HRSA RequirementsJean Maki, CHC, MBA

19 REQUIREMENTS

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For each requirement consider….

Board/Committee Oversight

Accountability

Operational Implementation

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Section I & Requirement 1: Needs

Needs

Assessment

Service

Area

SAC

UDS

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Section II: Services

Requirement 2: Required & Additional Services

Directly Contracted Referred Out

FORM 5A

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Requirement 3: Staffing

•Each site•Primary Source

•Secondary Source

•Licenses

•Contracts

•Agreements

•Subrecipient

•Clinical

•Non-clinical

Staffing Profile

Provider

Privileging Lists

Credentialing

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Requirement 4: Accessible Hours of

Operation/Locations

Hours of Operations

Form 5B: Service Site

Form 5C: Other Activities/Locations

Service Area Map (UDS)

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Requirement 5: After Hours Coverage

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Requirement 6: Hospital Admitting Privileges and

Continuum of Care

Continuity of Care

ER Referrals

Discharge

Patient

Tracking

Admitting Privileges

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Requirement 7: Sliding Fee Discounts

Fee Schedule(s)

Policies

Operating Procedures

Signagewww.jeanemaki.com

Requirement 8: Quality

Improvement/Assurance Plan

QI Plan

Incident Reporting

Peer Review

Risk Management

Safety

Clinical Directors

Job Description

Clinical Degree

HIPAA

Patient Confidentiality

Release of Information

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Requirement 9: Key Management Staff

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Requirement 10: Contractual/Affiliation

Agreements

Contracted Services

Contracts

Monitoring

Evaluationwww.jeanemaki.com

Requirement 11: Collaborative

Relationships

Letters of Support

MOUs

Collaboration!

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Requirement 12: Financial Management

and Control Policies

GAAP

CAP

Annual

Audit

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Requirement 13: Billing and Collections

Policies and Procedures

3rd Party Payor

Contracts

Collections

Billing

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Requirement 14: Budget

Expenses

•Costs of Operation

Revenues

•Grants

Patients

•Service Deliver Plan

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Requirement 15: Program Data Reporting

Systems

Decision Making

Data

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Requirement 16: Scope of Project

Sites

Services

Service Area

Target Population

Providers

Form 5A and Form 5B

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Requirement 17: Board Authority

Policy Oversight

Approves Grant Application and Budget

Measuring and Evaluating the Organization’s Progress

Selection of CEO

Services and Hours of Operations

Monthly Meetings

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Requirement 18: Board Composition

13, 52%

2, 8%

2, 8%

2, 8%

2, 8%

4, 16%

Board Members

Patients Finance Local Gov Commercial Legal Social Serviceswww.jeanemaki.com

Requirement 19: Conflict of Interest

Policy

Standards of Conduct

Prohibit conflict of Interest

Board Member is not an employee

CEO is a non-voting member of the Board

Bylaws

And

Policy

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