This transcript was exported on Apr 02, 2020 - view latest ... · First off, the HRSA statement from the Pin 2011-01 which was the first FTCA policy manual. Martin J. Bree: ... If

This transcript was exported on Apr 02, 2020 - view latest version here.

National Association of Community Health Centers (Completed 03/19/20)Transcript by Rev.com

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Katja Laepka:

Guests for a nice office hour today. A very warm welcome. I am Katja Laepka, I am the director of clinical training and workforce at NACHC. And on behalf of our entire team, I would like to warmly welcome you to this first office hour of our series of call in office hours for the next few months. And I will be serving as your moderator today.

Katja Laepka:

Today's office hour will be followed by our office hour on resiliency and joy in work next Wednesday, December 19th also at 2:00 P.M. Eastern Time.

Katja Laepka:

And if you have not yet seen information about it, just let us know and we will resend it and include information on the entire series as well.

Katja Laepka:

Our office hours are intended to support the professional development of Health Center clinical leaders like you, and especially in your administrative responsibilities.

Katja Laepka:

The topics covered in our office hours relate directly to the clinical leadership core competencies as supported by your online self assessment, and the development tool in the self directive learning engine, or SDLE in partnership with skill director.

Katja Laepka:

Today's office hour, just like the others in the series, has been developed to specifically address issues identified as a priority training need by you, our SDLE users themselves.

Katja Laepka:

The domain leader in ethical issues shows up continually as among the top training needs and learning gaps to be bridged.

Katja Laepka:

So today's office hour is devoted to these issues, and specifically the competency of guiding the clinical team in actively identifying and addressing general FTCA related issues, and even more specifically, how to prepare for an FTCA type visit.

Katja Laepka:

We are most delighted to have as today's National faculty, our trusted legal counsel, team of Molly Evans and Marty Bree of Feldesman Tucker Leifer, and Fidell.

Katja Laepka:

Following their presentation they will be happy to address any questions and/or concerns you may have.

Katja Laepka:

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To submit your questions, just send them at any time during the presentation or whenever you have it to all participants, we have the Q&A box.

Katja Laepka:

If you could please not use the chat box, that would be great. So Q&A only please, which you should be able to find in the lower right hand corner of your screen. We will answer as many questions and address as many concerns as we can today, and then later provide everyone with answers to questions we can't get to live today via Email.

Katja Laepka:

Thank you very much. And again, welcome. And I'll now turn things over to Molly and Marty. Molly?

Martin J. Bree:

Thank you Katja. This is Marty Bree. And I'm going to be doing the first portion of the training and then I'm going to be turning it over to Molly.

Martin J. Bree:

So here's the first slide we have. It's our typical disclaimer, and we'll move right through that.

Martin J. Bree:

The next two slides are just simply the background of Molly and myself. And then we can get right into the meat of the matter today. This is a one hour office hour. And we probably have three hours of material to get across, so we're going to be talking kind of quickly as we go through this, so we can also have time to answer your questions.

Martin J. Bree:

So today we're going to talk about FTCA site visits. First off, the HRSA statement from the Pin 2011-01 which was the first FTCA policy manual.

Martin J. Bree:

In that HRSA states that they may conduct a site visit at any point during the application review process or as part of it's oversight responsibilities relative to the FTCA program.

Martin J. Bree:

They claim they can also conduct random site visits for any initial applicant or deemed grantee to ensure the implementation of the statute. That's quite a statement.

Martin J. Bree:

HRSA has been conducting numerous FTCA site visits. They're all scheduled. The language of a random site visit shouldn't be construed to mean an unannounced site visit. Site visits are all planned in advance. Now to the next one.

Martin J. Bree:





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HRSA goes on in the manual to state that if a site visit results in a finding of a lack of implementation of the FTCA program requirements, this may be grounds for a negative deeming determination.

Martin J. Bree:

Let's be clear about this right from the beginning. If you've already been deemed for a calendar year, that deeming cannot be taking away, regardless of the findings of a site visit.

Martin J. Bree:

So for example, if you're deemed for calendar year 2018, and during 2018 you have an FTCA site visit that finds some program requirements, your 2018 deeming cannot be taken away. The statutory language says that. However, negative findings in a FTCA site visit could be used in the next year's deeming application. So, while you can't have your deeming taken away from you now, you could lose it in the future if you have significant findings on the FTCA site visit.

Martin J. Bree:

So what are the factors that might prompt the site visit? Well first off, if you're submitting in an initial deeming application, there is a chance that HRSA will want to do a site visit as part of that application process.

Martin J. Bree:

Another reason would be documentation that indicates non-compliance with requirements during the review of your FTCA application.

Martin J. Bree:

Your FTCA application shouldn't be containing information that would indicate you're not compliant with any of the requirements.

Martin J. Bree:

If there have been prior site visit findings perhaps on an operational site visit that are negative, this might trigger an FTCA site visit.

Martin J. Bree:

A history of repeat grant conditions, current grant conditions, could cause an FTCA site visit.

Martin J. Bree:

And finally, a history of medical malpractice claims. And that could be a number of claims, a number of small claims over a period of time, or it could even be just one claim that results in a large payment. But HRSA can use your claims history as a reason to make an FTCA site visit.

Martin J. Bree:

Now when site visitors come to the health center, their purpose is to really assess whether you are meeting the statutory requirements to be deemed. That is, appropriate policies and procedures that would reduce the risk of medical malpractice and lawsuits.





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Martin J. Bree:

That is, do you credential and privilege your clinical staff.

Martin J. Bree:

They also should be checking to see that you have cooperated with the Attorney General in defending any claims, which is another statutory requirement, and that you will take necessary corrective steps to assure against such claims in the future.

Martin J. Bree:

Let's see, that's the requirements of the federally supported Health Center's Act, that you have to meet to be deemed, and that's what your reviewers are going to look at.

Martin J. Bree:

So, what is the process?

Martin J. Bree:

Well, there are a number of pre site visit activities. The first one is the consulting group assigns a Review Team. And you will be informed of who that Review Team is.

Martin J. Bree:

Your Review Team will contact the health center, and they will run through the logistics of the visit and process, and go through the agenda.

Martin J. Bree:

They're going to ask for data and information, and you're going to have to submit to them documents. They will be specific about what documents they require ahead of time, and what documents they want available on site.

Martin J. Bree:

The Review Team will then do a preliminary analysis of the documents. Those documents that you've sent to them ahead of time, they're going to review them and probably have questions about them when they arrive.

Martin J. Bree:

Upon arrival, the first activity is the entrance interview. At that point that Review Team is going to provide an overview of their assessment and what they're going to be doing. And it's at that point when you have the opportunity to provide an overview of the organization.

Martin J. Bree:

This is an important opportunity for you to show the Review Team all of the positive aspects of your health center, all of the success stories you've had. During this overview that you're going to give them of your organization, and you can probably talk about your quality assurance program.

Martin J. Bree:





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It's important for example to give them specific examples of successes around quality improvement, how you've actually improved quality. So they can start off the review with a positive perspective on the health center.

Martin J. Bree:

The Review Team is going to want to visit one or more sites. Typically they'll settle in at your administrative location, because that's where most of the documentation that they're going to need to review will be located. But they will want to go to a clinical site, and they will want to conduct assessments of documents there, interviews with the staff and board members in order to determine compliance.

Martin J. Bree:

The interviews that they're going to be doing with your staff and your board members can be critical. So it's very important that the individuals that they get to interview are knowledgeable about the program, the FTCA program, and are knowledgeable about the area that they're being interviewed for.

Martin J. Bree:

When it comes to board members, again there's another area where we're going to have to make certain that our board members who are interviewed, are knowledgeable about the FTCA program, are knowledgeable about it's requirements, about your QA program, about your risk management activity.

Martin J. Bree:

It maybe that the site visiting will want to meet with all the board members, in which case you're going to have to make sure that your board has been well versed and trained in essence in the FTCA program.

Martin J. Bree:

At the end of the site visit, there will be an exit interview where the Review Team will be discussing their findings with you. And you have the ability at that point in time to ask questions.

Martin J. Bree:

It's very important that you clearly understand any findings that the Review Team has.

Martin J. Bree:

Don't let the Review Team go away without you clearly understanding any negative findings that they're going to report. This is your last real chance to actually talk with the Review Team.

Martin J. Bree:

So (silence)... Okay, there we go. Post-site visit activities.

Martin J. Bree:

So after the site visit the Review Team is going to draft a site visit action plan. That's basically a report that gets sent to the health center, and you have a period of time in which to respond to the findings of non-compliance.





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Martin J. Bree:

These findings, it is possible that these findings could end up causing conditions on your grant award. So it's very important to take the findings of the FTCA site visits seriously and respond within the appropriate timelines that HRSA has set out.

Martin J. Bree:

Now, preparing for the site visit. Now first off, you're going to want to prepare management staff and board members.

Martin J. Bree:

You want to make sure everybody has the same understanding regarding the health center's FTCA program. And you want to also identify point persons for each area that the review team is going to review.

Martin J. Bree:

Don't assume Review Team members are experts about your health center, about your community, about your operations, because they probably will not be.

Martin J. Bree:

Don't assume that the Review Team is knowledgeable about the FTCA program. And definitely do not ask Review Team members about coverage under the FTCA program.

Martin J. Bree:

Too many times a heath center will ask as an aside a Review Team member if this activity is covered. And the likelihood of getting a correct answer is low, okay.

Martin J. Bree:

Our Review Team members are not experts in the FTCA program, and they're not expected to be experts in the program. So it's best not to ask technical questions about the FTCA program to them.

Martin J. Bree:

We talked about the entrance conference and how important it is to highlight your current strengths and your future plans.

Martin J. Bree:

You should prior to the site visit review the statute 42 U.S.C. 233. And then you should review the FTCA policy manual. And the most recent deeming PAL, or program assistance letter.

Martin J. Bree:

Right now the most recent one, I believe, is 2018-02.

Martin J. Bree:

Each functional area of the health center should review the appropriate sections of the manual, and it's requirements.





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Martin J. Bree:

And this should include all of your staff members, not just the top management folks.Because the Review Team is going to have the opportunity to speak to staff members. We want to make sure our staff members have a good understanding of the FTCA program.

Martin J. Bree:

Certain important point when you prepare for the site visit is to ensure that you meet the deadlines for sending documents to the Review Team. It's not good form to be late with the documents to the Review Team when this is the group of individuals that's going to be taking a hard look at your operations.

Martin J. Bree:

So it's best to start off on the right foot with them, and make sure you get what they asked for to them in a timely fashion.

Martin J. Bree:

And with that, I'm going to turn it over to Molly.

Molly Evans:

Thank you Marty. What we have here is a list of the documents that we've seen in past FTCA site visits. In health centers that we've worked with, we've collected a list.

Molly Evans:

This list is... I have to say that it changes from time to time based on the reviews that we've seen.

Molly Evans:

One of the things that I think is somewhat frustrating for our health centers is, unlike the operation site visit, there is no FTCA site visit protocol that describes for you the documents that you need to have available for reviewers to look at, and or documents that you need to present ahead of time, or on site, etc.

Molly Evans:

This is a list that you eventually get once you learn that you have an FTCA site visit. But for continuous compliance efforts and making sure that you have these things in place regardless of whether or not you have an FTCA site visit on your horizon, that is something that we would hope that HRSA would put into place eventually, to allow you to know what the expectations are.

Molly Evans:

By the same, not only are the documents not available ahead of time, but also just the understanding of what the evaluation looks like. It feels more difficult to find out what that might be.

Molly Evans:

So to ease that burden somewhat, we've included here a list of the documents that you might expect to have requested from you by FTCA reviewers. The documents mimic the four areas that are evaluated as





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part of the FTCA deeming application. And that is Risk Management, Quality Improvement, Credentialing Privileging, and Claims Management.

Molly Evans:

Just as an aside, the two areas of quality and credentialing privileging are subjects that also appear as part of the operational site visit review, and are 330 grant requirements.

Molly Evans:

And so when you have reviews, when you have your 330 operational site visit, you are reviewed very similarly on the topics of quality and credentialing and privileging. And those are chapters 10 for quality, and chapter five of the compliance manual.

Molly Evans:

In terms of risk management and claims management, you can find those in chapter 21 of the compliance manual, and then the corresponding pieces of the operational site visit, site visit protocol, and that can give you some indication of the kinds of things you should have in place for something like this, in terms of an FTCA site visit.

Molly Evans:

Beyond that, we have these document lists. And as the document lists are laid out much like that deeming application section. So the first one being risk management and medical record policies and procedures.

Molly Evans:

You'll see we have those listed here on slide 14. And a lot of them should look familiar to you based on what you have submitted as part of your FTCA deeming application.

Molly Evans:

For example, in the FTCA deeming application you or the chief executive officer or executive director of your health center would have attested to the fact that your health center has a risk management policy and operating procedure, that it presents a risk management report to the governing board, that it conducts quarterly risk management assessments.

Molly Evans:

As well as some of the other policies we see listed here, like a medical record retention policy, an adverse occurrence policy, polices and procedures around infection control, things related to patient satisfaction.

Molly Evans:

Although interestingly, patient satisfaction shows up in the QI section of the compliance manual in the site visit protocol.

Molly Evans:





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But you will see this gives you a good flavor for the kinds of risk management policies and procedures that you would want to have available for reviewers.

Molly Evans:

And to the extent that you don't have an FTCA site visit planned, it's something that you can work towards in terms of a work plan of being in compliance and making sure that you have all of these pieces available.

Molly Evans:

Another piece of the puzzle that's a little bit frustrating is that there are no definitions of what HRSA expects as to these policies.

Molly Evans:

So that can get frustrating as well, because you may be looking for more guidance around that.

Molly Evans:

For example, I see we have a question about what is a medical records retention policy? And that's a great question, and especially in today's day and age where everyone is likely using an electronic medical record.

Molly Evans:

You might have had more of a medical records retention policy when you were on paper records and you described how long you retained records and when you destroyed them, if at all. But in today's environment that is different obviously, because we have electronic medical records.

Molly Evans:

So to satisfy that request I would say perhaps an archiving procedure around medical records.

Molly Evans:

If you have a patient that hasn't been to the health center in many years, is that record archived, or does it just exist in the electronic medical records?

Molly Evans:

I think that there is some flexibility in terms of what that might look like based on how your electronic medical works. But my educated guess is that, that really refers to a time when we were dealing with paper records.

Molly Evans:

To the extent that HRSA publishes more information around that, that will be wonderful, and we will be happy to comply with whatever that is.

Molly Evans:

Other policies that should be available around risk management, are policies around referral tracking, hospitalization tracking, and diagnostic tracking.





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Molly Evans:

Again, these are policies that the health center had to submit, and specifically had to upload as part of it's deeming application. So to the extent that you or the person trying to bring your health center to compliance in anticipation of an FTCA site visit, it's important to take a look at that deeming application in it's entirety, and make sure that it really reflects what the health center's actual operations are.

Molly Evans:

And things like these policies will be very important to demonstrate that you can operationalize them, and that they actually reflect the practice of the health center.

Molly Evans:

And that's why you see here for example under specialty of referral tracking, you will see that a log is also required to really demonstrate what that referral tracking looks like.

Molly Evans:

A lot of health centers that we work with will say to me that, "Well we have don't have a log, because this is all done through reporting in our electronic medical record." And I think that, that's totally sufficient. It's just a matter of being able to reflect how referrals are tracked within the health center, and that you have a mechanism in place to identify referral tracking so that you know that people aren't falling through the cracks or lost to care. And that's really the impetus behind that piece.

Molly Evans:

And you'll see again hospital tracking logs and diagnostic tracking logs are really the same sort of mentality in terms of ensuring that whatever you've said in your policy can actually be reflected in the practice.

Molly Evans:

And that's really what the FTCA site visit is in general, is terms of an evaluation of what the actual practice is at the health center, and doesn't reflect what you advise the federal government in your deeming application.

Molly Evans:

And you will see some of the other risk management policies here that you might be asked to provide in one of these reviews.

Molly Evans:

In addition to that, there are requirements around training.

Molly Evans:

Again, those come out of the deeming application as well, and there's an expectation that you have risk management training for all staff and for the governing board that is reflected in the deeming application.

Molly Evans:





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And specifically the deeming application contemplates risk management training around infection control, OBGYN, and HIPPA.

Molly Evans:

So pulling together information and evidence of risk management training documentation, as well as evidence of those trainings in terms of, if you have a learning management system, a way to demonstrate that your staff has taken the training. Or if you do it the old fashioned way and have sign-in sheets and agendas. That's totally acceptable as well.

Molly Evans:

Onto quality improvement and quality assurance, as I said earlier, quality and credentialing privileging are two areas of focus that also have an overlap in the 330 world.

Molly Evans:

Because of that, to the extent that you have an FTCA site visit where there are findings around quality or credentialing privileging, the reviewers do have the ability to give you a grant condition around those two areas, where they don't have that flexibility around risk management and claims management.

Molly Evans:

And again, that's because those two relate to requirements you have around your 330 grant. So thinking through that is also important.

Molly Evans:

You'll see that the QI plan and QI meeting minutes have always been an emphasis of what the expectation around QI are, and they are again here. And you'll see that reflected here.

Molly Evans:

As well as some of the other documents that you might have, governing documents at the health center, as well as grant related documents like your form 5A, B, and C.

Molly Evans:

Additionally, information around the clinical guidelines that are used at the health center, and clinical practice standards that you may have, whether or not you ask your providers to utilize a service up to date to identify guidelines, or you identify guidelines of certain accreditation organizations, or other organizations.

Molly Evans:

For example, in OB using ACOG's standards. Or the American Academy of Pediatrics standards for PEDS. Those sorts of things, identifying those guidelines and demonstrating that your providers are aware of what the health center's expectations are around clinical practice guidelines.

Molly Evans:

And you will see again that the protocols, there is an expectation that those guidelines and protocols are updated every, at least every three years.





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Molly Evans:

What's interesting to note about that, I will say the word requirement in quotations, is that you don't find that anywhere in the deeming application or the compliance manual.

Molly Evans:

So it shows up here in the document request list, which makes it challenging to know that you need to do that until you have a site visit in your future. Hopefully this presentation allows you to know that now, that that maybe an expectation.

Molly Evans:

Sample performance reports presented to the QI board and other minutes are also a component of the document evaluation, as well as your UDS report.

Molly Evans:

Onto credentialing privileging. With respect to this, provision in terms of the documents that reviewers will want to see. They will ask for your credentialing policies and procedures, credentialing privileging policies and procedures, as well as the underlying credentialing privileging files themselves.

Molly Evans:

It is my understanding that unlike the OSV where the health center has the opportunity to present certain files for it's various provider types, in other words four to five files for license independent practitioners, and four to five files for other licensed and certified practitioners, and two to three files for other clinical staff.

Molly Evans:

In this case, it's my understanding that the reviewers will pick the files themselves, based on the list that you provide them. You will see the list is number one on the slide.

Molly Evans:

So something to be aware of is the distinction between this review and the review that you may have in an OSV.

Molly Evans:

And then also this emphasis on peer review procedures, where you don't necessarily see guidance around what the expectations are around peer review at HRSA. And peer review is not even really mentioned as part of the compliance manual.

Molly Evans:

However, we have that here again, as an expectation as part of credentialing privileging. And that's certainly something that we've had in place for some time, where we've know that there's an emphasis on HRSA's part about that in terms of how that works, and the fact that they want to be able to do that.

Molly Evans:





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Onto the next slide. Some other documentation that is an expectation of the credentialing privileging pieces are documentation of the governing board or designee that has approved the credentialing and privileging of the providers.

Molly Evans:

Note that when PIN 2002-22 was superseded by the compliance manual, there is no current requirement that the governing board approves the privileges and credentials of the licensed independent practitioners.

Molly Evans:

The health center can determine who has that role at the health center. And so that is a change. But a lot of health centers that we work with keep that role at the level of the board, because the board wants to know what that is, and how that might work. So important to be aware of that.

Molly Evans:

So you will see that as part of the credentialing and privileging pieces.

Molly Evans:

Onto claims management. Again, remember the corollary on the 330 side is chapter 21 on claims management.

Molly Evans:

So to the extent you have a finding in claims management or in risk management, the likely outcome is corrective action that you have to do in a period of time, but does not draw a grant condition because there is no overlap with 330.

Molly Evans:

So on the claims management side there is an expectation that you have a policy and procedure around claims management and how you handle, analyze, and track claims.

Molly Evans:

Documents showing evidence that you inform your patients using plain language, that you are a deemed public health service employee.

Molly Evans:

And that means basically that they want you to tell your patients that you have FTCA coverage, and that they need to file an administrative claim in order to recover money damages, rather than filing a lawsuit in court. And that is what we see as the expectation around that.

Molly Evans:

The actual language that the Feds want to see, or an example of it, actually can be found in the deeming application itself. So if you have not included that language on your website and otherwise, it might be a good idea to take a look at that language within the deeming application and make sure that that is available both on your website, and then otherwise in your materials.





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Molly Evans:

And then finally, the reviewers may ask to see the claims files for claims that you have in the health center.

Molly Evans:

In the health centers that I've worked with, and the in the site visits that I've participated in, I haven't seen a heavy emphasis on the actual claims files. But there is an expectation that the health center is evaluating it's claims, it's staying on top of it's claims, it's assisting in the defense of the claims on an ongoing basis. And that it's to the extent that if it has certain trends, like it has several claims of the same sort and type, that it's trending that information and then figuring out if there's something, some sort of additional education that would need to go on or otherwise in order to improve x, y, or z process.

Molly Evans:

For example if you had three claims that revolved around referral tracking, there would potentially be an expectation from reviewers that you could identify what you were doing to make a change and improve things based on that, so that you didn't have more once you were aware of an issue at the health center, that you addressed it.

Molly Evans:

Professional liability is the same as the claims management in terms of the policies around tracking.

Molly Evans:

And then if the Feds want to know if you have an accreditation from direct commission or AAAHC, or if you're PCMH recognized, that's something that reviewers would want to know, I think to demonstrate that you already are accredited by organizations that evaluate you. That gives you some good credence in terms of your ability to be successful on one of these sorts of reviews.

Molly Evans:

In terms of the agenda. Again, and this is based on what we have seen in the health centers that we've worked with.

Molly Evans:

The agenda is very similar to an OSV agenda. And it is long for this program, which is obviously much smaller than the 93 or 95 compliance elements that are assessed in the OSV. It's still a two and a half day visit.

Molly Evans:

And you'll see the agenda here in terms of what it looks like.

Molly Evans:

It looks very similar to the extent that it includes an entrance conference, a tour of the facility, which does involve interviewing staff members.

Molly Evans:





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So consider in the anticipation of a site visit that you might prepare either a PCMH team or some group of providers at your health center to speak to reviewers in a way.

Molly Evans:

And when Marty was talking at the outset about preparing staff, to the extent that you're going to have some frontline staff meet with reviewers or talk to them during the facility tour. It's a good idea to remind them about the purpose of this review and what they might be asked about things, like referral tracking, hospitalization tracking, diagnostic tracking, and also the kind of training that they might receive.

Molly Evans:

The visit goes on with a lot of review of documents, and interviews with staff and the board. The board is also interviewed much like in the OSV. And that's something that health centers should prepare for, and prepare their boards for.

Molly Evans:

And then, much like the OSV there is an exit conference where the findings are discussed, and then you would receive a site visit report, or a site visit action plan from the Feds.

Molly Evans:

Just anecdotally, I'm looking at a site visit report from the health center for a site visit that was conducted in early September.

Molly Evans:

They received it back from the Federal Government at the very, very end of November, and they have to produce all of their corrective action items, which are not an insignificant list, by the beginning of January.

Molly Evans:

So that sort of gives you a look at what a timeline might be in terms of how long it takes to hear back in a site visit report, and when your turnaround time might be.

Molly Evans:

Presumably you can learn in your exit conference some of the areas that you're going to need to change so that you have some running room beyond after the receipt of the site visit report, in order to make those changes.

Molly Evans:

But that's what we've seen at least most recently.

Molly Evans:

During the site visits, always, and I think Marty mentioned this earlier, always important to put your best foot forward. And don't assume that you're going to get the benefit of the doubt.





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Molly Evans:

And while the review has an aspect of technical assistance to it, that doesn't mean that staff should feel free to lay out all of their concerns about the health center while the review team is on site.

Molly Evans:

And sometimes when you have staff members that are not normally participants in other sorts of audits, participating in this review much like your board and otherwise, that's an important reminder for people about the purpose of the review, and what the expectation might be of what they do during it.

Molly Evans:

There is always an opportunity to ask question of the review team while they're on site, as well as asking if there is another way to satisfy a requirement. If you don't have exactly what they might be looking for perse, are there other ways to ask the review team if there's another way to accomplish something, such that you could demonstrate it through another type of document or otherwise.

Molly Evans:

There is always some room. Because there is not very much guidance about what the expectations are around these certain pieces, that does give you some more flexibility about how you might demonstrate compliance with a particular requirement. So don't underestimate the ability to try to work through that in a way that might make sense.

Molly Evans:

And then making sure that you are ready for the review should go without saying, but may not always be obvious about how important that is. Such that, reviewers are not going on a scavenger hunt through the health center for information. Because that always... Not always, but can lead to additional concerns that you might not have otherwise faced if you had had everything ready for reviewers when they came on site.

Molly Evans:

And so these points are pretty, I should say, straightforward and not surprising, but worth discussing with staff members and thinking about before a review.

Molly Evans:

Then finally, making sure that staff members know to answer the questions that they are asked. And then not really expound beyond that.

Molly Evans:

When we talk to health center providers and staff members when they're going to testify in court, I think about it much the same way, or testify in a deposition. You answer the question that was asked. You don't need to expound beyond that. And it's certainly not a time to talk about all of your concerns about the various issues that you might have at the health center.

Molly Evans:





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Certainly you can receive good technical assistance from reviewers, many of whom have a lot of great qualifications and experience. But it's really only focusing on the question that was asked, or the requirement that is being evaluated and not going beyond that into other areas, and keeping your review team on task in that way as well.

Molly Evans:

And with that I will turn it back over to Marty to talk about some of the findings that we've seen in the health centers we work with.

Martin J. Bree:

Thank you, Molly. That was very interesting information. So let's talk a little bit about some of the findings that we see come out of the FTCA site visits.

Martin J. Bree:

The first area we'll look at is the area of credentialing and privileging. We've seen on a number of occasions that there has been a finding of lack of board involvement of an oversight of the privileging and credentialing program.

Martin J. Bree:

It's important to note that there has been a change in HRSA policy regarding the board's involvement with credentialing and privileging.

Martin J. Bree:

HRSA is now very clear that the governing board does not have to approve the privileges that are granted to clinical staff; that the governing board can delegate that to whomever they choose.

Martin J. Bree:

So if there is a temp on a review team member to create a finding around the board's failure to privilege... approve the individual privileges of providers, I think it's important to push back a little bit on that finding, and point out that HRSA's policy, which is in chapter five of the operational site, of the requirements manual in chapter five under staffing, that it's clear in that document that the board does not have to approve privileges. So we need to make sure that that's not becoming a finding for us.

Martin J. Bree:

That doesn't mean that you cannot have your board approve privileges, it's just that it's your choice.

Martin J. Bree:

Another credentialing and privileging finding that we see a lot is the failure to use peer review as part of the privileging process.

Martin J. Bree:

HRSA requires that we do peer review. They don't tell us much beyond that, except that we've got to use the results of peer review in the privileging process. So and that tops up as a finding on occasion. So you've got to be able to show how that's done.





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Martin J. Bree:

Another finding, and it's one that we see frequently, is missing documents in the credentialing and privileging files.

Martin J. Bree:

The review team is going to sit down and go through a large number of your HR or credentialing and privileging files, whatever you call them, to see if in fact you've got all the appropriate documents in there that you claim you check on.

Martin J. Bree:

If they look in that file and they don't find a copy of a government issued ID, they're going to have a finding.

Martin J. Bree:

If they go into the credentialing and privileging file and it's disorganized and it's difficult for them to find documents, that's going to be a problem and could end up with a finding on the report.

Martin J. Bree:

So you want to make certain that your files, that relate to the credentialing and privileging of your staff, are in order. It should be easy for reviewers to find those documents that they are looking for.

Martin J. Bree:

Let's go ahead now to resources that are available to you. HRSA has published on their website something called a credentialing and privileging file review resource. And this is a document that's supposed to assist you in implementing the credentialing and privileging procedures, and gives you some common examples of documentation methods and sources.

Martin J. Bree:

So if you go to the HRSA website, you can find that document. If you have trouble finding it, which sometimes happens on the HRSA website, you can email us and we will get you a copy of that document.

Martin J. Bree:

Okay, let's move on. Another example of a resource available to you is with the ECRI Institute. This is an organization that HRSA contracts with to give you access through the internet to their resources, and have a lot of resources related to quality assurance and risk management and those areas.

Martin J. Bree:

So ECRI or E-C-R-I like some people call it, they have available one of the documents, a guide for preparing files for an FTCA site visit. You might find that helpful.

Martin J. Bree:





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In the arena of quality improvement and quality assurance, we've seen findings of failure to have a QI/QA plans with specific clinical measures. You can forget the business plan portion of that, that has changed now. And unfortunately we're negligent and have not changed the slide.

Martin J. Bree:

Another problem area we see is the failure to have the QI committee meeting minutes for specific information on PDSA processes. And not enough detail in some kind of a PDA or process that you use in your QA program.

Martin J. Bree:

Third area of concern is that board minutes don't reflect discussion of QI activity.

Martin J. Bree:

We've seen many times where the board in fact discussed QI activities in some detail, yet the information didn't get into the board minutes.

Martin J. Bree:

You kind of have to be careful about how you write the board minutes. Too much detail in the board minutes is not really advisable. But when it comes to your QI program, you might want to have a little more detail than you normally would in other sections of your board minutes, okay, to avoid this kind of a finding.

Martin J. Bree:

We see findings around failure to conduct peer review appropriately. And that's a bit problematic, because HRSA has not provided us with any guidance on what is acceptable in conducting peer review.

Martin J. Bree:

So you know, we're kind of stuck between a rock and a hard place on that one, when you find that reviewer says you're not doing it appropriately.

Martin J. Bree:

Risk management findings. There is one finding there's no review of claims as they come in. As claims occur, the health center doesn't review them. And that is a requirement.

Martin J. Bree:

Failure to inform the board of claims. HRSA wants the governing board to know about claims and suits filed against the health center.

Martin J. Bree:

You don't have to give the governing board a whole lot of information about the claims, just simply that a claim was filed and it's current status, and that should be enough.

Martin J. Bree:





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Issues with diagnostic tracking and hospitalization tracking. These are problems that pop up. They pop up on FTCA site visits. They pop up on deeming applications.

Martin J. Bree:

One way of dealing with those kinds of issues is to take a look at a document that HRSA published most recently in 2017, which they call the FTCA deeming application evaluation self checklist.

Martin J. Bree:

If you can't find that on their website, send us an email and we will get it to you.

Martin J. Bree:

It's a document that shows specifically what they expect to find in a diagnostic tracking policy, a hospitalization tracking policy, and a referral tracking policy.

Martin J. Bree:

So you can go and you can take a look at the specific items they expect to see, and of course walk that with your policy to make sure you're hitting on all the items they want.

Martin J. Bree:

I'll point out to you that the credentialing information in that self checklist is not up to date, so we don't rely on that. Unfortunately HRSA has not published a new self checklist since they made the changes to their credentialing requirements.

Martin J. Bree:

Okay. We see a finding around no organized system to analyze claims in order to identify training needs.

Martin J. Bree:

And one that's easy to catch if you don't do it is no tracking that demonstrates provider attendance at risk management training. So you need a system to keep track of training, that your clinical staff has risk management training.

Martin J. Bree:

All right. Failure to notify patients about your FTCA deemed status. While that's not a statutory requirement, HRSA wants you to have a notice on your homepage of your website about the limitations or reliability created by your FTCA status. Okay, so that's one you need to comply with.

Martin J. Bree:

Let's see what else we have here... no process for clinical review of claims. We discussed that a little earlier, so. Those are the risk management findings.

Martin J. Bree:

So now we have about seven minutes left for questions. Did we have any that we need to address immediately?





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Katja Laepka:

Yeah, thank you Marty.

Molly Evans:

Oh sorry!

Katja Laepka:

As you mentioned-

Molly Evans:

Oh sorry. Katja go ahead.

Katja Laepka:

Oh no problem. Marty, thank you for your excellent presentation. We do have one question that came in so far, and everyone please feel free to submit your questions in the Q&A box. You can also raise your hand and we can unmute your line so you can ask us if you prefer.

Katja Laepka:

The one question we have so far is, what triggers an FTCA site visit? How often does HRSA conduct FTCA site visits? And are FTCA site visits done in lieu of operational site visits, because they very much look like operational site visits?

Molly Evans:

Those are great questions. I'll make sure that I answer all of them. I'll go backwards.

Molly Evans:

They are not in lieu of an operational site visit, but you're absolutely right that they have some of the same things that you would have at an operational site visit. However, they're different. They're run by a different part of the bureau, namely the FTCA branch.

Molly Evans:

It is my understanding in communications with members of the team there that there is no plan to eliminate them. In fact, from our perspective it seems like they have ramped up this year. And we hear a lot more health centers that we work with that have had them.

Molly Evans:

In terms of what triggers them, they can be random. They can be if you are going for your initial deeming, if you have a large number of medical malpractice cases, if there is concern on the review of your deeming application. If there is concern on your OSV, if there is concern on your 330 application.

Molly Evans:

So there are a variety of reasons, but there is no... it's not clear that every health center will have one. And that makes it different from an OSV where you can have an expectation that you will have one





Page 22 of 23

every 18 months. In this case, you may go years without having one, or you may be a health center that has had more than one. And we haven't been able to find a lot of rhyme or reason in them.

Molly Evans:

And I think I answered all those questions, but Katja if I missed one, let me know.

Katja Laepka:

Thank you, Molly. Yeah we hope that comprehensive answer was helpful, but let us know if we missed anything.

Katja Laepka:

There is another question that came in, also a multi-tier question. Did I hear it correctly that HRSA may change policy in that they would only need to approve credentialing but not privileging? Can BOD delegate privileging to staff?

Martin J. Bree:

The board of directors does not have to privilege providers. The board of directors can... actually the language that HRSA uses, they say the health center determines who approves privileges. So the health center can determine that it's the medical director if the health center chooses.

Katja Laepka:

Okay, thank you Marty.

Martin J. Bree:

And as far as credentialing, let me, approval of credentialing. We don't really approve credentials. We affirm them. We affirm that what the individual clinic claims they've accomplished in education and training is in fact true, that they have the degree that they claim they have, they have the DEA certification that they claim they have, etc.

Martin J. Bree:

Once we determine that all those things are correct, and they really are the person they say they are, then you go to the privileging process, and that's where you grant them the right to provide those particular services to your patients.

Katja Laepka:

Okay, thank you. We are almost out of time so we will need to wrap things up. But please keep your questions coming, we will keep checking here for the next few minutes. Also you can Email us your questions if you think of them after this presentation, after this office hour, if you are integrating the information and applying what you learned today. Just let us know anytime please, and we will answer your questions or as Marty and Molly said, excuse me, send you the resources that they researched. So if you can't find them yourselves, just let us know. We are here for you.

Katja Laepka:





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You will receive a presentation of the presentation, the slides. Many of you have asked. After this office hour we will send them out to you.

Katja Laepka:

And also, those of you who are SDLE users, this office hour, the recording of it will be mapped as a resource activity so you can use it in your personal development plan at any time.

Katja Laepka:

And along those lines, an important reminder. Please, because as you know professional development itself is an ongoing journey rather than a one time event, we very much encourage you kindly to complete another self assessment through the SDLE soon. The system is designed to be dynamic, so please to re-assess yourself at periodic intervals, including after participating in training such as today's office hour, so that you can see your ongoing progress over time, and so that you can be proud of that and celebrate it.

Katja Laepka:

And finally we'd like to remind you again of our next office hour, next Wednesday, December 19th, also at 2:00 P.M. Eastern Time. And that one will be on resiliency and joy in work. And again, let us know if you need more information about that or any of our other office hours coming up.

Katja Laepka:

So, I'm checking to see if any more questions came in. They didn't, but again, we are here for you after the office hour as well. So thank you again for joining us. And also again, thank you to Molly and Marty.

Katja Laepka:

And from all of us at NACHC, we wish you happy, healthy holidays. Take very good care. Thank you.

Molly Evans:

Thank you everyone.

