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):
- Conduct internal monitoring and auditing
- Implement compliance and practice standards
- Designate a Compliance Officer or contact
- Conduct appropriate training and education
- Respond appropriately to detected offenses and develop corrective action
- Develop open lines of communication
- 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.
- The OIG website contains both compliance findings as well as compliance tools and resources. This includes guidance for compliance programs for different types of health care organizations and a resource guide for measuring the effectiveness of a compliance program.
- NACHC offers a multitude of resources through their learning center. To access these resources click here. Note: membership number required.
- FTLF’s HealthCenterCompliance.com provides a variety of resources related to CHC Corporate Compliance/Risk Management programs. Some of the resources are available free of charge others are accessed through their NACHC toolkit that may be purchased via the site.
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.
- Blindskills, Inc. – Tips for Hospital Staff Members and Caregivers
- Vision Australia – Caring for patients who are blind or have low vision – calls out some things to think about for a different ages.
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:
- The Health Care Compliance Association (HCCA)
- The Society of Corporate and Compliance Ethics
- Health Insurance Portability and Accountability Act (HIPAA) resources from the HHS
Further resources are posted in the members-only section of CCHN’s website.
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
- BPHC’s Health Center Program Site Visit Protocol– the review instrument used to conduct the OSV that breaks down each chapter of the Compliance Manual into required documents, site team visit methodology, and site visit findings.
Resources to Help Prepare for the OSV
- CCHN’s Operational Site Visit General Tip Sheet is a two-page tip sheet based on OSVs that occurred in Colorado between 2011 and 2016.
- HRSA OSV Support Documents
- Health Center Staff Documents Checklit
- Policies and procedures are one of the key items that are reviewed during a site visit. Sample policies and procedures that can be used to update or replace missing policies or procedures can be found on:
- NACHC’s Health Center Information webpage
- The ECRI Institute, which offers a free membership to CHCs
- FTLF’s Health Center Compliance website, which does require a subscription to access the services. Reminder: CHCs that participate in corporate compliance trainings featuring FTLF speakers receive this subscription as part of the registration fee.
- CHC’s with special populations can also find some resources through one of the National Cooperative Agreements that focus on special populations.
- There are a few consulting firms that can be hired to perform a mock-OSV to help identify the key areas a CHC should focus on to prepare for the official OSV. Contact Kim Moyer for information on these consulting firms.
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.
- NACHC’s Understanding of the 340B Program supplies a high level overview of the 304B program as it pertains to CHCs.
- HRSA provides several resources pertaining to the 340B program. These resources can be accessed here.
- 340B Coalition is a web-based resource that provides information about the 340B program, stories about the impact of access to 340B discount pharmaceuticals, and 340B news, research and updated information. The 340B Colaition is a national group of safety-net providers and programs that are dedicated to protecting and improving the 340B Drug Discount program.
- Apexus, the exclusive prime vendor of the 340B program, offers several resources on a variety of 340B program issues.
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.
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.
- HealthIT.gov offers a variety of resources and information related to cybersecurity. Several pertinent resources are provided below with more being available here.
- Office of Civil Rights HIPAA Breach Reporting Tool – The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) on July 25, 2017, launched a revised version of its HIPAA Breach Reporting Tool. The updates are designed to improve navigation for those looking for information about breaches, as well as those looking to report incidents. New features, OCR says, include an enhanced functionality that highlights breaches currently under investigation and reported within the previous 24 months, an updated archive with older breaches, improved navigation on the tool, and tips for consumers. HHS said it plans to further expand and improve the site over time. HHS offers more information on Health Insurance Portability and Accountability Act (HIPAA) breach notification at its website.
- Michigan’s Primary Care Association (MCPA) in collaboration with Ohio Shared Information Services (OSIS) produced a 5 part webinar series on HIPAA Compliance and Meaningful Use. Each of the webinars is linked below. You can also find overviews of each of the webinars here.
- HIPAA/HITECH Requirements for FQHCs and the New Omnibus Rule: Part One (presented February 6, 2014)
- HIPAA/HITECH Requirements for FQHCs and the New Omnibus Rule: Part Two – Importance of Security (presented February 20, 2014)
- Meaningful Use Requirements for FQHCs from Security Risk Aspect (presented March 6, 2014)
- Preliminary Security Risk Assessment Tool for FQHCs (presented March 20, 2014)
- Remediation Steps Post Preliminary Security Risk Assessment for FQHCs (presented April 24, 2014)
The International Classification of Diseases (ICD) is the standard coding system for epidemiology, health management and clinical purposes.
- American Association of Professional Coders provides resources for medical coding.
- The Centers for Medicare & Medicaid Services (CMS) has a variety of resources and trainings available.
- PAHCOM, an organization of medical office managers, provides a wide selection of resources pertaining to medical practice needs.
- American Health Information Management Association (AHIMA) offers several coding tools.
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:
- Applying for Look-Alike status is done through an initial designation application, with renewal for this designation occurring through an annual certification process and, once every three years, a renewal of designation must be submitted.
- In order to apply to receive designation, an entity must demonstrate that it has been operating following the Health Center Program Compliance Manual for at least six months prior to the application. Because of this requirement, applicants for this designation may undergo an Operational Site Visit to verify compliance with the requirements prior to receiving designation. This is described in full detail in the Site Visit Protocol: Eligibility Requirements for Look-Alike Initial Designation Applicants.
- Look-Alikes must also report data for the UDS.
In addition to these resources, BPHC includes further information and technical assistance on Look-Alikes here.
For resource pertaining to Patient Centered Medical Home transformation go to CCHN’s Quality Initiatives Division page or click here.