In this section:
Primary Reviewer: Governance/Administrative Expert
Secondary Reviewer: Fiscal Expert
Authority: Section 330(a)(1) and 330(k)(3)(D) of the Public Health Service (PHS) Act; 42 CFR 51c.113 and 42 CFR 56.114; and 45 CFR 75.327
Health Center Program Compliance Manual Related Considerations
Documents the Health Center Provides
- Two most recent annual audits and management letters.
- Documents containing the health center’s standards of conduct (for example, articles of incorporation, bylaws, board manual, employee manual, policies and procedures, disclosure forms).
- For contracts that support the HRSA-approved scope of project:
- Five contracts AND related supporting procurement documentation for actions that use federal award funds. Choose the contracts that use the largest amounts of federal award funds.
Note: Use the same sample of contracts/agreements for the review of both Contracts and Subawards and Conflict of Interest. The sampling methodologies for Conflict of Interest are different from Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program, even though they may result in some overlap in the contracts/agreements reviewed.
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Agreements with any parent corporation, affiliate, subsidiary, or subrecipient organizations.
- For look-alikes that have parent, affiliate, or subsidiary organizations that are not a state, local government, or Indian tribe:
- Five contracts AND related supporting procurement documentation for procurements involving the related parent, affiliate, or subsidiary organizations.
Note: Contracts in the sample are either active or have a period of performance which ended less than 3 years ago.
- If a real or apparent conflict of interest was identified in a procurement action that occurred within the last 3 years: All related written disclosures that were completed by employees, officers, board members, and agents of the health center (for example, board minutes documenting disclosures, standard forms to report disclosures).
Compliance Assessment
- Is this a Look-Alike Site Visit?
Response is either: Yes or No
NOTE: Because look-alikes do not receive federal funding under section 330 of the PHS Act, any requirements that relate to the use of Health Center Program federal award funds do not apply to look-alikes.
Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.
Not Applicable For Look-alikes
The health center has and implements written standards of conduct that apply, at a minimum, to its procurements paid for in whole or in part by the federal award. Such standards:
- Apply to all health center employees, officers, board members, and agents1 involved in the selection, award, or administration of such contracts;
- Require written disclosure of real or apparent conflicts of interest;2
- Prohibit individuals with real or apparent conflicts of interest with a given contract from participating in the selection, award, or administration of such contract;3
- 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);4 and
- Enforce disciplinary actions on health center employees, officers, board members, and agents for violating these standards.
Site Visit Team Methodology
- Interview health center Project Director/CEO, board members, and other relevant staff involved in procurement and/or Human Resources (HR) about the health center’s standards of conduct and the process for disclosing any real or apparent conflicts of interest.
- Review the documents that contain standards of conduct related to procurement.
Note: Signed disclosure statements or forms from all health center staff and board members are NOT required to demonstrate compliance. The purpose of the review is to assess whether the health center has a mechanism in place for health center staff and board members to disclose real or apparent conflicts of interest when they arise.
Site Visit Findings
- Did the health center provide documents containing its standards of conduct for the selection, award, and administration of contracts that apply to its procurements paid for in whole or in part by the federal award?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
- Do these written standards of conduct:
- 3.1 Apply to all health center employees, officers, board members, and agents involved in the selection, award, or administration of contracts paid for in whole or in part by the federal award?
Response is: Yes, No, or Not Applicable
- 3.2 Require written disclosure of any real or apparent conflicts of interest?
Response is: Yes, No, or Not Applicable
- 3.3 Prohibit individuals with a real or apparent conflict of interest with a given contract from participating in the selection, award, or administration of any contract paid for in whole or in part by the federal award?
Response is: Yes, No, or Not Applicable
- 3.4 Prohibit accepting gratuities, favors, or anything of monetary value?
Response is: Yes, No, or Not Applicable
- 3.5 Provide for disciplinary actions for violating the conflict of interest requirements?
Response is: Yes, No, or Not Applicable
If No was selected for any of the above, an explanation is required, including specifying which areas were not addressed.
- 3.1 Apply to all health center employees, officers, board members, and agents involved in the selection, award, or administration of contracts paid for in whole or in part by the federal award?
- Does the health center have a process for employees, officers, board members, and agents of the health center to disclose in writing any real or apparent conflicts of interest when a conflict occurs?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
If the health center has a parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe, the health center has and implements written standards of conduct covering organizational conflicts of interest5 that might arise when conducting a procurement action involving a related organization. These standards of conduct require:
- Written disclosure of conflicts of interest that arise in procurements from a related organization; and
- Avoidance and mitigation of any identified actual or apparent conflicts during the procurement process.
Site Visit Team Methodology
- Review the agreements with any parent corporation, affiliate, subsidiary, or subrecipient organizations.
- Review the two most recent annual audits and management letters for any references to related party transactions.
- Review the documents that contain the health center’s written standards of conduct.
Site Visit Findings
- Does the health center have a parent, affiliate or subsidiary that is not a state, local government, or Indian tribe?
Response is either: Yes or No
- IF YES: Did the health center provide documents containing its written standards of conduct for the selection, award, and administration of contracts that involve the related party or organization?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
- Do the health center’s organizational conflict of interest standards prevent or mitigate any identified or apparent conflicts of interest?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
The health center has mechanisms or procedures for informing its employees, officers, board members, and agents of the health center’s standards of conduct covering conflicts of interest, including organizational conflicts of interest, and for governing its actions with respect to the selection, award and administration of contracts.
Site Visit Team Methodology
- Review the documents containing the health center’s standards of conduct, including those covering any organizational conflict of interest.
- If a real or apparent conflict of interest was identified in a procurement action that occurred within the last 3 years: Review all related written disclosures that were completed by employees, officers, board members, and agents of the health center (for example, board minutes documenting disclosures, standard forms to report disclosures).
- Interview health center Project Director/CEO, board members, and other relevant staff involved in HR and procurement. Discuss mechanisms or procedures for informing employees, officers, board members, and agents of the health center’s standards of conduct.
Site Visit Findings
When responding to the question(s) below, please note:
- For look-alikes, this element is applicable ONLY for those look-alikes that have a parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe as identified in the assessment of element “b.”
- For all other look-alikes, select “Not Applicable.”
- Does the health center inform employees, officers, board members, and agents of its conflict of interest standards of conduct?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
In cases where a conflict of interest was identified, the health center’s procurement records document adherence to its standards of conduct (for example, an employee whose family member was competing for a health center contract was not permitted to participate in the selection, award, or administration of that contract).
Site Visit Team Methodology
- Review the five contracts that use the largest amounts of federal award funds AND the related supporting procurement documentation.
Note: Use the same sample of contracts/agreements for the review of both Contracts and Subawards and Conflict of Interest. The sampling methodologies for Conflict of Interest are different from Required and Additional Health Services, Clinical Staffing, and Sliding Fee Discount Program, even though they may result in some overlap in the contracts/agreements reviewed. - For look-alikes that have parent, affiliate, or subsidiary organizations that are not a state, local government, or Indian tribe: Review the five contracts AND related supporting procurement documentation for procurements involving the related parent, affiliate, or subsidiary organizations.
Note: Contracts in the sample are either active or have a period of performance which ended less than 3 years ago. - In cases where a real or apparent conflict of interest was identified in the procurement action, review the related written disclosures that are completed by employees, officers, board members, and agents of the health center (for example, board minutes documenting disclosures, standard forms to report disclosures).
- Review the audits and management letters for any findings related to conflicts of interest.
Site Visit Findings
When responding to the question(s) below, please note:
- For look-alikes, this element is applicable ONLY for those look-alikes that have a parent, affiliate, or subsidiary that is not a state, local government, or Indian tribe as identified in the assessment of element “b.”
- For all other look-alikes, this element is “Not Applicable.”
- Did the health center identify any real or apparent conflicts of interest, including organizational conflicts of interest, for procurements involving federal funds? For look-alikes, did the health center identify any real or apparent organizational conflicts of interest for procurements involving any related parent, affiliate, or subsidiary organization?
Response is: Yes, No, or Not Applicable
- IF YES: Did the health center provide documentation showing that it adhered to its standards of conduct for all identified conflicts of interest, including the completion of written disclosures?
Response is: Yes, No, or Not Applicable
If No, an explanation is required.
Footnotes
1. An agent of the health center includes, but is not limited to, a governing board member, an employee, officer, or contractor acting on behalf of the health center.
2. A conflict of interest arises when the employee, officer, or agent (including but not limited to any member of the governing board), any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in or a tangible personal benefit from a firm considered for a contract. See: 45 CFR 75.327(c)1.
3. This includes, but is not limited to, prohibiting board members that are employees or contractors of a subrecipient of the health center from participating in the selection, award, or administration of that subaward. This also includes prohibiting board members who are employees of an organization that contracts with the health center from participating in the selection, award, or administration of that contract.
4. Health centers may set standards for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value. See Related Considerations in [Health Center Program Compliance Manual] Chapter 13: Conflict of Interest.
5. Organizational conflicts of interest mean that because of relationships with a parent company, affiliate, or subsidiary organization, the health center is unable or appears to be unable to be impartial in conducting a procurement action involving a related organization. See: 45 CFR 75.327(c)(2).