Key Management Staff

Primary Reviewer: Governance/Administrative Expert

Secondary Reviewer: Fiscal and Clinical Expert (as needed)

Authority: Section 330(k)(3)(H)(ii), and 330(k)(3)(I)(i) of the Public Health Service (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)

Health Center Program Compliance Manual Related Considerations

Document Checklist for Health Center Staff

  • Health center organization chart(s) with names and titles of key management staff (if updated since last submission to HRSA).
  • Position descriptions of key management staff (if updated since last submission to HRSA).
  • Bios or resumes for key management staff (if updated since last application submission to HRSA).
  • Co-applicant agreement (if applicable) (if updated since last application submission to HRSA).
  • Human Resources procedures relevant to recruiting and hiring of key management staff (if applicable, for health centers with key management staff vacancies).
  • Project Director/CEO employment agreement.
  • Project Director/CEO’s Form W-2 or, if a Form W-2 has not yet been issued, documentation of receipt of salary directly from the health center (for example, pay stub).
  • Notice of Award (NOA)/Notice of Look-Alike Designation (NLD) approving any Project Director/CEO position change(s) since start of the current project period or designation period OR documentation that a prior approval request(s) for such change(s) is still under review by HRSA.
  • Contracts for key management staff (if applicable).
  • Documentation associated with filling key management staff vacancies (if applicable) (for example, job advertisements, revised position descriptions).

Demonstrating Compliance

Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.

The health center has determined the makeup of and distribution of functions among its key management staff1 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.

Site Visit Team Methodology

  • Review Form 2: Staffing Profile and review the position descriptions or contracts for key management staff from the most recent Service Area Competition (SAC)/Renewal of Designation (RD) application, and if applicable, review any new job descriptions.
  • Review the health center organization chart(s).
  • Interview various members of the health center’s key management staff to determine how key functions are distributed and carried out.

Site Visit Findings

  1. Was the health center able to justify how the distribution of functions and allocation of time for each key management position is sufficient to carry out the approved scope of the health center project (for example, Is there a clear justification for a part-time Project Director/CEO or for the lack of a dedicated CFO position)?

    Response is either: Yes or No

    If No, an explanation is required, including describing why the distribution of functions and allocation of time for each key management position is insufficient to carry out the scope of project.

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).

Site Visit Team Methodology

N/A – HRSA assesses whether the health center has demonstrated compliance with this element through its review of the competing continuation application (SAC or RD). No review of this element is required through the site visit.

Site Visit Findings

N/A – HRSA assesses whether the health center has demonstrated compliance with this element through its review of the competing continuation application (SAC or RD). No review of this element is required through the site visit.

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).

Site Visit Team Methodology

  • Review health center organization chart(s) and compare to current key management staff. Note if there are any vacancies.
  • If a key management staff vacancy is noted, review Human Resources procedures relevant to recruiting and hiring of key management staff and interview person(s) responsible for health center hiring/Human Resources functions and documentation associated with filling the vacancy.

Site Visit Findings

  1. Does the health center have any vacant key management positions?

    Response is either: Yes or No

  2. IF YES: Will or has the health center implement(ed) a process for filling this position?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required, including specifying which position(s) are vacant.

The health center’s Project Director/CEO2 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.

Site Visit Team Methodology

  • Review health center organization chart(s).
  • Review position descriptions or contracts for key management staff and, if necessary, any other documentation of key management reporting structures.
  • Review the Project Director/CEO’s Form W-2 or, if a Form W-2 has not yet been issued by the health center, documentation of receipt of salary directly from the health center.
  • For public agencies with a co-applicant board, review the co-applicant agreement.
  • Interview Project Director/CEO.

Site Visit Findings

  1. Is the Project Director/CEO directly employed by the health center as confirmed by a Form W-2 (or, if a Form W-2 has not yet been issued by the health center, documentation of receipt of salary directly from the health center such as a pay stub)?

    Note: The Project Director/CEO is directly employed by the health center if the Project Director/CEO: (1) receives a salary directly from the health center; (2) is issued a W-2 that lists only the health center as the Project Director/CEO’s employer; and (3) has an employment agreement entered into with the health center that outlines the activities required to be performed by the Project Director/CEO.

    Response is either: Yes or No

    If No, an explanation is required.

  2. Does the Project Director/CEO report to the health center board?

    Note: In a public center with a co-applicant board where the public center employs the Project Director/CEO, the Project Director/CEO may report both to the co-applicant board and to another board or individual within the public agency.

    Response is either: Yes or No

    If No, an explanation is required.

  3. Does the Project Director/CEO oversee other key management staff in carrying out the day-to-day activities of the health center project?

    Response is either: Yes or No

    If No, an explanation is required.

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.

Site Visit Team Methodology

  • Determine whether there has been a change in the Project Director/CEO position since the start of the current project or designation period.
    • If yes, review the associated Notice of Award (NOA)/Notice of Look-Alike Designation (NLD) approving this change.
    • If the request to change the Project Director/CEO is still under review by HRSA, review documentation that a prior approval was submitted to HRSA and consult with the federal representative on the status of the request.

Site Visit Findings

  1. Has there been a change in the Project Director/CEO position since the start of the current project or designation period?

    Notes:

    • This ONLY includes situations in which the Project Director/CEO was disengaged from involvement in the project for any continuous period for more than 3 months or reduced time devoted to the project by 25 percent or more from the level that was approved at the time of award.
    • Only select “Not Applicable” if this is a Look-Alike Initial Designation Site Visit.

    Response is: Yes, No, or Not Applicable

  2. IF YES: Was there a Notice of Award (NOA)/Notice of Look-Alike Designation (NLD) from HRSA approving this change or did the health center provide documentation that the prior approval request is still under review by HRSA?

    Response is: Yes, No, or Not Applicable

    If No, an explanation is required.

 

Footnotes:

  • 1. 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.
  • 2. 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, [the Health Center Program Compliance Manual Chapter 11: Key Management Staff utilizes] 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.”
  • 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 [Health Center Program Compliance Manual] Chapter 19: Board Authority regarding public agencies with co-applicants.
  • 4. Refer to related requirements in [Health Center Program Compliance Manual] 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 percent or more from the level that was approved at the time of award [see: 45 CFR 75.308(c)(1)(ii) and (iii)].