compliance and the board

Compliance and the Board

Casie Pauley, MPAProgram Coordinator

Health Center Operations, CPCA 1

19 Key Health Center Program Requirements

Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. §254b)

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Role of a Compliance Program

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Seven Core

Elements of an Effectiv

e Complia

nce Progra

m

1. Written policies,

procedures and

standards of conduct

2. Compliance

program oversight3. Training

& Education

4. Opening the lines of communi-

cation

5. Auditing &

Monitoring

6. Consistent discipline 7.

Corrective actions

Why do we need Compliance?

• Health Care is one of the most regulated industries

• Rising health care costs results in increased

governmental scrutiny

• Government is the biggest payer

• It’s required by governmental agencies

• Risks of non-compliance are great!

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What does it mean to be a Health Center Board Member?

• Fiduciary Duties• Duty of Care• Duty of Loyalty• Duty of Obedience

• Board of Directors Functions and Responsibilities

• Where do you start learning about compliance?

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Governing Board Handbook

• HRSA’s Governing Board Handbook • BPHC designed this handbook as an orientation tool to assist new

members in understanding the structure and responsibilities of a governing board.

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http://bphc.hrsa.gov/technicalassistance/TAResources.aspx?Mode=SubTopicSubResource&STopic=Governance#Governance/Board

Program Requirement 17: Board Authority

• Policy making and monitoring

• Policies reviewed… When and how often? • Has the Board signed off on the revisions?

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Policy Making Process

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Board Considers New Policy

Is this policy in keeping with the mission

statement

NoIs this policy

or action necessary and appropriate?

Is this policy or action

necessary and appropriate?

Yes

No

No

Sufficient to warrant amending

mission statement

Yes

No

Board does not make this policyYesYes

Board makes this policy

Who’s Responsible?

• Long-term goals Day-to day operations• Short-term goals (monitor) Short-term goals (execute)• Personnel policies Staff development• Org. chart Staff hiring• CEO/Director evaluation only Staff evaluations• Staff salaries (budget line item) Staff salary approval• Budget (approves) Budget (develops)• Capitol purchases Maintenance• Major repairs Minor & Emergency repairs• Fees & collections (approves) Fees & Collections

(develops) 10

Who’s Responsible?

Board Oversight Administrator• Long-term goals Day-to day operations• Short-term goals (monitor) Short-term goals (execute)• Personnel policies Staff development• Org. chart Staff hiring• CEO/Director evaluation only Staff evaluations• Staff salaries (budget line item) Staff salary approval• Budget (approves) Budget (develops)• Capitol purchases Maintenance• Major repairs Minor & Emergency repairs• Fees & collections (approves) Fees & Collections

(develops) 11

Your Health Center Bylaws

• Should include:

• Term limits

• How and when board meetings will be conducted

• How board members and officers will be selected

• Duties of corporate officers/executive committee

• Committee Structure

• Description of the board’s relationship with the center’s CEO and

staff 12

The Board’s Role in Strategic Planning

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Program Requirement 17: Board Authority Cont’d

Establishment of general policies for the health center

Holding monthly meetings

Selection/dismissal and performance evaluation of the health

center CEO

Measuring and evaluating the organization’s progress in

meeting its annual and long-term programmatic and financial

goals and developing plans for long-range viability of the

organization

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• Does your board approve the applications related to the

health center project, including grants applications and other

HRSA requests regarding scope of project?

• Does your board approve the annual health center budget and

audit?

• Are these reviews and approvals being documented in the

board meeting minutes? 16

Questions for the Board: Requirement 17

Additional Questions: Requirement 17

• Does the board select the services (beyond those required in law, i.e., “Required Services”) to be provided by the health center, as well as the location and mode of delivery of those services?

• Does the board determine the hours during which services are provided at health center sites, ensuring that these are appropriate and responsive to the community’s needs?

• Are these reviews and approvals documented in the board minutes?

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Quality as Compliance

Where to Start1. Create the Basic Structures2. Evaluate & Determine Priorities3. Select Performance Measures4. Collect Data/Determine a Baseline5. Analyze Data/Evaluate Performance6. Plan & Implement Changes for Improvement 7. Monitor Performance Over Time

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• QI Committee • QI Plan & Health care plan• QI calendar • Clinical practice guidelines• Policies & procedures• Peer review • Chart audits• Patient satisfaction surveys & employee surveys• Tracking systems• Credentialing and privileging• Data sources

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Create the Basic Structures

Internal Monitoring

• Major Risk Areas• False Claims Act• HIPAA and HITECH Act• Grant Requirements• Anti-Kickback Act• Stark Act• Workplace Safety Laws• Employment Laws

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External Monitoring

Who Investigates?• OIG - Office of the Inspector General• OCR – Office for Civil Rights• HRSA/BPHC – Health Resources and Services

Administration/Bureau of Primary Health Care• State Privacy • CDPH – licensed clinics and facilities• Licensing boards – licensed professionals• CA Attorney – unlicensed individuals (e.g., MAs)• District Attorney • Federal Tort Claims Act (FTCA)

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Program Requirement 18: Board Composition

• 51% of Board members must be consumers• Must be representative of the individuals being served by the

health center • Must have between 9 and 25 members• Bylaws must specify a range or specific number• Non-consumer board members must be representative of the

community in which the health center’s service area is located• No more than one half (50%) of the non-consumer board

members may derive more than 10% of their annual income from the health care industry 23

Program Requirement 19: Conflict of Interest

• Bylaws should include provisions that prohibit conflict of interest.• Written standards of conduct • Board and Employee conflicts• Gratuities • Disciplinary Actions• Family Members• CEO/ED not a voting member

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What should the board do? Ask Questions

• How is your compliance program structured? Who is responsible? • Does the compliance committee report to the board?

How frequently? • What are the goals of the compliance program? • How are compliance risks determined?• How are compliance risks reported to the board? • Is there a code of conduct for the organization? • What compliance related training and education is

provided? 25

Additional Questions the Board Should be Asking

• Is your budget in line for this period? • Where are you on your strategic plan?• Do you receive Board packets and meeting minutes?• Do you see the Quality Meeting minutes?• Do you receive data on patient complaints?• Do you see productivity data?• Are you documenting major actions and decisions made

by the board?

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Policy Information Notice (PIN) 2014-01

• Health Center Program Governance PIN• Key clarity points• Structure and functioning of boards• Requirements for public centers under co-applicant

arrangements• Waiver for the 51% patient majority for eligible 330

grantees and lookalikes • Elimination of the waiver consideration for monthly

meeting requirement27

Resources

• New Governance PIN 2014-01http://bphc.hrsa.gov/policiesregulations/policies/pin201401.pdf

• Governance Overviewhttp://bphc.hrsa.gov/policiesregulations/governance/index.html

• Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors

https://oig.hhs.gov/fraud/docs/complianceguidance/CorporateResponsibilityFinal%209-4-07.pdf

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CPCAHealth Center Board

Peer Network

• The CPCA Health Center Board Peer Network provides an opportunity for Community Clinic and Health Center board members to be more involved in the organizations for which they govern. Stay up to date on issues impacting health center governance, state-wide policy issues and facilitate sharing with your peers across the state.

• http://www.cpca.org/index.cfm/health-center-resources/peer-networks-workgroups/health-center-board-peer-network/ 29

Questions?

Contact Casie Pauleycpauley@cpca.org

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