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Compliance and the Board. Casie Pauley, MPA Program Coordinator Health Center Operations, CPCA. 19 Key Health Center Program Requirements. Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. §254b). Role of a Compliance Program. - PowerPoint PPT Presentation
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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)
2
4
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!
5
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?
6
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.
7
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?
8
Policy Making Process
9
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
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
15
• 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?
17
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
18
• 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
19
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
20
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)
21
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
24
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?
26
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
28
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