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Health Center Program Compliance ManualHealth Center ProgramCompliance ManualLast updated: August 20, 20181
Health Center Program Compliance ManualTable of ContentsIntroduction . 6Applicability. 6Purpose . 6Structure of the Health Center Program Compliance Manual . 7Additional Health Center Responsibilities . 8Chapter 1: Health Center Program Eligibility . 10Non-Profit Organizations . 10Public Agency Organizations. 10Tribal or Urban Indian Organizations. 11Additional Eligibility Requirements for Look-Alike Designation. 11Chapter 2: Health Center Program Oversight . 13Program Oversight . 13Progressive Action Overview . 15Progressive Action Process . 16Immediate Enforcement Actions. 18Program Compliance and Application Review and Selection. 19Chapter 3: Needs Assessment. 21Authority . 21Requirements. 21Demonstrating Compliance . 21Related Considerations. 22Chapter 4: Required and Additional Health Services. 24Authority . 24Requirements. 24Demonstrating Compliance . 24Related Considerations. 26Chapter 5: Clinical Staffing. 28Authority . 28Requirements. 282
Health Center Program Compliance ManualDemonstrating Compliance . 28Related Considerations. 30Chapter 6: Accessible Locations and Hours of Operation . 32Authority . 32Requirements. 32Demonstrating Compliance . 32Related Considerations. 33Chapter 7: Coverage for Medical Emergencies During and After Hours . 34Authority . 34Requirements. 34Demonstrating Compliance . 34Related Considerations. 35Chapter 8: Continuity of Care and Hospital Admitting . 36Authority . 36Requirements. 36Demonstrating Compliance . 36Related Considerations. 37Chapter 9: Sliding Fee Discount Program. 38Authority . 38Requirements. 38Demonstrating Compliance . 38Related Considerations. 41Chapter 10: Quality Improvement/Assurance . 43Authority . 43Requirements. 43Demonstrating Compliance . 43Related Considerations. 45Chapter 11: Key Management Staff . 46Authority . 46Requirements. 46Demonstrating Compliance . 46Related Considerations. 47Chapter 12: Contracts and Subawards . 493
Health Center Program Compliance ManualAuthority . 49Requirements. 49Contracts: Procurement and Monitoring . 49Subawards: Monitoring and Management. 51Demonstrating Compliance . 52Contracts: Procurement and Monitoring . 52Subawards: Monitoring and Management. 53Related Considerations. 54Chapter 13: Conflict of Interest. 56Authority . 56Requirements. 56Demonstrating Compliance . 56Related Considerations. 58Chapter 14: Collaborative Relationships . 59Authority . 59Requirements. 59Demonstrating Compliance . 59Related Considerations. 60Chapter 15: Financial Management and Accounting Systems . 61Authority . 61Requirements. 61Demonstrating Compliance . 62Related Considerations. 63Chapter 16: Billing and Collections. 65Authority . 65Requirements. 65Demonstrating Compliance . 65Related Considerations. 67Chapter 17: Budget. 69Authority . 69Requirements. 69Demonstrating Compliance . 69Related Considerations. 704
Health Center Program Compliance ManualChapter 18: Program Monitoring and Data Reporting Systems . 71Authority . 71Requirements. 71Demonstrating Compliance . 71Related Considerations. 72Chapter 19: Board Authority. 73Authority . 73Requirements. 73Demonstrating Compliance . 75Related Considerations. 77Chapter 20: Board Composition . 78Authority . 78Requirements, . 78Demonstrating Compliance . 79Related Considerations. 82Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements . 84Authority . 84Requirements. 84Demonstrating Compliance . 85Credentialing and Privileging / Quality Improvement and Quality Assurance. 85Risk Management . 85Claims Management . 86Related Considerations. 87Appendix A: Health Center Program Non-Regulatory Policy Issuances That Remain in Effect 88Glossary . 895
Health Center Program Compliance ManualIntroductionApplicabilityThis Health Center Program Compliance Manual (“Compliance Manual”) applies to all healthcenters that apply for 1 or receive Federal award funds under the Health Center Programauthorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b) (“section330”), as amended (including sections 330(e), (g), (h), and (i)), as well as subrecipientorganizations 2 and Health Center Program look-alikes. Look-alikes do not receive Federalfunding under section 330 of the PHS Act; however, to receive look-alike designation andassociated Federal benefits, look-alikes must meet the Health Center Program requirements. 3For the purposes of this document, the term “health center” refers to entities that apply for orreceive a Federal award under section 330 of the PHS Act (including section 330 (e), (g), (h) and(i)), section 330 subrecipients, and organizations designated as look-alikes.This Compliance Manual does not apply to activities conducted outside of a health center’sHealth Resources and Services Administration (HRSA)-approved scope of project.4PurposeThe purpose of the Compliance Manual is to provide a consolidated resource to assist healthcenters in understanding and demonstrating compliance with Health Center Programrequirements. The Compliance Manual also addresses HRSA’s approach to determiningeligibility for and exercising oversight over the Health Center Program and details therequirements for obtaining deemed PHS employee status under section 224 (g)-(n) and (q) ofthe PHS Act.5The Compliance Manual identifies requirements found in the Health Center Program’sauthorizing legislation and implementing regulations, as well as certain applicable grantsregulations.6 These requirements form the foundation of the Health Center Program andsupport the core mission of this innovative and successful model of primary care. TheCompliance Manual does not provide guidance on requirements in areas beyond Health CenterNotices of Funding Opportunity (NOFOs) may include specified timelines for new awardees to demonstratecompliance with the requirements specified in this Manual following receipt of the Federal Health Center Programaward.242 U.S.C. 1395x(aa)(4)(A)(ii) and 42 U.S.C. 1396d(l)(2)(B)(ii).3Sections 1861(aa)(4)(B) and 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(4)(B) and 42 U.S.C.1396d(l)(2)(B)(iii)).4See .html for more information on scope of project.5Health Center FTCA Medical Malpractice Program procedures and information, as set forth in the FTCA HealthCenter Policy Manual, are not superseded by this Manual. See Appendix A for additional policy issuances whichremain in effect.6Section 330 of the PHS Act (42 U.S.C. §254b), as amended, 42 CFR Part 51c and 42 CFR Part 56 for Communityand Migrant Health Centers, respectively, and 45 CFR Part 75.16
Health Center Program Compliance ManualProgram requirements or outside HRSA’s oversight authority. In addition, the ComplianceManual is not intended to address best or promising practices or performance improvementstrategies that may support effective operations or organizational excellence.Health Center Program non-regulatory policy issuances that remain in effect after release of theCompliance Manual are listed in Appendix A. With the exception of these policies, theCompliance Manual supersedes other previous Health Center Program non-regulatory policyissuances (Policy Information Notices (PINs), Program Assistance Letters (PALs), Regional OfficeMemoranda, Regional Program Guidance memoranda, and other non-regulatory materials)related to Health Center Program compliance or eligibility requirements. In case of any conflictbetween a provision of the Compliance Manual and other HRSA-disseminated non-regulatorymaterials related to compliance and/or eligibility requirements, the provisions of theCompliance Manual
Aug 20, 2018 · Health Center Program Compliance Manual . Introduction . Applicability . This Health Center Program Comp
