.

Recommendations: CCHC should undertake a process whereby job descriptions are provided to

the supervisor on the occasion of the annual performance review and jointly reviewed by the

supervisor and employee. Updates can then be returned to HR to be applied to the master job

description file.


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)


The Center is open Monday through Friday from 8 to 5 with extended hours on Wednesdays

until 7 PM and Saturday hours from 9 to 1. The homeless are cared for not only within the

health center, but also at two shelter locations that are open 32 hours per week.







Review Team.

Page 15 of 42






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))


Professional health center staff is available to patients 24/7 through an answering service.

Providers rotate after hours and weekend call duties.







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)







Review Team.

Page 16 of 42

Center patients are hospitalized at either of the two nearby community hospitals − St John’s and

Memorial. While the providers have courtesy privileges, patients are cared for by the hospitalist

group in each facility. There is an electronic link between both hospitals and the Center to

apprise both groups of the needs of individual and to facilitate continuity of care. There is an

agreement with the hospitalist group which speaks to care for hospitalized patients, continuity of

care, and primary care provider involvement in discharge planning.







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 due to an individual’s inability to pay for

such services by the health center, 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.


CCHC has an appropriately designed sliding fee schedule that offers a full discount to

individuals and families at or below 100% of the FPG, a partial discount to individuals and






Review Team.

Page 17 of 42

families between 100% and 200% of the FPG and no discount to individuals and families above

200% of the FPG. CCHC’s sliding scale was based on the most recent poverty guidelines issued

on January 26, 2013.

Appropriate signage was observed throughout the main service site. Signage at check-in

indicated “Sliding Fee Available.” The actual sliding scale was displayed at check-in, nursing

stations and other key strategic locations around the facility. Sliding fee availability was also

referenced in patient brochures.



Performance Improvement Area: Sliding Scale Structure

Findings/Factors: CCHC utilizes a sliding fee structure based on a percentage of charges.

This creates a system where there are significant patient balances to be collected at the end of the

patient visit, as staff and patients cannot reasonably predict the total amount owed for services

prior to their visit. This information is provided to the patient after the visit. Frequently patients

indicate after service has been provided that they are unable to pay the balance of charges.

This has the potential to create bottlenecks in patient flow, as the same personnel handle check-in

and checkout at the main practice site.

Possible benefits of changing the co-pay structure for sliding fee patients to flat rate tiered co-

pays were discussed. When staff and patients know amount owed for services prior to visit, it is

more straightforward to collect entire amount owed prior to services. This cuts down on billing

for receivables, resulting in savings in staff time to produce receivables and postage, and

improves cash flow from collections prior to service.

It should also be noted that fear about uncertain costs might be a significant barrier to accessing

care for many patients.

Recommendations: CCHC should conduct a cost-benefit analysis to evaluate the benefits of

converting sliding scale structure from a percentage of charges to graduated flat fees.






Review Team.

Page 18 of 42


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.


The Center has a fully functional Quality Improvement Plan and Program that has Board

approval (January 2014) and involvement. The program examines service utilization and the

quality of services provided on a regular basis and makes appropriate changes in service delivery

based on those findings. Peer review in both medical and dental is completed on at least a

quarterly basis with all providers being actively involved in the process. In addition, chart

completion audits and problem-focused audits are completed to assure that support staff

members are also adhering to the set standards of care.











Review Team.

Page 19 of 42

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))


CCHC’s Key Management Staff consists of a President/CEO, Finance/Operations Director,

Human Resources/Compliance Director, Medical Director, and Dental Director. With the

exception of the President/CEO, all positions are currently filled with permanent incumbents

who are employees of the corporation. The President/CEO position is currently vacant, and

recruiting processes have been initiated. The Board has formally approved the appointment an

interim President/CEO (see Documents Reviewed).



Performance Improvement Area: Recruitment of a Permanent President/CEO

Findings/Factors: CCHC’s President/CEO is serving in a Board-approved interim capacity, and

a formal search process has been initiated.

Recommendations: CCHC is reminded that “if the grantee has an open position for or pending

change in the Project Director (i.e., President/CEO) position, then this change will require a

‘Prior Approval Request’ which must be submitted/processed via the EHB Prior Approval

Module and to contact their Project Officer for further information as needed.”


Program Requirement #10 – Contractual/Affiliation Agreements: Health center exercises

appropriate oversight and authority over all contracted services, including assuring that any sub

recipient(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))







Review Team.

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CCHC has letters of agreement and memoranda of understanding with various community

providers concerning provision of required services. These agreements do not have the potential

to threaten CCHC’s integrity, limit its autonomy, or compromise its compliance with federal

program requirements in terms of corporate structure, governance, management, finance, health

services, and/or clinical operations.



Performance Improvement Area: Linkage and Network Agreements

Findings/Factors: Some CCHC network and linkage agreements which essentially outline a

mutual commitment to collaborate in the provision of services for individuals receiving services

from both agencies and the acceptance of referrals refer to CCHC as Capital Community Health

Center instead of Central Counties Community Health Center. Capital Community Health

Center is a community-recognized moniker that has never been a formal dba of Central Counties.

Recommendations: CCHC should review all network and linkage agreements for accuracy and

relevancy.


Program Requirement #11 – Collaborative Relationships: Health center makes effort to

establish and maintain collaborative relationships 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))


CCHC is fully integrated into the greater Springfield Healthcare System. They enjoy an

excellent collaborative relationship with fellow private practice primary care physicians and

specialists. Two area hospitals, namely, St. John and Memorial, are especially supportive of

CCHC’s efforts and readily accept radiology, lab, and other referrals, offering the same sliding

fee schedule to CCHC referred patients.






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CCHC reports that there are no other safety net providers, including free clinics and faith-based

initiatives operating in Springfield. CCHC is in full collaboration with the Salvation Army for

the provision of Health Care for the Homeless (HCH) services at two Salvation Army shelters.

CCHC is a member of and is active in the Illinois PCA (CCHC’s past CEOs have been PCA

Board members) and collaborates fully with other area FQHCs, including Southern Illinois

University (SIU) Center for Family Medicine, a newly-funded grantee also located in

Springfield. Letters of support from the Illinois PCA and fellow Illinois FQHCs have never been

denied, nor has CCHC declined to issue letters of support to other Illinois FQHCs.



Performance Improvement Area: Use of Collaborative Relationships in Support of PCMH

Certification

Findings/Factors: An FQHC’s collaborative relationships can contribute to ensuring quality

care coordination and improving patient-centeredness.

Recommendations: As a PCMH, CCHC should examine current and future collaborative

relationships with a view toward ensuring that they:

Enhance coordination of care and services within the community,

Engage collaborative partners in problem solving activities when gaps in care/services

are identified among the population or the community as a whole, and

Enable interaction of an appropriate type and at the appropriate frequency to occur

between CCHC and its collaborative partners.


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)







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CCHC has an annual independent financial audit which states that it is performed in accordance

with federal audit requirements as set forth in OMB Circular A-133 including the compliance

supplement. The most recent audit report for fiscal year ending (FYE) June 30, 2013 contained

an unqualified opinion with respect to the grantee’s financial statement’s fair presentation of its

financial position and the results of its activities and changes in net assets and cash flows in all

material effects consistent with generally accepted accounting principles. The auditor’s report

on compliance with the requirements of major federal programs and internal control over

compliance contained unqualified opinions and no findings (the Section 330 was treated as a

major program for audit purposes), has no reportable audit conditions, and therefore, a corrective

action plan is not necessary. The grantee is qualified as a low-risk grantee. The threshold used to

distinguish between type A and type B programs was $300,000.

CCHC produces comprehensive monthly financial reporting for the Board of Directors and

management. This reporting package includes:

Key Statistics

Balance Sheet

Statement of Revenue & Expenditures

Detailed Other Expenses

Aged Accounts Receivable

Aged Accounts Payable

Monthly Productivity Report

YTD Productivity Report

Written Financial Policies are in place.











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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)


Collection percentages as calculated from the 2012 UDS highlight a very efficient and effective

system. The gross collection percentages are as follows:

Payor Type Percentage

Medicaid %

Medicare %

Private Pay %

Self-Pay %

Additionally, the net self-pay collections are %. Bad Debt write-offs totaled % of gross

charges. The most recent A/R aging indicates that 92% of the A/R is current and aged less than

120 days.

Written Billing and collection policies are in place as required.

Review of the FY 2013 Medicare Cost Report verifies that CCHC has a Medicare billing number

for each permanent site listed on form 5B.






(b) (4)

(b) (4)

(b) (4)

(b) (4)

(b) (4) (b) (4)






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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)


CCHC produces a well-detailed budget that is used for comparative reporting purposes on

a monthly basis. The budget is based on and is reflective of the current cost of operations,

expenses, and revenues necessary to accomplish the service delivery plan.







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)


CCHC utilizes NextGen for EHR and PMS and Sage MIP for financial reporting. CCHC

demonstrates the ability to generate appropriate clinical and financial data for reporting and

decision-making. This data is clearly utilized in the QI/QA process to measure outcomes and

performance and to enhance continuous improvement efforts. CCHC has a thorough and

complete strategic plan that displays a mission statement, strategic goals, and time-quantified

objectives. CCHC’s Board receives feedback on progress in meeting the objectives. A Board

retreat is triennially scheduled to update and extend the plan.







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Performance Improvement Area: ICD-10 Implementation

Findings/Factors: The conversion to ICD-10 will need to occur by October 1, 2014 as

announced by the Department of Health and Human Services in February 2012.

Recommendations: CCHC’s Management should research and continue project planning the

implementation of the required ICD-10 coding and its implications for billing management and

provider practice. See the following Performance Improvement Area for additional

recommendations regarding ICD-10.


Performance Improvement Area: Readiness of the Practice Management System (PMS) to

Implement ICD-10

Findings/Factors: The International Statistical Classification of Diseases and Related Health

Problems 10th Revision (ICD-10) is scheduled for implementation on October 1, 2014 and

requires a consolidated effort by Community Health Centers and their software vendors

(particularly PMS and EHR) to be fully updated and ready by the ICD-10 go live date.

Recommendations: CCHC should consider the advice published by Medical Group Management

Association (Robert Tennant, MA, MGMA Connection, March 2013) in developing a list of

questions that should be posed in communicating with their software vendor. Namely:

1. Will our software accommodate upgrade to ICD-10?

2. Is our current version of the software current or are upgrades required?

3. What will change regarding the visual screens and report formats?

4. What will this cost? Will there be additional maintenance fees?

5. Will our current hardware accommodate this upgrade?

6. Will there be an overlap between ICD-9 and 10 during which both systems will be loaded

on our system?

7. Will our system accommodate ICD-9 legacy data?

8. What about crosswalk issues?

9. What about mapping tools used by the government and commercial health plans?

10. Regarding CCHC’s clinicians, will they have the ability and tools to capture the

additional required documentation, such as templates?

11. Will the vendor offer training for clinicians and administrative personnel (including data

analysts)? What will it cost?






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Finally, CCHC should work with their vendor to determine implementation and training dates,

system testing dates, and any projected down time associated with the actual upgrade.


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)

Findings/Factors: Not Met.

Form 5B indicates that CCHC has five service delivery sites. These include:

CCHC Main site, 2239 E. Cook Street

St. John’s Springfield, 430 N 5 Street

Contact Ministries, Springfield 1100 E. Adams

Salvation Army 6th

Street, 530 N. 6th

Street

Salvation Army 11th

Street, 221 N 11th

Street

Of these five sites, two are no longer service delivery sites; CCHC no longer provides services

at St. John’s Springfield or Contact Ministries.

Recommendations: CCHC must accurately reflect service delivery sites on their Form 5B.

CCHC must work with their federal project officer to request a Change in Scope (CIS) to remove

inactive service delivery sites from their current scope of project.


Performance Improvement Area: Form 5C

Findings/Factors: CCHC does not have a form 5C, though there are indications that the health

center engages in activities such as health fairs that would be included on form 5C.

Recommendations: CCHC should reevaluate and reconsider adding form 5C to their scope of

project.






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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.


A review of the Board minutes of the past 12 months indicates that the Board scheduled and held

monthly meetings, approved the grant and other budgets, received departmental and executive

reports, elected officers, reelected members, and performed oversight of clinical and financial

operations as well as human resources. The Board received and approved the 2013 audit report.






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A review of the bylaws indicates compliance with the requirements of the Site Visit Guide.

CCHC does not have sub-recipients.

There is no evidence, actual or anecdotal; that the CCHC Board completed a formal performance

evaluation on the recently dismissed CEO, and the most recently completed self-evaluation was

completed in May 2009. They had previously not developed a CEO Succession Plan (see

documents left behind); however, a draft document has now been developed in preparation for

the President/CEO Search process.

The Board participated in a strategic planning retreat and fine tuning process followed by final

approval of the strategic plan. The plan is enjoying organizational buy-in and acceptance by

both Board and staff (see PR #15).

CCHC’s bylaws establish standing committees as follows: Executive, Finance, Operations and

Development, and Compliance and Quality Improvement, and there is evidence that these

committees are meeting and conducting business. Board meetings usually last about 60-70

minutes. The meeting minutes document Board level discussions on various management

reports (CEO, CFO), but are silent on QA/QI reports. Interviews with Board members however

indicated a strong understanding and knowledge of both finance and QI oversight, indicating that

the Board meeting minutes are not adequately capturing the extent and content of the various

committee reports and subsequent discussions. The Board minutes indicate that the full Board

grants clinical privileges to employed Licensed Independent Providers (LIPs).

Recommendations: The CCHC Board must institute a practice whereby they perform a formal

performance evaluation of the CEO annually (at a minimum) and more often should the situation

mandate. The Chair should advise board members when CEO evaluations are completed and

that fact should be noted in the Board minutes. The results of the evaluations should be filed in

the CEO’s employee record and granted the same confidentiality as that afforded to all

employees.


Performance Improvement Area: Board Self-Evaluation

Findings/Factors: The Board has not completed a self-evaluation since 2009.

Recommendations: The board should complete a self-evaluation using the tool maintained in

their corporate documents and utilize the results to measure existing competencies and the need

for additional training.






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Performance Improvement Area: Board Minutes

Findings/Factors: Board Minutes are not sufficiently detailed to reflect Board

acknowledgement of receipt of staff and QI Committee reports and other information relating to

QI status and initiatives. Interviews with Board members conducted on-site indicate all Board

members are much more familiar with this topic than would be indicated in the monthly minutes.

Recommendations: As opposed to just noting that a report is “received and approved,” the

minutes should reflect a summary of data contained in the QI report, summarize ensuing

discussion, and any concerns and possible next steps expressed and desired by members.


Performance Improvement Area: Strategic Planning

Findings/Factors: CCHC’s current strategic plan was developed in 2012 and projects time

quantified objectives and a work plan through 2014. CCHC’s Board is currently conducting a

search for a regular President/CEO with a desired fill date by spring of 2014. CCHC is also

undertaking a major construction project that will result in a sizable addition to their present

clinical/administrative site.

Recommendations: CCHC should consider scheduling and convening a strategic planning

process in conjunction with their successful recruitment process and likely in the summer or fall

of 2014.


Performance Improvement Area: Preparation for Strategic Planning

Findings/Factors: Strategic Plans cannot be developed in a vacuum. Prior to any retreat, an

updated needs assessment must be completed to ensure participants have access to the latest

status of all health status indicators and demographic trends of the service area. Additionally,

access to clinical data, including UDS, financial performance measures, and clinical performance

measures must also be made available to participants for their review and perusal prior to the

retreat.

Recommendations: CCHC should ensure participants are properly prepared to fully and

knowledgeably participate in a strategic planning process.






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Performance Improvement Area: Strategic Plan and Periodic Reports to the Board

Findings/Factors: A dynamic strategic plan that enjoys group buy-in by Board, community

partners, and staff is essential because the process prioritizes the work to be done. Strategic

planning facilitates making short-term decisions influenced by long-term implications. A

strategic plan provides a series of agreements about what needs to happen. It is a dynamic

document that lends flexibility to CCHC so that when change occurs, the plan can be adapted to

accommodate the changes. The Board therefore needs a process wherein they can stay cognizant

of their plan.

Recommendations: The CCHC Board should receive periodic (i.e., semi-annual) reports on

success (or lack thereof) in achieving the time-quantified objectives contained in their new

strategic plan. This will enable the Board to review progress and make necessary operational

short-term decisions to accommodate unforeseen events and hindrances to progress.


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






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Health Care for the Homeless (Section 330(h)) and/or the Public Housing Primary Care (Section

330(i)) Programs.


A review of electronic billing records indicates that eight of ten (80%) Board members are

consumers of health center services. All members live or work in the service area, and generally

represent the demographics of the residents. Per the 2012 UDS report, the demographics of the

patient population indicate that fewer than 3% of CCHC’s patients are Hispanic (either white or

black/African American), and 43% are African-American. Five member of the CCHC Board are

white, and five are African American. None of the ten Board members are of Hispanic ethnicity.

Both (100%) of the two non-consumer members earn more than 10% of their income from the

health care industry. The Board is rich in desired expertise, particularly clinical, as well as

dedicated community advocates. One of the consumer members is an advocate for persons

experiencing homelessness, and is well qualified for this responsibility.

Recommendations: CCHC must recruit additional non-consumer members to bring the “10% of

compensation ratio” to 50% or better. CCHC might consider using this opportunity to bring

additional recommended expertise to the Board, especially finance and perhaps legal (see

Performance Improvement, below).


Performance Improvement Area: Board Size

Findings/Factors: CCHC’s Board consists of ten voting and one non-voting ex-officio member

(the President/CEO). A community health center of CCHC’s size and complexity would likely

benefit from a board of eleven to thirteen members.

Recommendations: CCHC should consider increasing the number of voting Board members.


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.

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))






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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.


The corporate bylaws (Article V) discuss the duties and obligations of Board members relating to

Conflict of Interest. They further state that no Board member shall be an employee of the health

center or an immediate family member of an employee. Addendum A to the bylaws establishes

Standards of Conduct for Employees and Board Members. Conflict of Interest is fully discussed

in the Employee Handbook and the same Addendum A is part of the Handbook (reviewed and

revised 2010). Conflicts of Interest in procurement of goods and services are also discussed in

the Financial Policies.

CCHC requires that all employees, contractors, officers and board members disclose in writing

all business and family relationships that potentially create a conflict of interest. This disclosure

must be updated annually.

Taken together, CCHC adequately addresses Conflict of Interest.











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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: Percentage diabetic patients whose HbA1c levels are

less than 7 percent, less than 8 percent, less than or equal to 9 percent, or greater than 9

percent

Findings/Factors: The Grantee has not been satisfied with the HbA1c control of their diabetic

patients, and has been studying methods to improve A1C performance.

HgbA1C < 7 7-8 8-9 > 9

2010 32.9% * 20%* 47%

2011 30% 24% 17% 29%

2012 30% 24% 15.7% 30%

* 7-9 bracket for 2010

Recommendations:

Bring measurement of A1cs in-house to give immediate feedback to patients as well as to

increase compliance with testing.

Collaborate with Springfield health department for diabetic education workshops.

Pre-populate patient self-management goals in EMR to facilitate use and follow-up.

Consider group visits for chronic illnesses.






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Selected Performance Measure #2: Percentage of adult patients with diagnosed

hypertension whose most recent blood pressure was less than 140/90

Findings/Factors: The grantee has been instituting changes to improve the percentage of

patients with controlled blood pressures.

BP < 140/90

2010 64%

2011 68.6%

2012 68.6%

Recommendations:

Increase the frequency of visits for blood pressure management.

Perform micro-albumin urinalysis in-house to assess for possible kidney damage.

Stress importance of and provide education on diet and exercise.

Increase focus on self-management goals.






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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: Working Capital to Monthly Expense Ratio

Findings/Factors: For the fiscal year ending June 30, 2013 (audited), CCHC has negative

working capital of which results in a negative working capital to monthly expense

ratio of negative . However, CCHC has in investments, and no long term debts.

A simple evaluation of working capital to monthly expense ratio

however, the larger picture suggests far more financial stability for the organization.

Recommendations: CCHC should continue to monitor working capital and strategize to

improve working capital without negatively impacting investments.


Selected Performance Measure #2: Long Term Debt to Equity

Findings/Factors: For the fiscal year ending June 30, 2013, (audited) CCHC has no long term

debts and an equity balance of therefore the ratio .

Recommendations: Continue to monitor, especially in light of the main site facility addition

which may require some mortgage funding to complete.

(b) (4)(b) (4)(b) (4)

(b) (4)(b) (4)

(b) (4)(b) (4)






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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: All ARRA IDS grants have been

completed with funds expended and final reports submitted.


TA Recommendations (if applicable): N/A

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: CCHC has not been awarded Capital Grant

funding.

Findings/Factors (attach facility photos if taken): N/A

TA Recommendations (if applicable): N/A






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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)

Table 1: Summary of Key Health Center Program Requirements

Program

Requirement

Number

Program Requirement Technical

Assistance (TA)

Type

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)

NEED

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)

SERVICES

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)

SERVICES

http://www.bphc.hrsa.gov/about/requirements/index.html

http://www.bphc.hrsa.gov/policiesregulations/legislation/index.html

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=7d406c5e500062a91b3253d68dec3dfa&r=PART&n=42y1.0.1.4.27

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=4ba0764a4573232bfedad6ddbbadf611&r=PART&n=42y1.0.1.4.41

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=832210d8850428f707d794376f828941&r=PART&n=45y1.0.1.1.34






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Program

Requirement

Number


Assistance (TA)

Type

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)

SERVICES

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))

SERVICES

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)

SERVICES

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 due to an

individual’s inability to pay for such services by the

health center, 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))

SERVICES






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Program

Requirement

Number


Assistance (TA)

Type

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))

SERVICES

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))

MANAGEMENT

AND FINANCE

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))

MANAGEMENT

AND FINANCE






Review Team.

Page 40 of 42

Program

Requirement

Number


Assistance (TA)

Type

11.

Collaborative Relationships: Health center makes effort to

establish and maintain collaborative relationships 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))

MANAGEMENT

AND FINANCE

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)

MANAGEMENT

AND FINANCE

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)

MANAGEMENT

AND FINANCE

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)

MANAGEMENT

AND FINANCE

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)

MANAGEMENT

AND FINANCE






Review Team.

Page 41 of 42

Program

Requirement

Number


Assistance (TA)

Type

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)

MANAGEMENT

AND FINANCE

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)

GOVERNANCE






Review Team.

Page 42 of 42

Program

Requirement

Number


Assistance (TA)

Type

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)

GOVERNANCE

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.

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))

GOVERNANCE

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.