In this section:
Primary Reviewer: Governance/Administrative Expert
Secondary Reviewer: N/A
Authority: Section 330(k)(3)(H) of the Public Health Service (PHS) Act; 42 CFR 51c.303(i), 42 CFR 56.303(i), 42 CFR 51c.304(d), and 42 CFR 56.304(d); and 45 CFR 75.507(b)(2)
Health Center Program Compliance Manual Related Considerations
Documents the Health Center Provides
- Health center organization charts with names of key management staff.
- For public agencies or for organizations with a parent or subsidiary: Corporate organization charts.
- Articles of Incorporation.
- Bylaws (if updated since last application submission to HRSA).
- Any additional corporate or governing documents.
- For public agencies with a co-applicant: Co-applicant agreement (if updated since last application submission to HRSA).
- Any agreements with a parent corporation, affiliate, subsidiary, or subrecipient organizations.
- Any collaborative or contractual agreements with outside entities that impact the health center board’s authorities or functions.
- Board calendar or other related scheduling documents for the most recent 12 months.
- Board agendas and minutes for:
- The most recent 12 months.
- Any other relevant meetings from the past 3 years that demonstrate board authorities were clearly exercised, including approving key policies on:
- Sliding Fee Discount Program;
- Quality Improvement/Quality Assurance Program;
- Billing and Collections, specifically policies for waiving or reducing patient fees and any policies on patients’ refusal to pay;
- Financial Management and Accounting Systems; and
- Personnel.
Note: For look-alike initial designation applicants and newly-funded health centers that do not have 12 months of board agendas and minutes, all of the available board agendas and minutes from within the past 12 months.
- Sample of board packets from two board meetings that occurred during the most recent 12 months.
- Board committee minutes OR committee documents from the most recent 12 months that support board functions and activities.
- Strategic plan or long-term planning documents from within the past 3 years.
- Position description for the Project Director/CEO.
- Project Director/CEO employment agreement, highlighting the provisions that address Project Director/CEO selection, evaluation, and dismissal or termination.
- Most recent evaluation of Project Director/CEO.
Compliance Assessment
- Is the health center operated by an Indian tribe, tribal group, or Indian organization under the Indian Self-Determination Act or an Urban Indian Organization under the Indian Health Care Improvement Act?1
Response is either: Yes or No
NOTE: If “Yes” was selected, NONE of the questions for ANY of the elements in the Board Authority section are applicable.
Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.
The health center’s organizational structure, articles of incorporation, bylaws, and other relevant documents ensure the health center governing board maintains the authority for oversight of the Health Center Program project, specifically:
- The organizational structure and documents do not allow for any other individual, entity or committee (including, but not limited to, an executive committee authorized by the board) to reserve approval authority or have veto power over the health center board with regard to the required authorities and functions;2
- In cases where a health center collaborates with other entities in fulfilling the health center’s HRSA-approved scope of project, such collaboration or agreements with the other entities do not restrict or infringe upon the health center board’s required authorities and functions; and
- For public agencies with a co-applicant board,3 the health center has a co-applicant agreement that delegates the required authorities and functions to the co-applicant board and delineates the roles and responsibilities of the public agency and the co-applicant in carrying out the Health Center Program project.
Site Visit Team Methodology
- Review the health center organization charts, articles of incorporation, bylaws, and any additional corporate or governing documents.
- Review any corporate organization charts.
- Review the health center’s Form 5A and Form 5B to determine current HRSA-approved scope of project.
- Review any collaborative or contractual agreements with outside entities that impact the health center board’s authorities or functions.
- Review any co-applicant agreement.
- Review any agreements with parent corporation, affiliate, subsidiary, or subrecipient organizations.
Site Visit Findings
When responding to the question(s) below, please note:
For a public agency with a co-applicant board, the public agency is not considered to be an outside entity because it is the award recipient.
- Do health center documents and agreements confirm that:
- 2.1 No other individual, entity, or committee (including, but not limited to, an executive committee authorized by the board) reserves approval authority or has veto power over the health center board with regard to the required authorities and functions?
Response is either: Yes or No
- 2.2 The health center’s collaborations or agreements with other entities do not restrict or infringe upon the health center board’s required authorities and functions?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required.
- 2.1 No other individual, entity, or committee (including, but not limited to, an executive committee authorized by the board) reserves approval authority or has veto power over the health center board with regard to the required authorities and functions?
- FOR PUBLIC AGENCIES WITH A CO-APPLICANT BOARD: Does the health center have a co-applicant agreement that:
- 3.1 Delegates the required authorities and functions to the co-applicant board?
Response is: Yes, No, or Not Applicable
- 3.2 Delineates the required roles and responsibilities of the public agency and the co-applicant board in carrying out the health center project?
Response is: Yes, No, or Not Applicable
If No was selected for either of the above, an explanation is required.
- 3.1 Delegates the required authorities and functions to the co-applicant board?
The health center’s articles of incorporation, bylaws, or other relevant documents outline the following required authorities and responsibilities of the governing board:
- Holding monthly meetings;4,5
- Approving the selection (and termination or dismissal, as appropriate) of the health center’s Project Director/CEO;
- Approving the annual Health Center Program project budget and applications;
- Approving health center services and the location and hours of operation of health center sites;
- Evaluating the performance of the health center;
- Establishing or adopting policy6 related to the operations of the health center; and
- Assuring the health center operates in compliance with applicable federal, state, and local laws and regulations.
Site Visit Team Methodology
- Review the health center’s articles of incorporation, bylaws, and any additional corporate or governing documents.
- Review any co-applicant agreement.
Site Visit Findings
- Do the health center’s articles of incorporation, bylaws (either for the health center board or the co-applicant health center board), or other corporate documents (for example, co-applicant agreement) outline the following required health center authorities and responsibilities:
- 4.1 Holding monthly meetings?
Response is either: Yes or No
- 4.2 Approving the selection and the termination or dismissal of the health center’s Project Director/CEO?
Response is either: Yes or No
- 4.3 Approving the health center’s annual budget and applications?
Response is either: Yes or No
- 4.4 Approving health center services?
Response is either: Yes or No
- 4.5 Approving the location and hours of operation of health center sites?
Response is either: Yes or No
- 4.6 Evaluating the performance of the health center?
Response is either: Yes or No
- 4.7 Establishing or adopting policy related to the operations of the health center?
Response is either: Yes or No
- 4.8 Assuring the health center operates in compliance with applicable federal, state, and local laws and regulations?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required, including specifying which authorities or responsibilities are not addressed in such documents.
- 4.1 Holding monthly meetings?
The health center’s board minutes and other relevant documents confirm that the board exercises, without restriction, the following authorities and functions:
- Holding monthly meetings where a quorum is present to ensure the board has the ability to exercise its required authorities and functions;
- Approving the selection, evaluation and, if necessary, the dismissal or termination of the Project Director/CEO from the Health Center Program project;
- 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;
- 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;
- Monitoring the financial status of the health center, including reviewing the results of the annual audit, and ensuring appropriate follow-up actions are taken;
- Conducting long-range/strategic planning at least once every 3 years, which at a minimum addresses financial management and capital expenditure needs; and
- Evaluating the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management,7 and ensuring appropriate follow-up actions are taken regarding:
- Achievement of project objectives;
- Service utilization patterns;
- Quality of care;
- Efficiency and effectiveness of the center; and
- Patient satisfaction, including addressing any patient grievances.
Site Visit Team Methodology
- Interview Project Director/CEO about board roles and responsibilities (for example, evaluating health center performance, approving applications, conducting long-range planning, evaluating health center policies).
- Interview board (co-applicant board in the case of a public agency-co-applicant structure) about how it carries out board functions, specifically:
- How Project Director/CEO reports to the board.
- Board roles and responsibilities (for example evaluating health center performance, approving applications, conducting long-range planning, evaluating health center policies).
Note: The goal is to interview a majority of board members as a group. If this is not possible, interview officers and at least one patient board member. If a group board interview is not possible, interview board members individually.
- If conducting a review for a public agency health center, interview relevant public agency staff (for example, leadership and staff who work with the health center project) about their various roles and responsibilities.
- Review the board calendar or other related scheduling documents for the most recent 12 months.
- Review the board agendas and minutes for the most recent 12 months and any other relevant meeting minutes from the past 3 years that demonstrate board authorities were clearly exercised.
Note: For look-alike initial designation applicants and newly-funded health centers that do not have 12 months of board agendas and minutes, review all of the available board agendas and minutes from within the past 12 months. - Review any relevant board committee minutes OR committee documents for the most recent 12 months that support board functions and activities.
- Review the sample of board packets from two board meetings that occurred during the most recent 12 months.
- Review the strategic planning or related documents from within the past 3 years.
- Review the most recent Project Director/CEO evaluation documentation.
- Review the position description and employment agreement for the Project Director/CEO.
Site Visit Findings
-
Do board minutes document that the board met monthly for the past 12 months and had a quorum present that enabled the board to carry out its required authorities and functions?
Notes:
- The health center determines how to set quorum for board meetings consistent with state, territorial or other applicable law.
- For look-alike initial designation applicants and newly-funded health centers that did not have 12 months of board agendas and minutes, determine whether the board met monthly based on the board minutes provided.
Response is either: Yes or No
If No, an explanation is required.
- Based on the review of board minutes, board agendas, other relevant documents, and interviews conducted with the Project Director/CEO and board members, are there examples of how the board exercises the following authorities and functions:
- 6.1 Approving the selection, evaluation, and, if necessary, dismissal or termination of the Project Director/CEO from the health center project?
Response is either: Yes or No
- 6.2 Approving applications related to the health center project? For example, Service Area Competition (SAC), look-alike Renewal of Designation (RD), New Access Point (NAP), and supplemental funding applications.
Response is either: Yes or No
- 6.3 Approving the health center project’s annual budget, which outlines the proposed uses of both federal Health Center Program award and non-federal resources and revenue?
Response is either: Yes or No
- 6.4 Approving the health center project’s sites and hours of operation?
Response is either: Yes or No
- 6.5 Approving the health center project’s services and any decisions to subaward or contract for a substantial portion of the health center’s services?
Response is either: Yes or No
- 6.6 Monitoring the financial status of the health center, including reviewing the results of the annual audit and ensuring appropriate follow-up actions are taken?
Response is either: Yes or No
- 6.7 Conducting long-term strategic planning at least once every 3 years, which at a minimum addresses financial management and capital expenditure needs?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required, including specifying any restrictions on the board in carrying out these authorities and functions.
- 6.1 Approving the selection, evaluation, and, if necessary, dismissal or termination of the Project Director/CEO from the health center project?
- Based on the review of board minutes, board agendas, other relevant documents, and interviews conducted with the Project Director/CEO and board members, are there examples of how the board evaluates the performance of the health center using quality assurance/quality improvement assessments and other information received from health center management?
Response is either: Yes or No
If No, an explanation is required.
-
IF YES: Based on these performance evaluations, are there examples of follow-up actions that are reported back to the board about:
Note: Only select “Not Applicable” for an item below if follow-up action was not necessary.
- 8.1 Achievement of Health Center Program project objectives?
Response is: Yes, No, or Not Applicable
- 8.2 Service utilization patterns?
Response is: Yes, No, or Not Applicable
- 8.3 Quality of care?
Response is: Yes, No, or Not Applicable
- 8.4 Efficiency and effectiveness of the health center?
Response is: Yes, No, or Not Applicable
- 8.5 Patient satisfaction, including addressing any patient grievances?
Response is: Yes, No, or Not Applicable
If No OR Not Applicable was selected for any of the above, an explanation is required.
- 8.1 Achievement of Health Center Program project objectives?
The health center board has adopted, evaluated at least once every 3 years, and, as needed, approved updates to policies in the following areas: Sliding Fee Discount Program (SFDP), Quality Improvement/Assurance, and Billing and Collections.8
Site Visit Team Methodology
- Review the board minutes from the past 3 years to confirm that the board has reviewed and, if needed, approved updates to the following policies:
- SFDP;
- Quality Improvement/Quality Assurance Program; and
- Billing and Collections, specifically policies for waiving or reducing patient fees and any policies on patients’ refusal to pay.
- Interview the same board members identified in element “c” about the board’s evaluation of the health center’s SFDP, quality improvement/quality assurance program, and billing and collections policies. Also, discuss any related updates to these policies.
Site Visit Findings
- Within the last 3 years, did the board adopt or evaluate health center policies in the following areas:
- 9.1 SFDP?
Response is either: Yes or No
- 9.2 Quality Improvement/Quality Assurance Program?
Response is either: Yes or No
- 9.3 Billing and Collections policy for waiving or reducing patient fees and, if applicable, refusal to pay?
Response is either: Yes or No
If No was selected for any of the above, an explanation is required.
- 9.1 SFDP?
- Did the health center provide one to two examples of how it has modified or updated its policies, if needed, because of these evaluations?
Note: Select “Not Applicable” if updates were not needed because of these evaluations.
Response is: Yes, No, or Not Applicable
If No OR Not Applicable, an explanation is required.
The health center board has adopted, evaluated at least once every 3 years, and, as needed, approved updates to policies that support financial management and accounting systems and personnel policies. However, in cases where a public agency is the recipient of the Health Center Program federal award or designation and has established a co-applicant structure, the public agency may establish and retain the authority to adopt and approve policies that support financial management and accounting systems and personnel policies.
Site Visit Team Methodology
- Review the board minutes from the past 3 years to confirm that the board has reviewed and, if needed, approved updates to the following policies:
- Financial Management and Accounting Systems; and
- Personnel.
- Interview the same board members identified in element “c” about their process for evaluating financial management and accounting systems and personnel policies.
- If conducting a site visit for a public agency health center with a co-applicant board: Review the co-applicant agreement to determine if the public agency retains authority for adopting and approving personnel and financial management policies.
Site Visit Findings
When responding to the question(s) below, please note:
The content of a health center’s financial management and personnel policies may vary. For example, a health center may still demonstrate compliance even if its procurement procedures are not part of its board-approved financial management policy. Assess compliance with procurement procedures in Contracts and Subawards.
-
Within the last 3 years, did the board evaluate health center policies that support the following areas:
Note: For health centers where the public agency retains the authority to adopt and approve personnel policies or policies that support financial management and accounting systems, select “Not Applicable.”
- 11.1 Financial management and accounting systems?
Response is: Yes, No, or Not Applicable
- 11.2 Personnel?
Response is: Yes, No, or Not Applicable
If No was selected for any of the above, an explanation is required.
- 11.1 Financial management and accounting systems?
Footnotes
1. The governing board of a health center operated by Indian tribes, tribal groups, or Indian organizations under the Indian Self-Determination Act or Urban Indian Organizations under the Indian Health Care Improvement Act is exempt from the specific board authority requirements discussed in [Health Center Program Compliance Manual Chapter 19: Board Authority]. Section 330(k)(3)(H) of the PHS Act.
2. This does not preclude an executive committee from taking actions on behalf of the board in emergencies, on which the full board will subsequently vote.
3. Public agencies are permitted to utilize a co-applicant governance structure for the purposes of meeting Health Center Program governance requirements. Public centers may be structured in one of two ways to meet the program requirements: 1) the public agency independently meets all the Health Center Program governance requirements based on the existing structure and vested authorities of the public agency’s governing board; or 2) together, the public agency and the co-applicant meet all Health Center Program requirements.
4. Where geography or other circumstances make monthly, in-person participation in board meetings burdensome, monthly meetings may be conducted by telephone or other means of electronic communication where all parties can both listen and speak to all other parties.
5. Boards of organizations receiving a Health Center Program award/designation only under section 330(g) may meet less than once a month during periods of the year, as specified in the bylaws, where monthly meetings are not practical due to health center patient migration out of the area. 42 CFR 56.304(d)(2).
6. The governing board of a health center is generally responsible for establishing and/or approving policies that govern health center operations, while the health center’s staff is generally responsible for implementing and ensuring adherence to these policies (including through operating procedures).
7. For more information related to the production of reports associated with these topics, see [Health Center Program Compliance Manual] Chapter 18: Program Monitoring and Data Reporting Systems, Chapter 15: Financial Management and Accounting Systems, and Chapter 10: Quality Improvement/Assurance.
8. Policies related to billing and collections that require board approval include those that address the waiving or reducing of amounts owed by patients due to inability to pay, and if applicable those that limit or deny services due to refusal to pay.