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View the Health Center Program Compliance Manual Chapter 4: Required and Additional Health Services

Required and Additional Health Services-a. Providing and Documenting Services within Scope of Project: Within 90 days, provide documentation that the health center is providing access to all required health services and that required and any additional service(s) are accurately recorded on Form 5A: Services Provided. If the health center is not currently providing access to the service(s) OR the change(s) in scope required to correct Form 5A is not yet approved and verified, provide an action plan detailing the steps the health center will take to implement the provision of all required services and/or correct Form 5A. Acceptance of this plan by HRSA will result in a condition, which provides 120 days for the health center to submit documentation that it is providing access to the required service(s) and/or has corrected its Form 5A. Please see Chapter 4: Required and Additional Health Services of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) requiring corrective action. (45 CFR 75.207(a) and 45 CFR 75.371)

Required and Additional Health Services-b. Ensuring Access for Limited English Proficient Patients: Within 90 days, provide documentation that the health center has provisions for interpretation and translation that enable patients with Limited English Proficiency to have reasonable access to health center services. Please see Chapter 4: Required and Additional Health Services of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Required and Additional Health Services-c. Providing Culturally Appropriate Care: Within 90 days, provide documentation that the health center makes arrangements and/or provides resources (for example, training) that enable its staff to deliver services in a manner that is culturally sensitive and bridges linguistic and cultural differences. Please see Chapter 4: Required and Additional Health Services of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 5: Clinical Staffing

Clinical Staffing-a. Staffing to Provide Scope of Services: Within 90 days, provide documentation that the health center has the clinical staff and/or contracts or formal referral arrangements in place to provide the required and additional services included in the HRSA-approved scope of project. If that documentation is not yet available, provide an action plan detailing the steps the health center will take to achieve appropriate staffing to carry out the HRSA-approved scope of project. Acceptance of this plan by HRSA will result in a condition, which provides 120 days for the health center to submit documentation that appropriate staffing is in place to carry out the HRSA-approved scope of project. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Clinical Staffing-b. Staffing to Ensure Reasonable Patient Access: Within 90 days, provide documentation of how the number and mix of clinical staff ensures reasonable patient access to health center services given the size, demographics, and health needs of the patient population. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Clinical Staffing-c. Procedures for Review of Credentials: Within 90 days, provide the health center's updated operating procedures for the initial and recurring review of credentials for all clinical staff members (licensed independent practitioners (LIPs), other licensed or certified practitioners (OLCPs), and other clinical staff providing services on behalf of the health center) who are health center employees, individual contractors, or volunteers. Specifically document that these credentialing procedures contain provisions for verification of the following, as applicable: 1) Current licensure, registration, or certification using a primary source; 2) Education and training for initial credentialing; 3) Completion of a query through the National Practitioner Data Bank (NPDB); 4) Identity (for initial credentialing only); 5) Drug Enforcement Administration (DEA) registration; and 6) Current documentation of basic life support training. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) requiring corrective action. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Clinical Staffing-d. Procedures for Review of Privileges: Within 90 days, provide the health center's updated operating procedures for the initial granting and renewal of privileges for clinical staff members (licensed independent practitioners (LIPs), other licensed or certified practitioners (OLCPs), and other clinical staff providing services on behalf of the health center) who are health center employees, individual contractors, or volunteers. Specifically document that these privileging procedures address the following: 1) Verification of fitness for duty, immunization, and communicable disease status; 2) For initial privileging, verification of current clinical competence via training, education, and, as available, reference reviews; 3) For renewal of privileges, verification of current clinical competence via peer review or other comparable methods; and 4) Process for denying, modifying or removing privileges based on assessments of clinical competence and/or fitness for duty. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) requiring corrective action. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Clinical Staffing-e. Credentialing and Privileging Records: Within 90 days, provide documentation of corrective actions taken to ensure up to date and complete credentialing and privileging of clinical staff (employees, individual contractors, and volunteers), including the maintenance of related files or records, consistent with operating procedures. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371) NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Clinical Staffing-f. Credentialing and Privileging of Contracted or Referral Providers: Within 90 days, provide documentation of actions taken by the health center to ensure that providers, who work for other organizations and provide services within the health center’s scope of project (via contracts or formal written referral arrangement), are licensed, certified or registered, as verified through a credentialing process in accordance with applicable Federal, state and local laws; and competent and fit to perform the specific health center service(s), as assessed through a privileging process. Please see Chapter 5: Clinical Staffing of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 7: Coverage for Medical Emergencies During and After Hours

Coverage for Medical Emergencies During and After Hours-a. Clinical Capacity for Responding to Emergencies During Hours of Operation: Within 90 days, provide documentation that confirms the health center has at least one staff member trained and certified in basic life support present during the health center’s regularly scheduled hours of operation at each HRSA-approved service site (consistent with all service sites listed on Form 5B) to ensure the health center has the clinical capacity to respond to patient medical emergencies that may occur at a health center service site. Please see Chapter 7: Coverage for Medical Emergencies During and After Hours of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Coverage for Medical Emergencies During and After Hours-b. Procedures for Responding to Emergencies During Hours of Operation: Within 90 days, provide the health center’s updated operating procedures for responding to patient medical emergencies during regularly scheduled hours of operation. In addition, please document that the health center is following these procedures by providing an example of how the health center has responded to an emergency or by providing a description of how the health center prepares for responding to patient medical emergencies during regularly scheduled hours of operation (e.g., staff training or drills on use of procedures). Please see Chapter 7: Coverage for Medical Emergencies During and After Hours of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Coverage for Medical Emergencies During and After Hours-c. Procedures or Arrangements for After Hours Coverage: Within 90 days, provide the health center’s updated procedure and/or formal arrangements for after-hours coverage that document all the following: 1) Coverage by an individual with the qualification and training necessary to exercise professional judgment in assessing a health center patient's need for emergency medical care; 2) The ability to refer patients either to a licensed independent practitioner for further consultation or to locations such as emergency rooms or urgent care facilities for further assessment or immediate care as needed; and 3) Patients, including those with limited English proficiency, are informed of and are able to access after-hours coverage. Please see Chapter 7: Coverage for Medical Emergencies During and After Hours of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) requiring corrective action. (45 CFR 75.207(a) and 45 CFR 75.371)

Coverage for Medical Emergencies During and After Hours-d. After Hours Call Documentation: Within 90 days, provide documentation of steps taken by the health center to ensure that after-hours calls and any necessary follow-up resulting from such calls, are documented for the purposes of continuity of care. Please see Chapter 7: Coverage for Medical Emergencies During and After Hours of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 8: Continuity of Care and Hospital Admitting

Continuity of Care and Hospital Admitting-a. Documentation of Hospital Admitting Privileges or Arrangements: Within 90 days, provide documentation that the health center has obtained provider hospital admitting privileges or at least one formal arrangement between the health center and a hospital or entity for the purpose of admitting health center patients to a hospital. Please see Chapter 8: Continuity of Care and Hospital Admitting of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Continuity of Care and Hospital Admitting-b. Procedures for Hospitalized Patients: Within 90 days, provide updated internal operating procedures, and, if applicable, related provisions in formal written arrangements for health center patients who are hospitalized as inpatients or who visit a hospital's emergency department (ED) that address the following areas: 1) Receipt and recording of medical information related to the hospital or ED visit; and 2) Follow-up actions by health center staff, when appropriate. Please see Chapter 8: Continuity of Care and Hospital Admitting of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Continuity of Care and Hospital Admitting-c. Post-Hospitalization Tracking and Follow-up: Within 90 days, provide documentation of steps taken by the health center to ensure that the health center: 1) Receives and tracks patient medical information related to hospital or emergency department (ED) visits; and 2) Health center staff take follow-up actions based on information received, when appropriate. Please see Chapter 8: Continuity of Care and Hospital Admitting of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 9: Sliding Fee Discount Program

Sliding Fee Discount Program-a. Applicability to In-Scope Services: Within 90 days, provide documentation of corrective actions taken by the health center to ensure sliding fee discounts or other types of discounts are in place for any in-scope health center service(s) currently not included in the Sliding Fee Discount Program (SFDP). Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-b. Sliding Fee Discount Program Policies: Within 90 days, provide updated policy(ies) for the health center's Sliding Fee Discount Program (SFDP) that apply to all patients and that address the following areas: 1) Definitions of income and family; 2) Assessment of all patients for sliding fee discount eligibility based only on income and family size; 3) Structure of the health center’s sliding fee discount schedule(s); and if applicable, 4) Setting of a flat nominal charge(s) at a level that is nominal from the perspective of the patient and does not reflect the actual cost of the service being provided. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-c. Sliding Fee for Column I Services: Within 90 days, provide an updated sliding fee discount schedule(s) for services provided directly by the health center (Form 5A: Column I), that is structured as follows: 1) A full discount or only a nominal charge is provided for individuals and families with annual incomes at or below 100 percent of the current Federal Poverty Guidelines (FPG); 2) Partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, adjusted based on gradations in income levels with at least three discount pay classes; and 3) No discounts are provided to individuals and families with annual incomes above 200 percent of the current FPG. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-d. Multiple Sliding Fee Discount Schedules: Within 90 days, provide documentation of corrective actions taken to ensure that all health center sliding fee discount schedules are based on services and/or service delivery methods and no other factors. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-e. Incorporation of Current Federal Poverty Guidelines: Within 90 days, provide an updated sliding fee discount schedule(s) that incorporates the most recent Federal Poverty Guidelines. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-f. Procedures for Assessing Income and Family Size: Within 90 days, provide updated operating procedures for assessing and re-assessing all patients for income and family size that are consistent with the health center's sliding fee discount program policies. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-g. Assessing and Documenting Income and Family Size: Within 90 days, provide documentation of corrective actions taken to ensure that the health center is consistently assessing and re-assessing patient income and family size, including the maintenance of related records of such assessments. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-h. Informing Patients of Sliding Fee Discounts: Within 90 days, provide documentation that the health center informs patients of the availability of sliding fee discounts and how to apply for such discounts. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-i. Sliding Fee for Column II Services: Within 90 days, provide documentation that the health center ensures its in-scope service(s) provided to health center patients through contracts/agreements (Form 5A: Column II) are discounted as follows: 1) A full discount or only a nominal charge is provided for individuals and families with annual incomes at or below 100 percent of the current Federal Poverty Guidelines (FPG); 2) Partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, adjusted based on gradations in income levels with at least three discount pay classes; and 3) No discounts are provided to individuals and families with annual incomes above 200 percent of the current FPG. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-j. Sliding Fee for Column III Services: Within 90 days, provide documentation that the health center ensures its in-scope service(s) provided to health center patients through formal referral arrangements (Form 5A: Column III) are EITHER discounted as follows: 1) A full discount or only a nominal charge is provided for individuals and families with annual incomes at or below 100 percent of the current Federal Poverty Guidelines (FPG); and partial discounts are provided for individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the current FPG, adjusted based on gradations in income levels with at least three discount pay classes OR 2) Discounted in a manner such that individuals and families with incomes above 100 percent of the current FPG and at or below 200 percent of the FPG receive an equal or greater discount for these services than if the health center’s sliding fee discount schedule (SFDS) were applied to the referral provider’s fee schedule; and individuals and families at or below 100 percent of the FPG receive a full discount or are assessed only a nominal charge for these services. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-k. Applicability to Patients with Third Party Coverage: Within 90 days, provide documentation of the process the health center has in place to ensure patients who are eligible for sliding fee discounts and have third-party coverage are charged no more for any out-of-pocket costs than they would have paid under the applicable sliding fee discount schedule (SFDS) discount pay class. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Sliding Fee Discount Program-l. Evaluation of the Sliding Fee Discount Program: Within 90 days, provide a completed evaluation of the health center's sliding fee discount program (SFDP) used to assess its effectiveness in reducing financial barriers to care for patients at or below 200% of the Federal Poverty Guidelines. In addition, provide examples of identified areas where changes to the SFDP were needed, if applicable, along with documentation of implementation of those changes. If the health center has identified the need for changes to its SFDP but documentation of the implementation of such changes is not yet available, provide an action plan detailing the steps the health center will take to implement such changes. Acceptance of this plan by HRSA will result in a condition, which provides 120 days for the health center to submit documentation that it has implemented changes to its SFDP, as identified in its evaluation. Please see Chapter 9: Sliding Fee Discount Program of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 10: Quality Improvement/Assurance

Quality Improvement/Assurance-a. QI/QA Program Policies: Within 90 days, provide updated policy(ies) for the health center's quality improvement/quality assurance program that addresses: 1) The quality and utilization of health center services; 2) Patient satisfaction and patient grievance processes; and 3) Patient safety, including adverse events. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Quality Improvement/Assurance-b. Designee to Oversee QI/QA Program: Within 90 days, provide documentation that the health center has designated an individual(s) to oversee the quality improvement/quality assurance (QI/QA) program whose responsibilities include: 1) Ensuring the implementation of QI/QA operating procedures and related assessments; 2) Monitoring QI/QA outcomes; and 3) Updating QI/QA operating procedures. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Quality Improvement/Assurance-c. QI/QA Procedures or Processes: Within 90 days, provide documentation that the health center is addressing all of the following areas through operating procedures or processes/systems: 1) Adhering to current evidence-based clinical guidelines, standards of care, and standards of practice in the provision of health center services, as applicable; 2) Identifying, analyzing, and addressing patient safety and adverse events and implementing follow-up actions, as necessary; 3) Assessing patient satisfaction; 4) Hearing and resolving patient grievances; 5) Completing periodic quality improvement/quality assurance (QI/QA) assessments on at least a quarterly basis to inform the modification of the provision of health center services, as appropriate; and 6) Producing and sharing reports on QI/QA to support decision-making and oversight by key management staff and by the governing board regarding the provision of health center services. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Quality Improvement/Assurance-d. Quarterly Assessments of Clinician Care: Within 90 days, provide documentation that the health center’s physicians or other licensed health care professionals conduct quality improvement/quality assurance (QI/QA) assessments on at least a quarterly basis, using data systematically collected from patient records. Specifically provide examples of completed QI/QA assessments or related documentation that demonstrate the health center is 1) Reviewing provider adherence to current evidence-based clinical guidelines, standards of care, and standards of practice in the provision of health center services, as applicable; and if applicable 2) Implementing follow-up actions due to patient safety and adverse events. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Quality Improvement/Assurance-e. Retrievable Health Records: Within 90 days, provide documentation that the health center maintains a retrievable health record for each patient and has a process for ensuring the format and content of its health records are consistent with both Federal and state laws and requirements. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

Quality Improvement/Assurance-f. Confidentiality of Patient Information: Within 90 days, provide documentation of steps taken by the health center to protect the confidentiality of patient information and safeguard this information against loss, destruction, or unauthorized use, consistent with Federal and state requirements. Please see Chapter 10: Quality Improvement/Assurance of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: For FTCA-deemed health centers, future deeming actions require health centers to have demonstrated compliance with this requirement.

View the Health Center Program Compliance Manual Chapter 11: Key Management Staff

Key Management Staff-a. Composition and Functions of Key Management Staff: Within 90 days, provide updated documentation that the health center has determined the makeup and distribution of functions among its key management staff and the percentage of time dedicated to the Health Center Program project for each position, as necessary to carry out the HRSA-approved scope of project. Please see Chapter 11: Key Management Staff of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Key Management Staff-b. Documentation for Key Management Staff Positions: Within 90 days, provide documentation, such as position descriptions and/or resumes, that includes the training and experience qualifications, as well as the duties or functions, for each health center key management staff position. Please see Chapter 11: Key Management Staff of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Key Management Staff-c. Process for Filling Key Management Vacancies: Within 90 days, provide documentation of actions taken by the health center to fill one or more vacant key management staff positions. Please see Chapter 11: Key Management Staff of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Key Management Staff-d. CEO Responsibilities: Within 90 days, provide documentation that the Project Director/CEO: 1) Is directly employed by the health center; 2) Reports to the health center governing board; and 3) is responsible for overseeing other key management staff in carrying out the daily operations of the health center's approved scope of project. Please see Chapter 11: Key Management Staff of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Key Management Staff-e. HRSA Approval for Project Director/CEO Changes: Within 90 days, provide documentation that the health center has submitted a request for HRSA's approval for the Project Director/CEO change via HRSA’s Electronic Handbooks (EHB) Prior Approval Module which also includes the resume of the final candidate identified or selected by the health center's governing board and the position description used in filling the related Project Director/CEO vacancy. Please see Chapter 11: Key Management Staff of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 12: Contracts and Subawards

Contracts and Subawards-a. Procurement Procedures: Within 90 days, provide updated written procurement procedures that comply with Federal procurement standards and that include a process for ensuring that all procurement costs directly attributable to the Federal award are allowable, consistent with Federal Cost Principles. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-b. Records of Procurement Actions: Within 90 days, provide updated written procurement procedures and documentation of other corrective actions that will ensure records for future procurement actions paid for in whole or in part under the Federal award, will include all of the following: 1) Rationale for method of procurement; 2) Selection of contract type; 3) Contractor selection or rejection; 4) Basis for contract price; and if applicable 5) Documentation related to noncompetitive procurements. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-c. Retention of Final Contracts: Within 90 days, provide updated written procurement procedures that ensure the health center will retain final contracts and related procurement records, consistent with Federal document maintenance requirements, for procurement actions paid for in whole or in part under the Federal award. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-d. Contractor Reporting: Within 90 days, provide documentation of the health center's ability to access contractor records and reports related to health center activities in order to ensure that all activities and reporting requirements are being carried out in accordance with the provisions and timelines of the related contract. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-e. HRSA Approval for Contracting Substantive Programmatic Work: Within 90 days, provide documentation that the health center has submitted a request for HRSA's approval to contract for substantive programmatic work via HRSA’s Electronic Handbooks (EHB) Prior Approval Module which includes a justification for contracting for such work. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-f. Required Contract Provisions: Within 90 days, provide an updated, executed contract to document the inclusion of all required contract provisions with respect to activities and services, mechanisms to oversee contractor performance, and requirements to provide data to support health center required reporting. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-g. HRSA Approval to Subaward: Within 90 days, provide documentation that the health center has submitted a request for HRSA's approval to carry out a portion of the health center's scope of project through a subaward(s) via HRSA’s Electronic Handbooks (EHB) Prior Approval Module which includes a justification for making the subaward. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-h. Subaward Agreement: Within 90 days, provide a subaward agreement(s) that includes all of the following provisions: 1) Specific portion of the HRSA-approved scope of project to be performed by the subrecipient; 2) Applicability of all Health Center Program requirements to the subrecipient; 3) Applicability to the subrecipient of any distinct statutory, regulatory, and policy requirements of other Federal programs associated with HRSA-approved scope of project; 4) Mechanisms for the health center to monitor subrecipient compliance and performance; 5) Requirements for the subrecipient to provide data necessary to meet the health center's reporting requirements to HRSA as well as record retention and access, audit and property management requirements; and 6) Requirements that all costs paid for by the Federal subaward are allowable consistent with Federal Cost Principles. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-i. Subrecipient Monitoring: Within 90 days, provide documentation that: 1) The health center's subrecipient(s) is compliant with all Health Center Program requirements; and 2) The health center has a process and schedule for ongoing monitoring of its subrecipient(s) that includes: a) Confirming compliance with Health Center Program requirements; b) Reviewing financial and performance reports to ensure performance goals are met, UDS data are submitted, and funds used for authorized purposes; c) Ensuring that corrective action is taken by the subrecipient in response to audits, on-site reviews and other means, including resolution of any finding of non-compliance with Health Center Program requirements; and d) Issuing management decisions for audit findings pertaining to the subaward. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Contracts and Subawards-j. Retention of Subaward Agreements and Records: Within 90 days, provide documentation of corrective action taken to ensure that the health center maintains final subrecipient agreements and related records, consistent with the Federal document maintenance requirements. Please see Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 13: Conflict of Interest

Conflict of Interest-a. Standards of Conduct: Within 90 days, provide updated written standards of conduct that apply, at a minimum, to health center procurements paid for in whole or in part by the Federal award and address all of the following areas: 1) Apply to all health center employees, officers, board members, and agents involved in the selection, award, or administration of such contracts; 2) Require written disclosure of real or apparent conflicts of interest; 3) Prohibit individuals with real or apparent conflicts of interest with a given contract from participating in the selection, award, or administration of such contract; 4) Restrict health center employees, officers, board members, and agents involved in the selection, award, or administration of contracts from soliciting or accepting gratuities, favors, or anything of monetary value for private financial gain from such contractors or parties to sub-agreements (including subrecipients or affiliate organizations); and 5) Enforce disciplinary actions on health center employees, officers, board members, and agents for violating these standards. In addition, provide a sample of written disclosures completed by officers, employees, board members and agents of the health center that documents the implementation of these standards of conduct. Please see Chapter 13: Conflict of Interest of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Conflict of Interest-b. Standards for Organizational Conflicts of Interest: Within 90 days, provide updated written standards of conduct that the health center has in place to address organizational conflicts of interest that might arise when conducting a procurement action involving a related organization (parent, affiliate, or subsidiary) and which require: 1) Written disclosure of conflicts of interest that arise in procurements from a related organization; and 2) Avoidance and mitigation of any identified actual or apparent conflicts during the procurement process. Please see Chapter 13: Conflict of Interest of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Conflict of Interest-c. Dissemination of Standards of Conduct: Within 90 days, provide documentation that the health center informs its employees, officers, board members, and agents of the health center’s standards of conduct which cover conflicts of interest, and which govern actions with respect to the selection, award, and administration of contracts. Please see Chapter 13: Conflict of Interest of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Conflict of Interest-d. Adherence to Standards of Conduct: Within 90 days, provide documentation of corrective actions the health center will take to ensure adherence to its standards of conduct whenever a conflict of interest is identified. Specifically address how an actual or apparent conflict of interest will be identified, disclosed, and documented whenever the health center engages in its procurement process. Please see Chapter 13: Conflict of Interest of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 15: Financial Management and Accounting Systems

Financial Management and Accounting Systems-a. Financial Management and Internal Control Systems: Within 90 days, provide documentation of corrective actions taken to ensure the health center's financial management and internal control system reflects GAAP or GASB principles and addresses the following: 1) Health center expenditures are consistent with the HRSA-approved budget and other approvals; 2) Effective control over and accountability for funds, property, and other assets; 3) Safeguarding of all assets to assure they are used for authorized purposes; and 4) Tracking of financial performance. Please see Chapter 15: Financial Management and Accounting Systems of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Financial Management and Accounting Systems-b. Documenting Use of Federal Funds: Within 90 days, provide documentation of corrective actions taken to ensure that the health center's financial management system can account for all Federal awards, including identifying and recording the source and application of funds for federally-funded activities. Please see Chapter 15: Financial Management and Accounting Systems of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Financial Management and Accounting Systems-c. Drawdown, Disbursement and Expenditure Procedures: Within 90 days, provide an updated procedure(s) for: 1) Drawing down and disbursing Federal award funds with minimal time between the transfer from HRSA to the disbursement by the health center and 2) Ensuring that expenditures are allowable. Please see Chapter 15: Financial Management and Accounting Systems of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Financial Management and Accounting Systems-d. Submitting Audits and Responding to Findings: Within 90 days, provide documentation of the health center's process for ensuring: 1) Audits are conducted and submitted in accordance with the provisions of 45 CFR Part 75, Subpart F: Audit Requirements and 2) Findings, questioned costs, reportable conditions and/or material weaknesses in the previous year’s audit report are addressed. Please see Chapter 15: Financial Management and Accounting Systems of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Financial Management and Accounting Systems-e. Documenting Use of Non-Grant Funds: Within 90 days, provide updated health center procedures or systems that ensure non-grant funds generated from Health Center Program project activities: 1) Will be utilized to further the objectives of the project by benefiting the current or proposed patient population; and 2) Will not be utilized for purposes that are specifically prohibited by the Health Center Program. Please see Chapter 15: Financial Management and Accounting Systems of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 16: Billing and Collections

Billing and Collections-a. Fee Schedule for In-Scope Services: Within 90 days, provide an updated fee schedule that includes fees for all in-scope services typically billed for in the local health care market. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-b. Basis for Fee Schedule: Within 90 days, provide an updated fee schedule and documentation that the schedule was updated using data on locally prevailing rates and actual health center costs. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-c. Participation in Insurance Programs: Within 90 days, provide documentation of the health center's participation in Medicaid, CHIP, Medicare, and if identified, other appropriate public or private assistance or health insurance programs. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-d. Systems and Procedures: Within 90 days, provide documentation that the health center has systems and/or operating procedures that address the following: 1) Educating patients on insurance and, if applicable, related third-party coverage options available to them; 2) Timely billing of Medicare, Medicaid, CHIP, and if applicable, other public and private assistance programs or insurance; and 3) Requesting applicable payments from patients, while ensuring that no patient is denied service based on inability to pay. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-e. Procedures for Additional Billing or Payment Options: Within 90 days, provide updated operating procedures for the health center's additional billing options or payment methods that ensure these methods are accessible to all patients regardless of income level or sliding fee discount pay class. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-f. Timely and Accurate Third Party Billing: Within 90 days, provide documentation of corrective actions the health center has taken to ensure that claims are submitted to third party payor sources in a timely and accurate manner. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-g. Accurate Patient Billing: Within 90 days, provide documentation of the corrective actions taken and/or updated operating procedures that ensure the health center 1) Charges patients in accordance with its fee schedule and correctly applies corresponding sliding fee discounts; and 2) Makes reasonable efforts to collect such amounts owed from patients. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable component(s) to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-h. Policies or Procedures for Waiving or Reducing Fees: Within 90 days, provide updated health center policies and/or operating procedures that include the specific circumstances when, due to any patient’s inability to pay, the health center will waive or reduce its fees or payments. In addition, provide documentation of actions that will ensure the health center waives or reduces fees in accordance with these policies and/or procedures. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-i. Billing for Supplies or Equipment: Within 90 days, provide documentation of the health center's method(s) to inform patients, prior to the time of service, of any charges or “out-of-pocket costs” for supplies or equipment that are related to, but not included in, the service itself as part of prevailing standards of care. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Billing and Collections-j. Refusal to Pay Policy: Within 90 days, provide the health center's updated policy that specifies how the health center distinguishes between refusal to pay and inability to pay and requires the health center to notify patients of the following: 1) Amounts owed and the time permitted to make such payments; 2) Collection efforts that will be taken when these situations occur; and 3) How services will be limited or denied when it is determined that the patient has refused to pay. Please see Chapter 16: Billing and Collections of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 19: Board Authority

Board Authority-a. Maintenance of Board Authority Over Health Center Project: Within 90 days, provide final, executed documentation that ensures the health center governing board maintains authority for oversight of the health center project. Specifically provide final, executed documentation of organizational or other changes that address a finding(s) that: 1) Another individual, entity or committee reserves approval authority or has veto power over the health center board with respect to required authorities and functions; 2) Collaborations or agreements with another entity infringe or restrict the health center's required authorities and functions; or, if applicable, 3) The co-applicant agreement did not delegate required authorities and functions to the co-applicant board and/or did not delineate the roles and responsibilities of both the co-applicant board and the public agency in carrying out the health center project. If final, executed documentation of organizational or other changes necessary for the board to maintain all required authorities is not yet available, provide an action plan detailing the steps the health center will take to implement and finalize such changes. Acceptance of this plan by HRSA will result in a condition, which provides 120 days for the health center to submit final, executed documentation that confirms the health center has implemented the organizational or other changes necessary for the board to maintain all required authorities. Please see Chapter 19: Board Authority of the Health Center Program Compliance Manualfor additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Authority-b. Required Authorities and Responsibilities: Within 90 days, provide updated articles of incorporation, bylaws, or other relevant documents that confirm the required authorities and responsibilities of the health center governing board: 1) Holding monthly meetings; 2) Approving selection (and termination or dismissal) of the health center's Project Director/CEO; 3) Approving the annual health center project budget and application; 4) Approving health center services and the location and hours of operation of health center sites; 5) Evaluating the performance of the health center; 6) Establishing or adopting policy related to the operations of the health center; and 7) Assuring the health center operates in compliance with applicable Federal, State, and local laws and regulations. Please see Chapter 19: Board Authority of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Authority-c. Exercising Required Authorities and Responsibilities: Within 90 days, provide board minutes and any other relevant documentation that confirms the health center's governing board is exercising, without restriction, the following authorities and functions: 1) Holding monthly meetings where a quorum is present to ensure the board has the ability to exercise its required authorities and functions; 2) Approving the selection, evaluation and, if necessary, the dismissal or termination of the Project Director/CEO from the Health Center Program project; 3) Approving applications related to the Health Center Program project, including approving the annual budget, which outlines the proposed uses of both Health Center Program award and non-Federal resources and revenue; 4) Approving the Health Center Program project’s sites, hours of operation and services, including decisions to subaward or contract for a substantial portion of the health center’s services; 5) Monitoring the financial status of the health center, including reviewing the results of the annual audit, and ensuring appropriate follow-up actions are taken; 6) Conducting long-range/strategic planning at least once every three years, which at a minimum addresses financial management and capital expenditure needs; and 7) Evaluating the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management, and ensuring appropriate follow-up actions are taken. Please see Chapter 19: Board Authority of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Authority-d. Adopting, Evaluating, and Updating Health Center Policies: Within 90 days, provide documentation that the governing board has adopted, evaluated, and, if needed, approved updates to policies in the following areas: 1) Sliding Fee Discount Program, 2) Quality Improvement/Assurance, and 3) Billing and Collections. Please see Chapter 19: Board Authority of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Authority-e. Adopting, Evaluating, and Updating Financial and Personnel Policies: Within 90 days, provide documentation that the governing board has adopted, evaluated, and, if needed, approved updates to policies that support financial management, accounting systems, and personnel. Please see Chapter 19: Board Authority of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

View the Health Center Program Compliance Manual Chapter 20: Board Composition

Board Composition-a. Board Member Selection and Removal Process: Within 90 days, provide updated bylaws or other relevant documents that confirm the health center has a process for ongoing selection and removal of board members and that preclude any other entity, committee, or individual (other than the board) from selecting either the board chair or the majority of health center board members, including a majority of the non-patient board members. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Composition-b. Required Board Composition: Within 90 days, provide updated bylaws or other relevant documentation that require the health center governing board to be composed as follows: 1) At least 9 and no more than 25 members, with either a specific number or a range of board members prescribed; 2) At least 51 percent of board members are patients served by the health center; 3) Patient members of the board, as a group, represent the individuals who are served by the health center in terms of demographic factors, such as race, ethnicity, and sex; 4) Non-patient members are representative of the community served by the health center or the health center’s service area; 5) Non-patient members are selected to provide relevant expertise and skills such as: Community affairs; Local government; Finance and banking; Legal affairs; Trade unions and other commercial and industrial concerns; and Social services; 6) No more than one-half of non-patient board members derive more than 10 percent of their annual income from the health care industry; and 7) No health center employees and no immediate family members (i.e., spouses, children, parents, or siblings through blood, adoption, or marriage) of employees may be health center board members. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Composition-c. Current Board Composition: Within 90 days, provide updated documentation that the health center governing board is composed of: 1) At least 9 and no more than 25 members; 2) A patient majority (at least 51 percent); 3) Patient board members, who as a group, represent the individuals who are served by the health center in terms of demographic factors, such as race, ethnicity, and sex, consistent with the demographics reported in the health center’s Uniform Data System (UDS) report; 4) For those health centers that receive any award/designation under one or more of the special populations subparts, Representative(s) from or for each of the special population(s); and 5) Non-patient board members representative of the community in which the health center is located, with relevant skills and expertise; and no more than 50 percent of such members earn more than 10 percent of their annual income from the health care industry. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Composition-d. Prohibited Board Members: Within 90 days, provide documentation that the health center has verified that the governing board does not include members who are current employees of the health center, or immediate family members of current health center employees (i.e., spouses, children, parents, or siblings through blood, adoption, or marriage). In addition, provide documentation of the health center's process for periodic verification. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions. (45 CFR 75.207(a) and 45 CFR 75.371)

Board Composition-e. Waiver Requests: Within 90 days, provide a justification for a waiver of the patient majority requirement that describes: 1) The undue hardship in recruiting a patient majority based on the characteristics of the special population and/or service area; and 2) the health center’s attempts to recruit a majority of special population board members within the past three years. In addition, describe the specific strategies that will ensure special population patient participation and input in the direction and ongoing governance of the organization. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. If you no longer wish to request a waiver, please notify your Project Officer. (45 CFR 75.207(a) and 45 CFR 75.371)

NOTE: Failure to satisfy this condition may result in the application of additional board composition conditions which will require the health center to demonstrate it has recruited a majority of governing board members who are patients.

Board Composition-f. Utilization of Special Population Input: Within 90 days, provide board minutes or other documentation that demonstrates how the health center governing board has utilized special population input in the following areas: 1) selecting health center services; 2) setting hours of operation of health center sites; 3) defining budget priorities; 4) evaluating the organization’s progress in meeting goals, including patient satisfaction; and 5) assessing the effectiveness of the sliding fee discount program. If documentation is not available, provide an action plan detailing the steps the health center will take to ensure the incorporation of special population input into governing board decision-making in these areas. Acceptance of this plan by HRSA will result in a condition, which provides 120 days for the health center to submit board minutes or other documentation that confirms the health center has utilized special population input in making decisions. Please see Chapter 20: Board Composition of the Health Center Program Compliance Manual for additional information and contact your project officer with any questions, including the applicable components to be addressed. (45 CFR 75.207(a) and 45 CFR 75.371)

Needs Assessment

Required and Additional Health Services

Clinical Staffing

Accessible Locations and Hours of Operation

Coverage for Medical Emergencies During and After Hours

Continuity of Care and Hospital Admitting

Sliding Fee Discount Program

Quality Improvement/Assurance

Key Management Staff

Contracts and Subawards

Conflict of Interest

Collaborative Relationships

Financial Management and Accounting Systems

Billing and Collections

Budget

Program Monitoring and Data Reporting Systems

Board Authority

Board Composition