Chapter 11: Key Management Staff

Note: This chapter contains language that was revised based on the Bipartisan Budget Act of 2018. View the revisions. (PDF - 583 KB)

Authority

Section 330(k)(3)(H)(ii), and 330(k)(3)(I)(i) of the PHS Act; 42 CFR 51c.104(b)(4), 42 CFR 51c.303(p), 42 CFR 56.104(b)(5), and 42 CFR 56.303(p); and 45 CFR 75.308(c)(1)(ii)(iii)

Requirements

  • The health center must have position descriptions for key personnel [also referred to as key management staff] that set forth training and experience qualifications necessary to carry out the activities of the health center.
  • The health center must maintain sufficient key personnel [also referred to as key management staff] to carry out the activities of the health center.
  • The health center must request prior approval from HRSA for a change in the key person specified in the Health Center Program award or Health Center Program look-alike designation.
  • The health center must directly employ its Project Director/CEO.1

Demonstrating Compliance

A health center would demonstrate compliance with these requirements by fulfilling all of the following:

  1. The health center has determined the makeup of and distribution of functions among its key management staff2 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.
  2. The health center has documented the training and experience qualifications, as well as the duties or functions, for each key management staff position (for example, in position descriptions).
  3. The health center has implemented, as necessary, a process for filling vacant key management staff positions (for example, vacancy announcements have been published and reflect the identified qualifications).
  4. The health center’s Project Director/CEO is directly employed by the health center,3 reports to the health center’s governing board4 and is responsible for overseeing other key management staff in carrying out the day-to-day activities necessary to fulfill the HRSA-approved scope of project.
  5. If there has been a post-award change in the Project Director/CEO position,5 the health center requests and receives prior approval from HRSA.

The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:

  • The health center’s governing board determines when a less than full time Project Director/CEO position is sufficient to oversee the day-to-day activities of the HRSA- approved scope of project.
  • The health center determines when and if it is appropriate and necessary to contract for key management staff positions (other than the CEO, who may not be a contractor), rather than directly employ such individuals.
  • The health center determines key management staff position titles (for example, utilizing the title “CEO” or “Project Director”) and how functions are distributed among its key management staff positions (for example, determining in a smaller health center whether it is appropriate to combine the CEO and CFO functions).

Footnotes

  1. While the position title of the key person who is specified in the award/designation may vary, for the purposes of the Health Center Program, this Chapter will utilize the term “Project Director/CEO” when referring to this key person. Under 45 CFR 75.2, the term “Principal Investigator/Program Director (PI/PD)” means the individual(s) designated by the recipient to direct the project or program being supported by the grant. The PI/PD is responsible and accountable to officials of the recipient organization for the proper conduct of the project, program, or activity. For the purposes of the Health Center Program, “Project Director/CEO” is synonymous with the term “PI/PD.”
  2. Examples of key management staff may include Project Director/CEO, Clinical Director/Chief Medical Officer, Chief Financial Officer, Chief Operating Officer, Nursing/Health Services Director, or Chief Information Officer.
  3. Public agency health centers utilizing a co-applicant structure would demonstrate compliance with the statutory requirement for direct employment of the Project Director/CEO by demonstrating that the public agency, as the Health Center Program awardee/designee of record, directly employs the Project Director/CEO. Refer to related requirements in Chapter 19: Board Authority regarding public agencies with co-applicants.
  4. Refer to related requirements in Chapter 19: Board Authority regarding the selection and dismissal of the Project Director/CEO by the health center board as part of its oversight responsibilities for the Health Center Program project.
  5. Such changes include situations in which the current Project Director/CEO will be disengaged from involvement in the Health Center Program project for any continuous period for more than 3 months or will reduce time devoted to the project by 25% or more from the level that was approved at the time of award [see: 45 CFR 75.308(c)(1)(ii) and (iii)].

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Date Last Reviewed:  January 2018


Health Center Compliance Manual

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