Other – CHC Resource Page

Risk Management/Compliance

Managing risk and monitoring your CHC’s compliance efforts is essential given the current healthcare environment. Risk management and compliance are not the same things:

  • Risk management is a system of procedures designed to reduce exposure to and possibility of certain types of liability, as well as managing potential and actual risks that occur.
  • Corporate compliance is a risk management component that is an internal process used to detect and resolve fraud, waste, and abuse through self-identification and self-correction. The seven elements of an effective compliance program are (adapted from a resource by the Office of the Inspector General (OIG), Department of Health and Human Services (HHS), 2000):


  1. Conduct internal monitoring and auditing
  2. Implement compliance and practice standards
  3. Designate a Compliance Officer or contact
  4. Conduct appropriate training and education
  5. Respond appropriately to detected offenses and develop corrective action
  6. Develop open lines of communication
  7. Enforce disciplinary standards through well-publicized guidelines


Tools and Resources

The ECRI Institute, which is free for CHCs to access, has a multitude of resource to assist with risk management. Most of the tools are focused on clinical risk but could be adapted depending on the need.

There are a variety of resources available to assist CHCs in developing, implementing and maintaining a compliance program.


Resources for Website Accessibility for Individuals with Disabilities 

The following resources aim to aid CHCs in ensuring access to health care for those with visual impairments. Each resource provided below should be reviewed to determine whether they fit the needs of your CHC.

  • American Academy of Family Physicians:
    • Blog post on from a patient’s perspective – Caring Better for Patients Who Are Blind or Visually Impaired. This one calls out an important thing for staff helping with appointments. If reminders or confirmations are sent to the patient, a patient who is visually impaired might prefer a call where as a patient who is hard of hearing might prefer a text message or letter. Finding out the best way to send reminders is key.

Also NACHC recently gathered a series of resources related to updating organizational websites to be compliant with requirements from the ADA. To access these resources, click here.


General compliance resources that are not specifically targeted to CHCs include the following:

Further resources are posted in the members-only section of CCHN’s website.

Operational Site Visits

The Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC) utilizes Operational Site Visits (OSV or site visit) to verify CHC compliance with the Health Center Program Compliance Manual. Both CHC grantees and Look-Alikes routinely undergo site visits, which are conducted by consultants who assess the CHC’s administrative, financial, clinical and governance practices. The following tools and resources can help CHCs prepare for, survive and thrive from a site visit. Don’t see what you’re looking for? Contact Kim Moyer.


Resources Explaining the OSV Process


Resources to Help Prepare for the OSV

The following resources are only available to CCHN members. In order to access these resources, CHCs need the member username and password. Please contact Kim Moyer if you need this information. [list type=circle_list]

  • Tip sheets for the top six areas with findings in 2016. To access the members only page, click here.
  • CHC staff who participated in recent OSV presented about their experiences to their peers in several meetings over the past two years. Recordings of these presentations and the slides used during the presentations can be found here.
  • Examples of tools that CHCs have utilized to help prepare for an OSV can also be found in the technical assistance section of the members only side of the CCHN website.


Created in 1992, the 340B Drug Pricing Program aims to provide discounts on prescription drugs to select safety net providers, including CHCs and Look-alikes. Resources provided below aim to inform CHCs on the development, certification and management of their 340B program.



Federal Tort Claims Act (FTCA Deeming Requirements): Compliance Manual Chapter 21

The Federal Tort Claims Act (FTCA) has long been the legal mechanism for compensating those who have suffered personal injury due to the negligent or wrongful action of employees of the U.S. government. Under Section 224 of the Public Health Service Act, employees of eligible health centers may be deemed to be federal employees thereby qualifying for protection under the FTCA.

Eligible health centers must submit an original deeming and annual renewal deeming application in order to be covered.

While FTCA provides coverage for most of what is needed, there continues to be gaps that CHCs should be prepared for. It is recommended that CHCs acquire gap coverage for scenarios such as: prior acts, moonlighting activities, coverage for part-time contractors, volunteers, Good Samaritan coverage, out of scope activities, residents in training, other care to non-CHC patients, etc.


ECRI Institute

Clinical Risk Management and Credentialing Programs

ECRI offers free resources to CHCs, including the Event Reporting Toolkit and Risk Management Plan with step-by-step guides to implement these key programs, Credentialing Toolkits, and sample policies and a tools library with templates and examples.


The HIPAA Privacy Rule, enacted in 1996, creates a minimum standard for protecting the privacy of individually identifiable health information. This rule focuses specifically on electronic protected health information (ePHI) and provides set administrative, technical, and physical standards to protect ePHI. The following tools and resources can assist CHCs prepare, review and improve their HIPAA related activities.



The International Classification of Diseases (ICD) is the standard coding system for epidemiology, health management and clinical purposes.

Look-Alike Clinics

Community Health Center Look-Alikes (Look-Alike), just like funded Community Health Centers, provide services to low-income, underserved populations and follow the same Health Center Program Requirements. However, Look-Alikes do not receive any funding through section 330 of the Public Health Service (PHS) Act to provide services to uninsured users. More about the Look-Alike model, and how it compares to the section 330 CHC model, can be found here.


The majority of resources available on CCHN’s website apply to Look-Alikes. However, there are differences in the application procedure for Look-Alikes as well as minor differences in Uniform Data System (UDS) reporting. These differences include:

In addition to these resources, BPHC includes further information and technical assistance on Look-Alikes here.


Patient Centered Medical Home

For resource pertaining to Patient Centered Medical Home transformation go to CCHN’s Quality Initiatives Division page or click here.