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C-86-02-073-2-49 1. DATE ISSUED: 2. PROGRAM CFDA: 93.224 01/05/2017 3. SUPERSEDES AWARD NOTICE dated: 12/08/2016 except that any additions or restrictions previously imposed remain in effect unless specifically rescinded. 4a. AWARD NO.: 4b. GRANT NO.: 5. FORMER GRANT 6 H80CS000441601 H80CS00044 NO.: NOTICE OF AWARD H66CS00459 AUTHORIZATION (Legislation/Regulation) Public Health Service Act, Title III, Section 330 6. PROJECT PERIOD: Public Health Service Act, Section 330, 42 U.S.C. 254b FROM: 11/01/2001 THROUGH: 12/31/2017 Affordable Care Act, Section 10503 Public Health Service Act, Section 330, 42 U.S.C. 254, as amended. 7. BUDGET PERIOD: Authority: Public Health Service Act, Section 330, 42 U.S.C. 254b, FROM: 01/01/2017 THROUGH: 12/31/2017 as amended Public Health Service Act, Section 330, 42 U.S.C. 254b, as amended 8. TITLE OF PROJECT (OR PROGRAM): HEALTH CENTER CLUSTER 9. GRANTEE NAME AND ADDRESS: 10. DIRECTOR: (PROGRAM DIRECTOR/PRINCIPAL MARICOPA COUNTY PUBLIC HLTH SERVS DEPT INVESTIGATOR) 220 S 12th Ave Corinne Velasquez Phoenix, AZ 850073101 MARICOPA COUNTY PUBLIC HLTH SERVS DEPT DUNS NUMBER: Division Line: Clinical Services/Dept of Public Health 145454000 1645 E Roosevelt St BHCMIS # 090750 Phoenix, AZ 850063638 11.APPROVED BUDGET:(Excludes Direct Assistance) 12. AWARD COMPUTATION FOR FINANCIAL ASSISTANCE: [ ] Grant Funds Only a. Authorized Financial Assistance This Period $3,056,819.00 [X] Total project costs including grant funds and all other financial participation b. Less Unobligated Balance from Prior Budget Periods a . Salaries and Wages : $1,680,977.00 i. Additional Authority $0.00 b . Fringe Benefits : $674,681.00 ii. Offset $0.00 c . Total Personnel Costs : $2,355,658.00 c. Unawarded Balance of Current Year's Funds $1,783,144.00 d . Consultant Costs : $0.00 d. Less Cumulative Prior Awards(s) This Budget $1,273,675.00 e . Equipment : $0.00 Period f . Supplies : $95,121.00 e. AMOUNT OF FINANCIAL ASSISTANCE THIS $0.00 ACTION g . Travel : $25,000.00 13. RECOMMENDED FUTURE SUPPORT: (Subject to the h . Construction/Alteration and Renovation : $0.00 availability of funds and satisfactory progress of project) i . Other : $76,769.00 YEAR TOTAL COSTS j . Consortium/Contractual Costs : $614,680.00 Not applicable k . Trainee Related Expenses : $0.00 14. APPROVED DIRECT ASSISTANCE BUDGET:(In lieu of cash) l . Trainee Stipends : $0.00 a. Amount of Direct Assistance $0.00 m Trainee Tuition and Fees : $0.00 b. Less Unawarded Balance of Current Year's Funds $0.00 . c. Less Cumulative Prior Awards(s) This Budget Period $0.00 n . Trainee Travel : $0.00 d. AMOUNT OF DIRECT ASSISTANCE THIS ACTION $0.00 o . TOTAL DIRECT COSTS : $3,167,228.00 p . INDIRECT COSTS (Rate: % of S&W/TADC) : $454,091.00 q . TOTAL APPROVED BUDGET : $3,621,319.00 i. Less NonFederal Share: $564,500.00 ii. Federal Share: $3,056,819.00 15. PROGRAM INCOME SUBJECT TO 45 CFR 75.307 SHALL BE USED IN ACCORD WITH ONE OF THE FOLLOWING ALTERNATIVES: A=Addition B=Deduction C=Cost Sharing or Matching D=Other [D ] Estimated Program Income: $564,500.00 16. THIS AWARD IS BASED ON AN APPLICATION SUBMITTED TO, AND AS APPROVED BY HRSA, IS ON THE ABOVE TITLED PROJECT AND IS SUBJECT TO THE TERMS AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING: a. The grant program legislation cited above. b. The grant program regulation cited above. c. This award notice including terms and conditions, if any, noted below under REMARKS. d. 45 CFR Part 75 as applicable. In the event there are conflicting or otherwise inconsistent policies applicable to the grant, the above order of precedence shall prevail. Acceptance of the grant terms and conditions is acknowledged by the grantee when funds are drawn or otherwise obtained from the grant payment system. REMARKS: (Other Terms and Conditions Attached [ X ]Yes [ ]No) This NoA is issued to add one or more OffCycle Conditions. Electronically signed by Clare Oscar , Grants Management Officer on : 01/05/2017 17. OBJ. CLASS: 41.51 18. CRSEIN: 1866000472A2 19. FUTURE RECOMMENDED FUNDING: $3,056,819.00 SUB SUB ACCOUNT FYCAN CFDA DOCUMENT NO. AMT. FIN. ASST. AMT. DIR. ASST. PROGRAM CODE CODE 17 3980879 93.224 15H80CS00044 $0.00 $0.00 HCH HealthCareCenters_15 Page 1 A printer version document only. The document may contain some accessibility challenges for the screen reader users. To access same information, a fully 508 compliant accessible HTML version is available on the HRSA Electronic Handbooks. If you need more information, please contact HRSA contact center at 877-464-4772, 8 am to 8 pm ET, weekdays. NOTICE OF AWARD (Continuation Sheet) Date Issued: 1/5/2017 7:40:25 PM Award Number: 6 H80CS00044-16-01 17 398879G 93.527 15H80CS00044 $0.00 $0.00 HCH HealthCareCenters_15 Page 2 NOTICE OF AWARD (Continuation Sheet) Date Issued: 1/5/2017 7:40:25 PM Award Number: 6 H80CS00044-16-01 HRSA Electronic Handbooks (EHBs) Registration Requirements The Project Director of the grant (listed on this NoA) and the Authorizing Official of the grantee organization are required to register (if not already registered) within HRSA's Electronic Handbooks (EHBs). Registration within HRSA EHBs is required only once for each user for each organization they represent. To complete the registration quickly and efficiently we recommend that you note the 10 digit grant number from box 4b of this NoA. After you have completed the initial registration steps (i.e.,created an individual account and associated it with the correct grantee organization record), be sure to add this grant to your portfolio. This registration in HRSA EHBs is required for submission of noncompeting continuation applications. In addition, you can also use HRSA EHBs to perform other activities such as updating addresses, updating email addresses and submitting certain deliverables electronically. Visit https://grants3.hrsa.gov/2010/WebEPSExternal/Interface/common/accesscontrol/login.aspx to use the system. Additional help is available online and/or from the HRSA Call Center at 877 Go4HRSA/8774644772. Terms and Conditions Failure to comply with the remarks, terms, conditions, or reporting requirements may result in a draw down restriction being placed on your Payment Management System account or denial of future funding. Program Specific Condition(s) 1. Due Date: Within 90 Days of Award Issue Date R.7.1 Board Authority: Health center governing board maintains appropriate authority to oversee the operations of the center, including:• holding monthly meetings ;• approval of the health center grant application and budget ; • selection/dismissal and performance evaluation of the health center CEO ;• selection of services to be provided and the health center hours of operations ;• measuring and evaluating the organization’s progress in meeting its annual and long term programmatic and financial goals and developing plans for the long range viability of the organization by engaging in strategic planning, ongoing review of the organization’s mission and bylaws, evaluating patient satisfaction, and monitoring organizational assets and performance ; and• establishment of general policies for the health center. (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304) Note: In the case of public centers (also referred to as public entities) with co applicant governing boards, the public center is permitted to retain authority for establishing general policies (fiscal and personnel policies) for the health center (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304(d)(iii) and (iv)). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with all applicable board authority requirements OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 2. Due Date: Within 90 Days of Award Issue Date R.5.3 Credentialing and Privileging Policies, Procedures and Documentation: Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged (Section 330(a)(1), (b) (1)(2), (k)(3)(C), and (k)(3)(I) of the PHS Act). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with ensuring credentialing and privileging policies and procedures are in place that meet the requirements articulated by the Health Resources and Services Administration (HRSA) in Policy Information Notices (PIN) 2002 22 and 2001 16 and if applicable, documentation that demonstrates that all providers are appropriately credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. • The plan must include a description of health center processes to ensure all health center providers are appropriately licensed, credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project. This plan must also ensure policies and procedures will address credentialing and privileging for all licensed or certified health center practitioners, employed or contracted, volunteers and locum tenens, currently providing services at the health center sites or locations in accordance with the requirements of Policy Information Notices (PIN) 2002 22 and 2001 16. • Appropriate documentation of credentialing and privileging must include written confirmation of credentialing and privileging (i.e., primary source copies of the health center’s provider files that document provider licensure, registration, or certification ; education, training, current competence, and health fitness, among other things) for all licensed or certified health center practitioners, employed or contracted, volunteers and locum tenens, currently providing services at all health center sites or locations in accordance with the requirements of PINs 2002 22 and 2001- 16. Please note that the Federally Supported Health Centers Assistance Act (FSHCAA), section 224 of the PHS Act (42 U.S.C. 233(g) (n)), as a condition of health center eligibility for deemed federal employment, requires that health centers demonstrate implementation of appropriate policies and procedures to reduce the risk of medical malpractice and associated lawsuits, and review and verification of the professional credentials, fitness, and license status, among other items, of its licensed or certified health care practitioners. Review PIN 200222 and PIN 2001 16 for additional guidance on the credentialing and privileging requirements for health center providers. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 3. Due Date: Within 90 Days of Award Issue Date R.2.4 Sliding Fee Discount Program: Health center has a system in place to determine eligibility for patient discounts adjusted on the basis Page 3 NOTICE OF AWARD (Continuation Sheet) Date Issued: 1/5/2017 7:40:25 PM Award Number: 6 H80CS00044-16-01 of the patient’s ability to pay. This system must provide a full discount to individuals and families with annual incomes at or below 100% of the Federal poverty guidelines (only nominal fees may be charged) and for those with incomes between 100% and 200% of poverty, fees must be charged in accordance with a sliding discount policy based on family size and income. No discounts may be provided to patients with incomes over 200% of the Federal poverty guidelines. No patient will be denied health care services due to an individual’s inability to pay for such services by the health center, assuring that any fees or payments required by the center for such services will be reduced or waived. (Section 330(k)(3)(G) of the PHS Act, 42 CFR 51c.303(f)) and 42 CFR 51c.303(u). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with sliding fee discount program requirements, including updating the schedule of discounts if appropriate OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 4. Due Date: Within 90 Days of Award Issue Date R.5.5 Billing and Collections Policies and Procedures: Health center has systems in place to maximize collections and reimbursement for its costs in providing health services, including written billing, credit and collection policies and procedures. (Section 330(k)(3)(F) and (G) of the PHS Act). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with having policies and procedures in place that ensure appropriate charging, billing and collections, including updating the schedule of charges if appropriate OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 5. Due Date: Within 90 Days of Award Issue Date R.2.5 Quality Improvement/Quality Assurance Program: Health center has an ongoing Quality Improvement/Quality Assurance (QI/QA) program that includes clinical services and management, and that maintains the confidentiality of patient records. The QI/QA program must include: a clinical director whose focus of responsibility is to support the quality improvement/assurance program and the provision of high quality patient care ; periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center ; and such assessments shall:• be conducted by physicians or by other licensed health professionals under the supervision of physicians ;• be based on the systematic collection and evaluation of patient records ; and• identify and document the necessity for change in the provision of services by the health center and result in the institution of such change, where indicated. (Section 330(k)(3)(C) of the PHS Act and 42 CFR 51c.303(c)(1 2)). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with the requirement for having a QI/QA program OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 6. Due Date: Within 90 Days of Award Issue Date R.7.2 Conflict of Interest Provisions: Health center bylaws or written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants and those who furnish goods or services to the health center. No board member shall be an employee of the health center or an immediate family member of an employee. The Executive Director/Chief Executive Officer may serve only as a non voting exofficio member of the board. (45 CFR 75.327 and 42 CFR 51c.304(b)) Within 90 days, provide an action plan detailing the steps the health center will implement in order to ensure conflict of interest provisions are in place, including requirements for competitive procurements OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 7. Due Date: Within 90 Days of Award Issue Date R.7.3 Board Size: The health center governing board is composed of individuals, a majority of whom are being served by the center and, this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex. Specifically,• Governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.• The remaining nonconsumer members of the board shall be representative of the community in which the center's service area is located and shall be selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.• 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. Note: Upon a showing of good cause the Secretary may waive, for the length of the project period, the patient majority requirement in the case of a health center that receives a grant pursuant to subsection (g), (h), (i), or (p). (Section 330(k)(3)(H) of the PHS Act and 42 CFR 51c.304) Within 90 days, provide an action plan detailing the steps the health center will implement in order to achieve the required board size OR provide board approved documentation that action(s) have been implemented resulting in compliance with this requirement. Your organization will be required to submit a revised Form 6A as documentation once the board size requirement has been met. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 8. Due Date: Within 90 Days of Award Issue Date Page 4 NOTICE OF AWARD (Continuation Sheet) Date Issued: 1/5/2017 7:40:25 PM Award Number: 6 H80CS00044-16-01 R.4.1 Arrangements for Hospital Admitting and Continuity of Care: Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, the health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act). Within 90 days, provide an action plan detailing the steps the health center will implement in order to comply with obtaining admitting privileges or developing other firmly established arrangements for health center patients that require hospitalization and which ensures continuity of care OR provide documentation that action(s) have been implemented resulting in compliance with this requirement. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) 9. Due Date: Within 90 Days of Award Issue Date R.6.2 Maintaining Accurate Scope of Project: Health center maintains its funded scope of project (sites, services, service area, target population and providers), including any increases based on recent grant awards. (45 CFR 75.308) Based upon a review of your current scope of project, one or more services, sites, other activities and/or target population are not correctly reflected in the scope of project. Within 90 days, complete the appropriate change in scope (CIS) request/action necessary to correct the scope of project. Once the change in scope is submitted, respond to this condition by uploading a statement documenting the satisfactory completion of the CIS request/action. Please contact your project officer for additional assistance and/or information on the required elements of your response. (45 CFR 75.207(a) and 45 CFR 75.371) All prior terms and conditions remain in effect unless specifically removed. Contacts NoA Email Address(es): Name Role Email Corinne Velasquez Program Director corinnevelasquez@mail.maricopa.gov Jane E Cochrane Business Official janecochrane@mail.maricopa.gov Note: NoA emailed to these address(es) Program Contact: For assistance on programmatic issues, please contact Stephanie McCoy at: MailStop Code: 17N70C HRSA/BPHC 5600 Fishers Ln Rockville, MD, 208571750 Email: smccoy@hrsa.gov Phone: (301) 443 1848 Fax: (301) 594 4435 Division of Grants Management Operations: For assistance on grant administration issues, please contact Clare Oscar at: MailStop Code: 10SWH03 OFAM/DGMO/HCB 5600 Fishers Ln Rockville, MD, 208521750 Email: coscar@hrsa.gov Phone: (301) 443 8862 Page 5 PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 1 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #17 BOARD AUTHORITY Compliance Review Findings: MCPHD is a Section 330(h) public entity. The health department is the grantee, and currently there is no board of directors to oversee Section 330(h) funding. The health department is overseen by the Maricopa County Board of Supervisors. MCPHD had an advisory group that provided limited oversight to the 330(h) program, but it has not met since 2015. In discussion with the division administrator, there is no board of directors, and there is not a formal co-applicant agreement in place. There are no bylaws to review, and no board minutes have been taken. MCPHD does not hold monthly board meetings and it does not maintain minutes that would demonstrate the following: • Approval of the health center’s grant application and budget • Approval and presentation of the audit • Selection, dismissal, and performance evaluation of the CEO/project director • Selection of services to be provided and the health center hours of operations • Development of plans for long-range viability of the organization by engaging in strategic planning • Ongoing review of the organization’s mission and bylaws • Evaluation of patient satisfaction • Measurement and evaluation of the organization’s progress in meeting its annual and long-term programmatic goals • Monitoring of organizational assets and performance • Approval of health center’s policies • Approval of credentialing and privileging Based on HRSA PIN 2014-01, there are no board-approved bylaws. Therefore, they do not reflect and discuss the following: • MCPHD’s mission • Authorities, functions, and responsibilities of a governing board as a whole • Provision regarding what authority the executive committee has to act on behalf of the full board • Board membership and individual member responsibilities • Process for selection/removal of board members • Election of officers • Meeting schedule and quorum • Officer responsibilities, terms of office, selection/removal process • Description of standing committees • Provisions regarding conflict of interest • Provisions regarding board dissolution As a public entity, MCPHD does not have a co-applicant agreement or arrangement. Action Recommended for Compliance: In order to be compliant with Section 330(h) governance regulations, MCPHD must develop a governing board of directors to oversee the program. The governing board of directors must comply with requirements outlined in the entire HRSA PIN 2014-01. Program Response: Introduction Maricopa County appreciates the opportunity to have participated in the Operational Site Visit conducted August 23, 2016 through August 25, 2016, and September 12, 2016 and September 16, 2016. Maricopa County has operated the Health Care for the Homeless Program under Section 330(h) for over 30 years. The Program has provided primary care and enabling services to hundreds of thousands of our most vulnerable community members during that period of time. It has been an honor and a privilege to have served our homeless population by providing exceptional, high quality health care services. HRSA released Policy Information Notice (PIN) 2014-01 in January 2014. The PIN provided detailed information about the governance requirements for Health Care for the Homeless Programs. Unfortunately, the new governance requirements are not conducive to the structural and operational nuances of a local government agency such as Maricopa County. Maricopa County operates under the jurisdiction of a locally elected Board of Supervisors as established by the Arizona Constitution, with powers and duties as delineated in Arizona Revised Statutes. Although the PIN offered two options to meet the governance requirements, by using either the current Board of Supervisors (with some modification) or the establishment of a co-applicant board, neither option will allow Maricopa County to continue providing high quality health care and enabling services to the homeless population without the Board of Supervisors accepting substantial financial risk coupled with loss of programmatic control and oversight from the County Manager and the Director of the Department of Public Health. Plan of Action Conditions related to compliance with PIN 2014-01 and governance of the Health Care for the Homeless Program are included in the most recent Notice of Award, dated January 5, 2017. The conditions, numbered 1 through 9, were all included in the final report of the Operational Site Visit conducted in August and September 2016. This plan is submitted and proposed for the condition as listed and numbered as 1. Conditions numbered as 2 through 6 (partial), 8 and 9, have been addressed separately. The conditions numbered as 6 (partial) and 7 are not applicable to programs funded solely through Section 330(h), and therefore, and in accordance with the PIN, the Maricopa County Health Care for the Homeless Program is exempt from these requirements. The exemption as allowed in the PIN includes portions of the condition numbered as 6 related to board members as employees of the health center, and the CEO serving only as a nonvoting exofficio member of the board and the condition numbered as 7, related to the composition of the governing board. Maricopa County is in the final year of the current project period. The project period will end December 31, 2017, and if it were to continue, Maricopa County would be submitting an application for a new project period through the 2017 Service Area Competition process. Because of its inability to meet the governance requirements under its current structure, Maricopa County does not intend to submit an application in the upcoming Service Area Competition solicitation. It should be noted that the Maricopa County Health Care for the Homeless Program is in compliance with conditions numbered as 2, 3, 4, 5, 6, 8 and 9, with the exception of approval of those items by a governing board established pursuant to PIN 2014-01. To remedy the governing board situation and to resolve the issue of noncompliance with PIN 2014-01, the Maricopa County Department of Public Health is proposing to work with another agency in the community to submit an application for funding under the upcoming Service Area Competition solicitation. In effect, the Maricopa County Department of Public Health will cease its operation of the Health Care for the Homeless Program on December 31, 2017, and another agency, if chosen by HRSA in their grant award process, will open a new Health Care for the Homeless Program on January 1, 2018. The County will seek to work with another community agency that will offer, at a minimum, the same level of quality services that are currently being provided to the homeless population and in the same location that services are currently being offered within the county. There are a number of agencies within Maricopa County that are currently providing services to the homeless community, and at least one of those agencies has expressed an interest in submitting an application to provide services within the area that the Maricopa County Health Care for the Homeless Program is currently serving. The agency that has expressed interest currently operates another Health Care for the Homeless Program in Maricopa County, and also recently underwent an Operational Site Visit which resulted in no unmet governance or compliance issues. The Department of Public Health will assist another agency with the preparation of its application through the Service Area Competition process, and will commit its full support and assistance to that agency. Once a new applicant is selected by HRSA to provide services within the service area, the Department of Public Health will commit the resources necessary to ensure a smooth transition of the program to the new grantee. Maricopa County intends to be "in compliance" with the governance requirements as set forth in PIN 2014-01 by January 1, 2018, by no longer operating a Health Care for the Homeless Program. Between now and January 1, 2018, the Maricopa County Department of Public Health will be working with another agency (or agencies) to develop a solid, robust application to be submitted under the upcoming Service Area Competition, and then working with HRSA's new grantee to ensure a smooth transition that is intended to be "invisible" to the homeless clients currently being served. We are hopeful that HRSA will be agreeable to continue funding the Maricopa County Health Care for the Homeless Program through the last year of the current project period (ending December 31, 2017). Attachments: • None PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 2 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #3 STAFFING Compliance Review Findings: Health center maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged. (Section 330(a)(1), (b)(1)-(2), (k)(3)(C), and (k)(3)(I) of the PHS Act). Action Recommended for Compliance: The credentialing and privileging policy and procedure must be approved by a governing board. In addition, each candidate presented for credentialing and/or privileging must be approved by a governing board. A governing board must approve the credentialing and privileging of providers. Program Response: At the time of the site visit, the reviewer was able to review the Credentialing and Privileging Policy C47, titled Credentialing and Privileging. Dr. Vicki Copeland reviewed the policy and the provider files to show that the credentialing and privileging had been completed for the HCH providers and locum tenens. The policy includes the description of health center processes to ensure all health center providers are appropriately licensed, credentialed and privileged to perform the activities and procedures detailed within the health center’s approved scope of project. This plan must also ensure policies and procedures will address credentialing and privileging for all licensed or certified health center practitioners, employed or contracted, volunteers and locum tenens, currently providing services at health center sites or locations in accordance with the requirements of Policy Information Notices (PIN) 2002-22 and 2001-16. The reason that the Credentialing and Privileging Requirement was unmet is because MCDPH HCH needed to provide board approved documentation that actions(s) have been implemented resulting in compliance with this requirement. Policy and credentialing and privileging of HCH medical providers approved by the Maricopa County Board of Supervisors on _____________,2017. Attachments: • Policy C47, Credentialing and Privileging, with Attachments A and B • Request for Clinical Privileges and Delegation Agreement for HCH Providers DEPARTMENT OF PUBLIC HEALTH SERVICES HEALTH CARE FOR THE HOMELESS PROGRAM POLICIES, PROCEDURES, & PRACTICES Title: Credentialing and Privileging Effective Date: 8118/2016 Applicability: Healthcare for the Homeless Clinic Staff Next Revision Date: 2/2/2018 Responsible Party: Medical Director Last Revision Date: 2/2/2017 APPROVED: tap G j DPPN: C47 11/4(-- Page: 1 of 5 I. PURPOSE To establish a policy and procedure that ensures that the practitioners at Healthcare for the Homeless have the appropriate credentials and privileges to care for patients at Healthcare for the Homeless. This applies to all practitioners, including direct employees, contracted employees or volunteers, II. POLICY A. Healthcare for the Homeless providers will have their credentials evaluated as outlined below to be sure that they are able to provide care within their scope of practice legally in the state of Arizona and the United States of America as well as to prescribe medications or order or perform treatment according to their education, training and experience. III. PROCEDURES A, Initial Credentialing and Privileging for all licensed independent practitioners, including physicians, physician assistants, physical therapists, licensed social workers requires the following: a. Primary source verification i. Current licensure, registration or certification ii, Relevant education, training, or experience Hi, Current competence b. Secondary source verification i. Government issued identification ii. Immunizations iii. Tuberculosis status iv. Health fitness or ability to perform requested privilege ANNEX C POLICY 47 as of 2/17 Page 1 of 5 v. DEA registration vi. Hospital admitting privileges, if applicable c. National Practitioner Data Bank query d. OIG List of Excluded Individuals and Entities query e. Evidence of malpractice insurance, if not a direct employee of Marieopa County Department of Public Health f. Practitioner will also complete CAQH application, if employed, attestation will be printed and signed and maintained in personnel file. g. Practitioner will also complete an AHCCCS application and Medicare application if not done previously h. Request for Clinical Privileges is completed i. Delegation Agreement is completed, if applicable B. Initial Credentialing for other licensed or certified practitioners, including registered nurses and licensed practical nurses requires the following: a. Primary source verification i. Current licensure, registration or certification b. Secondary source verification i. Education and training ii. Government issued identification iii. Immunizations iv, Tuberculosis status c. National Practitioner Data Bank query C. Initial privileges will be granted to licensed practitioners through verification of the current competence in each service requested. Licensed independent practitioners request initial privileges by completion of the request for privileges form. The Medical Director will make an assessment of current competence to perform the privileges requested by evaluation of : a. Graduation within one year of an accredited program will be accepted for cognitive privileges b. Professional references from two peers in similar field of practice with comparable degrees or supervisory roles obtained in writing attesting to direct observation of ability to perform requested privileges or knowledge of practice within the last two years prior to the request. Procedure logs may be submitted in lieu of direct observation. c. Verification of active board certification in a specialty such as family medicine, internal medicine, pediatrics or emergency medicine as applicable. Practitioners who are not board certified or eligible to become board certified within two years of privileging will not routinely be granted privileges. However, the Medical Director reserves the right to make exceptions to the Board Certification requirement in individual cases after a thorough review of an individual practitioner's credentials and experience. d. Additional privileges may be obtained through obtaining relevant training with appropriate certificate or direct training under another practitioner who ANNEX C POLICY 47 as of 2/17 Page 2 of 5 has that privilege and is willing to attest in writing to the practitioner's ability to perform the requested privilege. D. Once the necessary documents for privileging and credentialing are complete the Healthcare for the Homeless Medical Director recommends the approval (or non- approval) of the applicant and privileges requested to the Governing Board, who will provide the ultimate approval and determination in writing. E. Approval is granted for credentialing and privileging if: a. There is no history of medical malpractice claims b. There is no current or previously successful challenge to licensure or registration c. There has not been an involuntary termination of medical staff membership at another organization d. There has not been an involuntary limitation, reduction, denial or loss of clinical privileges F. Further review and documentation of cure is required if the applicant has: a. History of medical malpractice b. A current, or a previously successful, challenge to licensure or registration c. Been subject to involuntary termination of medical staff membership at another organization d. Been subject to involuntary limitation, reduction, denial or loss of clinical privileges. G. Initial credentialing and privileging extends for a period of two years. H. Initial privileging of other licensed or certified healthcare practitioners is documented on a competency checklist or form and completed during the employee orientation process via a supervisory evaluation. I. Recredentialing and Reprivileging a. Revision or renewal of licensed independent practitioner occurs every two years and includes the following: i. Primary source verification of current license and board certification, although it is incumbent upon the practitioner to maintain current licensure and certification, including updates regarding any licenses that were surrendered in the credentialing period ii. Secondary source verification of immunizations and TB status, although Department of Public Health requires annually Hi. Secondary source verification of DEA registration, as applicable iv. National Practitioner Data Bank query v. OIG List of Excluded Individuals and Entities query vi. Any updates required on the CAQH which typically occurs quarterly, along with a recently signed attestation by the practitioner vii. Any updates or changes to relevant education, training or experience viii. Review of data regarding practitioner's performance, including review of performance improvement, peer review and quality review ix. Updated Request for Clinical Privileges form completed by the practitioner. Precipitating factors for change in scope of privileges ANNEX C POLICY 47 as of 2/17 Page 3 of 5 may include but are not limited to: 1. Relevant training which has occurred since the prior granting of privileges 2. Concerns raised through the peer review or quality review process J. Once the necessary documents for reprivileging and recredentialing are complete the Healthcare for the Homeless Medical Director recommends the approval (or non- approval) of the applicant and privileges requested for an additional two years to the governing board, who will provide the ultimate approval and determination in writing. a. Reprivileging of other licensed or certified health care providers will also occur every two years. i. It is accomplished and documented via supervisor's performance evaluation and assessment that the practitioner is competent to perform the duties of their job description. ii. Maintaining licensure or certification in field. K. Temporary Privileges may be granted to a licensed independent practitioner whose application is awaiting final approval for a maximum of 120 days. The following must be completed prior to the granting of temporary privileges: i. Verification of current licensure, registration or certification ii. Verification of relevant education, training, or experience iii. Current competence and evidence of ability to perform privileges requested iv. National Practitioner Data Bank query v. No history of malpractice claims within the past 5 years vi. No current or previously successful challenge to licensure or registration vii, Never been subject to involuntary termination of medical staff membership at another organization viii. Never been subject to involuntary limitation, reduction, denial or loss of privileges. L. Appeal Process a. An appeal process is available to licensed independent practitioners when initial privileges are denied or when privileges are revoked, not renewed or restricted. b. Governing Board, Medical Director of Healthcare for the Homeless, Clinic Supervisor of Healthcare for the Homeless, Director of Clinical Services and Medical Director of Clinical Services will be notified in writing of applicant or practitioner's desire to appeal. E-mail may be used as an alternative with return receipt requested and received. Applicant will then need to present evidence as to why privileges should not be denied, revoked, or restricted. IV. EVALUATION/REVIEW CRITERION To be reviewed annually by Medical Director and Governing Board. ANNEX C POLICY 47 as of 2/17 Page 4 of 5 V. REFERENCES VI. DEFINITIONS VII. APPENDICES Appendix A: Request for Clinical Privileges Appendix B: Delegation Agreement ANNEX C POLICY 47 as of 2/17 Page 5 of 5 Request for Clinical Privileges Medical Providers (M.D., D.O., P.A., N.P.) Practitioner’s Name _________________________________________________ Initial Privileging/New Hire YES/NO Reprivileging YES/NO Part A: Cognitive (please check those requested) o Evaluation, diagnosis, and treatment of adult patients presenting with medical problems. Ability to perform history and physical examination, formulate a differential diagnosis, order appropriate lab or diagnostic studies, order appropriate referrals, design a treatment plan, including appropriate follow up care. Knowledge and recognition of basic psychopathology and psychiatric medications and their use in treating patients with behavioral health conditions. o Routine Prenatal Care o Pediatrics o Well Child Care o Diagnosis, treatment, management of infants, children, adolescents for routine illnesses, disorders, and injuries Part B: Procedures o I&D Abscesses o Epidermoid or sebaceous cyst removal o EKG interpretation (all PA and NP will have overread by physician) o Simple laceration repair (suture, staple, adhesive) o Wound debridement and care o Large joint aspiration and/or injection o Toenail removal o Intrauterine device removal o Intrauterine device insertion o Subdermal contraception implant insertion o Subdermal contraception implant removal o Skin biopsy and lesion removal o Lesion destruction by curettage or cryotherapy o Simple splinting o Any additional skills or procedures to be added: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Acknowledgement of Practitioner: I acknowledge that I have requested only those privileges for which by current competence, training and/or experience, I am qualified to perform and which I wish to exercise at Healthcare for the Homeless. I understand that I am bound by the applicable policies and procedures of Healthcare for the Homeless in the exercise of these privileges. ______________________________________________ __________________ Requesting Practitioner’s Signature and Degree Date At this time, Healthcare for the Homeless is of the opinion that the practitioner’s competency, professional performance, judgment, technical skill and health status are satisfactory and support the scope of clinical privileges requested. Thereby, these privileges are granted. ________________________________________________ __________________ Medical Director, Healthcare for the Homeless Date Healthcare for the Homeless 220 S. 12th Avenue. • Phoenix, Arizona 85007 Phone: (602) 372-2100 • Fax: (602) 372-2164 DELEGATION AGREEMENT The Physician Assistant: _____________________, is a certified physician assistant and is supervised by _______________________, who retains professional and legal responsibility for the care rendered by the above named physician assistant in any Maricopa County Department of Public Health Clinic to any patient of all ages. The supervising physician is accessible by phone or in person during working hours for consultations of patient management, and if not, alternate supervision will be arranged. Physician Assistant Scope of Practice will include: • History collection: to include physical exam and assessment. • Formulation: to include Diagnostic Impressions, initiation and completion of treatment plans in care of Public Health patients of all ages. • Medication administration: to include prescribing medications as necessary within limitations as stated under the approved prescribing authority form. Provide medications as required for treatment that will include: IM/SC, oral and topical application. • Labs: to include selecting, ordering, collecting, performing and interpreting appropriate laboratory tests. • Health counseling and education. • Basic Life Support and First Aid as necessary. • Precept and supervise medical students and medical residents in their learning experience with Maricopa County Department of Public Health (MCDPH). • Participation of Public Health emergencies as needed/required based on trainings. • Will comply with state requirements for CME hours. In addition, the Physician Assistant has been delegated the following healthcare tasks: • Phlebotomy • TST placement and reading • Cryotherapy • Injections ____________________________________________________________________ Physician Assistant Signature Date ____________________________________________________________________ Supervising Physician Date ____________________________________________________________________ Supervising Physician Date ____________________________________________________________________ Public Health Medical Director Date PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 3 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #7 SLIDING FEE DISCOUNTS Compliance Review Findings: There is a sliding fee discount scale, but the grantee makes it clear that it exists only to meet the federal requirement. It is only used for patients who are not homeless, but the grantee does not have any patients who are not homeless, because it refers any non- homeless patients to another FQHC. As for any homeless patient who qualifies for the sliding fee scale, the grantee chooses to waive 100 percent of all fees, no matter what the patient’s family income or family size is. The sliding fee scale, which is applied to all services per the sliding fee scale policy, has been updated to reflect the latest federal poverty guidelines (FPG). There is a category (Schedule A) for patients at or below 100 percent of FPG in which 100 percent of the fee is waived, and there is no nominal fee charged. For patients between 101 percent and 200 percent of FPG, there are four discount categories (Schedules B through E) with discounts ranging up to 30 percent. However, the sliding fee scale is not in compliance with BPHC requirements for the following reasons: • Patients in the 101–125 percent category of FPG also have 100 percent of their fees waived, so there is no distinction from Schedule A based on family size and income. • Patients above 200 percent of FPG are also provided with a discount (40 percent), which is not allowed. • The sliding fee scale has been calculated only for family sizes up to four members; for purposes of completeness, the chart should be extended to include at least a family size of eight. • Lack of signage that announces the availability of a sliding fee scale and that states the grantee’s policy not to deny care based on inability to pay. • Lack of signage stating the grantee’s policy not to deny care based on any illegal grounds for discrimination such as age, gender, race, skin color, country of origin, sexual preference, gender identification, or veteran status. • Lack of a comprehensive sliding fee scale policy. The current written policy fails to include language relative to eligibility renewal terms, or an annual review of the entire sliding fee scale program to ensure that no part presents a barrier to care. The requirement that referral sources offer discounts to their fees that match or exceed those offered by the grantee is not applicable, because the grantee will pay for any specialty services for which they refer their homeless patients. Action Recommended for Compliance: The sliding fee scale must be corrected to reflect that there is a distinction between patients at or below 100 percent of FPG and patients between 101–125 percent of FPG and to state that patients above 200 percent of FPG are not eligible for a sliding fee scale discount. There must be signage in appropriate languages prominently posted in the patient waiting areas that announces that a sliding fee scale is available and that no one will be denied care based on inability to pay. Last, the sliding fee scale policy must be reviewed and updated to include all provisions as outlined in PIN 2014-02 and in the HRSA Health Center Program Site Visit Guide, including language relative to eligibility renewal terms and an annual review of the entire sliding fee scale program to ensure that no part presents a barrier to care. This revised policy must be put in place, even in the absence of a properly constituted board of directors that would normally review and approve them. Program Response: • Patients in the 101-125 percent category of FPG are distinct on Schedule A based on family size and income and their fees are waived. • Patients above 200 percent of FPG are not provided a discount based on the schedule. • The sliding fee has been calculated for a family size of 8 members. • The Sliding Fee Scale is posted in several prominent spots within the Clinic and at the Front Desk and states that no patient will be turned away due to an inability to pay. • Language has been added to the policy regarding income eligibility for renewals and annual reviews. Language has also been added requiring annual review of the entire sliding fee scale program to ensure that no part presents a barrier to care. • Approved by the Maricopa County Board of Supervisors on _____________, 2017. Attachments: • Revised policy A16, Sliding Fee Schedule • Revised Sliding Fee Schedule DEPARTMENT OF PUBLIC HEALTH SERVICES HEALTH CARE FOR THE HOMELESS PROGRAM POLICIES, PROCEDURES, & PRACTICES Title: SLIDING FEE SCHEDULE Effective Date: 1/1/2011 Applicability: ALL HCH STAFF Next Revision Date: 1/31/18 Responsible Party: HCH PROGRAM SUPERVISOR Latest Revision Date: 1/31/17 APPROVED: DPPN: Al6 Page 1 of 2 I. PURPOSE To establish a sliding fee schedule for all homeless patients seen at Health Care for the Homeless (HCH). POLICY It is the policy of Health Care for the Homeless (HCH) to provide essential services regardless of the patient's ability to pay. Discounts are offered depending upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Discounts apply to any amount due from patients. Discounts need to be all inclusive, covering visits, procedures, etc. Once approved, the discount will be honored for twelve months,( unless there is a change to patient income/household compensation after which the patient must reapply). III. PROCEDURES Determining Eligibility for Discounts/Discount Application Process A. Registration staff will complete income information in eCW upon each visit to HCH to determine initial and renewateligibility. eCW will assign sliding fee schedule based on information provided. B. If the applicant appears to be eligible for Medicaid and/or Medicare a written denial of coverage by Medicaid and/or Medicare may also be required. C. The collection of family size and income information from all patients must be a part of the usual registration process. D. Verbal income verification is completed on initial registration and is updated upon every visit to HCH. E. Each patient will sign an attestation of their income. ANNEX A POLICY 16 as of 1/31/17 Page 1 of 2 IV. SERVICES COVERED AND EXCLUDED A. Medical: The discount is applied to all in-office services and off-site services supplied by HCH health care providers. B. Pharmacy: OTC and prescriptions are provided, copayments when available, without charge. C. Behavioral Health: Visit copayments, prescriptions and prescription copayments with Public Health for uninsured patients. V. EVALUATION / REVIEW CRITERION This policy and the entire sliding fee scale program will be reviewed annually by the Policies and Procedures Committee for content and to ensure that no part of the Sliding Fee Scale presents a barrier to care. VI. REFERENCES The US Department of Health and Human Services Poverty Guidelines; ASPE.hhs.gov . HRSA PIN 2014-02 VII. DEFINITIONS VIII. APPENDICES A. Sliding Fee Schedule Chart ANNEX A POLICY 16 as of 1/31/17 Page 2 of 2 Maricopa County, Department of Public Health Health Care for the Homeless 220 South 12th Avenue, Phoenix, AZ 85007 Sliding Fee Scale for all HCH patients, Effective July 1, 2016 Schedule Co-Pay Schedule B Schedule D Schedule F A $0 0% - 100% 126% - 150% 176% - 200% B $5 101% - 125% 151% - 175% Over 200% C $11 Waive Fee 10% Visit Fee 20% Visit Fee 5% Visit Fee 15% Visit Fee No Discount D $16 Schedule A Schedule C Schedule E E $22 F $108 100% and Below 101% to 125% 126% to 150% 151% to 175% 176% to 200% Over 200% Family Size Federal Poverty Level Federal Poverty Level Federal Poverty Level Federal Poverty Level Federal Poverty Level Federal Poverty Level 1 Below $11,880 $11,881 to $14,850 $14,851 to $17,820 $17,821 to $20,790 $20,791 to $23,760 $23,761 and Above 2 Below $16,020 $16,021 to $20,025 $20,026 to $24,030 $24,031 to $28,035 $28,036 to $32,040 $32,041 and Above 3 Below $20,160 $20,161 to $25,200 $25,201 to $30,240 $30,241 to $35,280 $35,281 to $40,320 $40,321 and Above 4 Below $24,300 $24,301 to $30,375 $30,376 to $36,450 $36,451 to $42,525 $42,526 to $48,600 $48,601 and Above 5 Below $28,440 $28,441 to $35,550 $35,551 to $42,660 $35,552 to $49,770 $35,553 to $56,880 $56,881 and Above 6 Below $32,580 $32,581 to $40,725 $40,726 to $48,870 $40,727 to $57,015 $40,728 to $65,160 $65,161 and Above 7 Below $36,730 $36,731 to $45,913 $45,914 to $55,095 $45,915 to $64,278 $45,916 to $73,460 $73,461 and Above 8 Below $40,890 $40,890 to $51,113 $51,114 to $61,335 $51,115 to $71,558 $51,116 to $81,780 $81,781 and Above NO PATIENT WILL BE TURNED AWAY BECAUSE OF AN INABILITY TO PAY PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 4 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #13 BILLING AND COLLECTIONS Compliance Review Findings: The Health Care for the Homeless program uses eClinicalWorks for both its practice management system and EHR. An encounter form is generated at check-in and is used by the clinical staff to record the appropriate procedures and diagnoses. If the patient is covered by Medicaid – the only insurance that the program accepts – the encounter is sent to the contract billing service (Falcon Practice Management) to prepare and submit a claim. Any patient covered by any other insurance is referred to another FQHC, although if the patient continues to want to be seen by the grantee, he will not be turned away. However, the third-party payer will not be billed. The number of patients in this category is very small, which is the reason that the grantee chooses to refer them to another FQHC. If the visit is generated by an uninsured patient who is homeless – and the grantee sees only homeless patients – the entire fee is written off. (The sliding fee scale applies to only non-homeless patients, of whom the grantee has none.) Falcon submits claims on a weekly basis. Denials are corrected and resubmitted within 24 hours of receipt. Payments are posted when Falcon receives the explanations of benefits (EOBs) from the grantee staff. Medicaid contractual allowances are not recorded until payment is received. (There is no concern about either when sliding fee scale discounts are recorded or about billing self-pay patients since, as mentioned above, the grantee waives all fees for all homeless patients, and all non-homeless patients are referred to another FQHC.) The full-fee schedule is not calculated based on the actual costs of providing services. There are no billing and collections policies and procedures that state when the contract service submits its claims, corrects and resubmits denied claims or posts payments. In fact, there are no patient billing and collection policies and procedures to speak of. Even if there were, they would not be board-approved because the five-member Maricopa County Board of Supervisors that oversees this program’s activities and ostensibly would approve policies does not qualify as a governing body under BPHC rules. For this reason, this requirement is NOT met. Action Recommended for Compliance: The billing and collection policies and procedures (P&P) must be reviewed and updated to include all activities of the billing function, whether it is in-house or contracted. The grantee is urged to borrow policies from other FQHCs (preferably those who use eClinicalWorks) and use them as templates to develop its own P&P that are specific to its personnel, systems, and infrastructure. Even in the absence of a properly constituted board of directors that has the responsibility of reviewing and approving these new policies, the grantee must have them in place to allow for consistent application of protocols and to identify tasks and the personnel responsible and schedules for completing them. Program Response: • This condition is met, with the exception of board approval. • Policy approved by the Maricopa County Board of Supervisors on _____________, 2017. Attachments: • Policy A25, Billing and Collections DEPARTMENT OF PUBLIC HEALTH SERVICES HEALTH CARE FOR THE HOMELESS PROGRAM POLICIES, PROCEDURES, & PRACTICES Title: Billing and Collections Effective Date: 08/18/2016 Applicability: Healthcare for the Homeless Clinic Staff Next Revision Date: 02/16/18 Responsible Party: Last Revision Date: 02/16/17 APPROVED: br DPPN: A25 1.. ..., I i Page: 1 of 2 I. PURPOSE To ensure that billing and collections are conducted by Healthcare for the Homeless in compliance with national standards and federal and state regulations while providing access to healthcare to people experiencing homelessness II. POLICY The billing and collections procedures followed by Healthcare for the Homeless will be in compliance with national standards and federal and state regulations. They will increase access the healthcare and not be a barrier to healthcare. III. PROCEDURES A. The providers, clinical staff, case management staff and any other staff providing a billable will correctly code all encounters and patient visits in the electronic medical record. a. Coding will be consistent with national and state regulations. b. Coding will only be done for actual work performed on the day of service. c. Coding will not be done for a service not performed, a planned future service, or upcoded. B. Billing, whether internal or external will be done in the following ways: a. Billing will be consistent with national and state regulations, including Centers for Medicare and Medicaid Services (CMS), Arizona Health Care Cost Containment System (AHCCCS),and Health Resources and Services Administration (HRSA). b. Billing will only be done for actual work performed on the day of service. ANNEX A POLICY 25 as of 2/16/17 Page 1 of 3 c. Billing will not be done for a service not performed, a planned future service or upcoded. d. Billing will utilize the current fee schedule for Healthcare for the Homeless e. Billing software will be the choice of vendor, as long as it is in compliance with this HCH policy. f. Billing claims must be filed within thirty business days of visit. g. Denied or incomplete billing claims that are returned must be resubmitted within five business days. h. All other billing procedures and practices performed by the vendor may be at their discretion as long as it is in compliance with this HCH policy. C. Collections, whether internal or external will be done in the following ways: a. Collections will be consistent with national and state regulations, including Centers for Medicare and Medicaid Services (CMS), Arizona Health Care Cost Containment System (AHCCCS), and Health Resources and Services Administration (HRSA). b. Collections will only be done for actual work performed on the day of service. c. Collections will not be done for a service not performed, a planned future service or up coded. d. Payments will be posted to patient account within two business days. e. Collections will utilize the current fee schedule and sliding fee scale for Healthcare for the Homeless. f. Collections will never balance bill a patient or client. g. Collections or any staff at Healthcare for the Homeless will not attempt to collect any money directly from a patient, patient's family, guardian, estate or other source. h. Based upon medical necessity and federal poverty guidelines, services will be provided to patients without an attempt to collect any copays, fees, or deductibles. Balances due will not be a barrier to accessing care at Healthcare for the Homeless. i. Collection software will be the choice of vendor, as long as it is in compliance with this HCH policy. J. All other collection procedures and practices performed by the vendor may be at their discretion as long as it is in compliance with this HCH policy. k. HCH will monitor timeliness of claims submissions/resubmissions, denials, adjustments and accounts receivables. D. Monitoring will be completed by HCH Clinic Supervisor each quarter, by randomly selecting twenty-five claims from the previous quarter to verify that policy timeframes are being met by vendor, as set forth in this policy. ANNEX A POLICY 25 as of 2/16/17 Page 2 of 3 IV. EVALUATION/REVIEW CRITERION To be reviewed annually by policy and procedure committee. V. REFERENCES VI. DEFINITIONS VII. APPENDICES ANNEX A POLICY 25 as of 2/16/17 Page 3 of 3 PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 5 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #8 QUALITY IMPROVEMENT/ASSURANCE PLAN Compliance Review Findings: MCPHD has a number of individual medical records policies that, taken together, form a HIPAA-compliant guide to the treatment of medical records. Each patient has his/her own file in the eClinicalWorks system. Permission must be given for sharing of information. Their system is password protected, and levels of security exist on a need- to-know basis. There are no old records to be stored, as all information in paper form is scanned into the EHR system as it comes into the health center. Peer review is accomplished quarterly. A date is chosen, and five files are randomly chosen per provider for review. The review is for clinical judgment and participation in preventive medicine activities. The QA/I committee receives aggregate data. The medical director uses the data for performance reviews. Various other file reviews are also conducted in an effort to gather USD information. The medical director has responsibility for the QA/QI plan, and this responsibility is noted in the job description. There is a comprehensive QA/QI plan in place, but it is not approved by a governing board. Each department sets goals for the year as they relate to the UDS measures. MCPHD’s QA/QI committee consists of the management team and a representative from each department (e.g., behavioral health, case managers, outreach team). The medical director creates the agenda and includes issues of clinical services and clinical management. Risk management issues such as sentinel events are also considered. Someone is assigned to head up a Plan, Do, Study, Act (PDSA) cycle for problem solving. The clinical supervisor participates in the clinical services quality assessment committee, which is composed of managers within the clinical services division of the health department. There is a weekly managers meeting weekly and a monthly all-staff meeting. Information is gathered and shared and used to assess the services offered and the use of those services. Action Recommended for Compliance: The quality improvement/ quality assurance policy and procedure must be approved by MCPHD’s governing board. Further, changes and readjustments must be considered and approved. Program Response: • HCH has a Medical/Clinical Director whose focus of responsibility is to support the quality improvement/assurance program and the provision of high quality patient care; periodic assessment of the appropriateness of the utilization of services and the quality of services provided or proposed to be provided to individuals served by the health center. • Such assessments are: o Conducted by physicians or by other licensed health professionals under the supervision of the physician o Be based on the systematic collection and evaluation of patient records and o Identify and document the necessity for change in the provision of services by the health center and result in the institution of such change, where indicated. • This condition is met, with the exception of board approval. • Policy approved by the Maricopa County Board of Supervisors on _____________, 2017. Attachments: • Policy A29, Quality Improvement Policy • HCH Quality Assurance Program Plan for 2017 DEPARTMENT OF PUBLIC HEALTH DIVISION OF CLINICAL SERVICES POLICIES, PROCEDURES AND PRACTICES Title: Effective Date: Quality Assurance Program January 31,2007 Applicability: Next Review Date: Division Staff October 16, 2017 Responsible Party: Latest Revision Date: Division Administration October 16, 2015 APPROVED: , e'r Page 1 of 4 L '1) iP r----&---*--g7 7 I. PURPOSE To ensure that the Division of Clinical Services personnel conduct quality assurance (QA) activities in an effort to improve the overall quality of services provided. IL POLICY The Clinical Services Division will constantly strive to improve the quality of care and customer service provided to patients seeking services in Division facilities. III. PROCEDURE A. The QA Program shall focus on the identification and resolution of known or suspected problems that have a direct or indirect impact on patient care and customer service. The QA Program will include the following: An established set of clinical, administrative, and programmatic standards by which conformity would be maintained. 2. A tracking system to identify patients in need of follow-up and/or continuing care. 3. Ongoing medical chart audits to determine conformity with agency protocols. 4. Evaluation of individual clinician performance to provide feedback and to initiate corrective action when deficiencies are noted. ANNEX A POLICY 29 Page 1 5. A regular review of clinical protocols to ensure that the standards of care being practiced meet or exceed the community standard. 6. A process to elicit consumer comments such as a satisfaction survey. 7. An ongoing and systematic documentation process of quality assurance activities performed. B. A Quality Assurance Plan will be established to explain the division's program and commitment to monitor, evaluate, and improve the quality of health care and services given to the citizens of Maricopa County (Attachment A). C. Quality Indicators, 1 Each program within the Division shall identify at least one known or suspected problem for improvement that has a direct or indirect impact on patient care or customer service. 2. Once selected, the known or suspected problem will be written as a Quality Indicator. The Quality Indicator will set forth the expectations, measurements, and methodology that will be used to improve the problem. 3. Quality Indicators will be piloted between July 1 and December 31 of each year. During the pilot period, Quality Indicator results will be measured, at a minimum, on a quarterly basis. Quality Indicator results will not be reported during the pilot period. Changes may be made to the Quality Indicator and to the audit tool during the pilot period. 4. Quality Indicators are required to be replaced once the program has met or exceeded the expected goal for four consecutive quarters. 5. Quality Indicators shall not be replaced until the program has met or exceeded the expected goal for four consecutive quarters. Changes in the expected goal can be made only on January 1 of each year. ANNEX A POLICY 29 Page 2 D. Reporting Results. 1. On January 1 following the pilot period, a Quality Indicator will go into effect for a 12-month period. During this time, Quality Indicator results will be reported on a schedule established by the Division Administrator (Attachment B). No changes will be made to the Quality Indicator or to the audit tool after January 1. 2. The Division Administrator will compile the quarterly results from each program to form a Quarterly QA Report for the Division. The Quarterly QA Report will be distributed to all Program Managers, the Division Medical Director and the Director of the Department of Public Health per the schedule established (Attachment B). 3. If the Quality Indicator results fall below the expected goal in any quarter, a corrective action plan will be included when submitting the results for the Quarterly QA Report. The corrective action plan will include specific actions that will be taken in order for the program to meet the goals established. 4. The Division Administrator will compile all quarterly reports to prepare the annual QA Report for the Division. The annual QA Report will be distributed to all Program Managers, the Division Medical Director and the Director of the Department of Public Health no later than 30 days following the end of the calendar year. The annual QA Report will include any changes made or actions taken as a result of an identified concern about the delivery of services related to patient care or customer service. E. QA Committee. 1. The QA Committee shall be comprised of each program manager, the Division Medical Director, and the Division Administrator. 2, The QA Committee shall meet at least quarterly to review the following: a. QA Indicator results from the previous quarter. b. Medication errors. ANNEX A POLICY 29 Page 3 c. Patient complaints. d. Quality issues. e. Clinic incidents. 3. The QA Committee shall make recommendations to the Division Administrator and Division Medical Director related to resolutions for issues that are identified in E.2.a. e. The Division Administrator shall maintain documentation of all changes made or actions taken as a result of an identified concern about the delivery of services related to patient care or customer service. F. All reports, supporting documentation, and QA Committee meeting minutes shall be maintained for a period of five years. IV. REFERENCES V. DEFINITIONS VI. APPENDICES Appendix A: Division Quality Assurance Plan ANNEX A POLICY 29 Page 4 Clinical Services Division Quality Management Program October 3, 2013 I. Purpose The purpose of the Quality Management Program (QMP) of the Clinical Services Division (CSD) is to explain the division's program and commitment to monitor, evaluate, and improve the quality of health care and services given to the citizens of Maricopa County. Focusing on the technical quality of care, the efficiency of care, and the quality of service received by the clients, the division objectively and systematically monitors and assesses the quality and appropriateness of care and services that it delivers. Through these activities, the division identifies opportunities for improvement, unresolved quality issues, client complaints, and inefficiencies in care and service delivery. The CSD QMP uses techniques of continuous quality improvement to correct deficiencies, improve care processes and improve service. II. Authority The authority and accountability for the program ultimately rests with the Director of the Department of Public Health of Maricopa County (Director). The Director has delegated the development, implementation and evaluation of the program to the Clinical Services Division Administrator (Administrator). The Director will review and approve the overall program, the quality improvement (QI) initiatives, and the program's annual evaluation. Additionally, the Director is responsible for assuring that there are appropriate resources to carry out the program. An annual evaluation of the program is submitted to the Director. This evaluation includes a description of completed and continuing QM activities. The evaluation trends and measures performance in quality of clinical care and quality of service, analyzes whether there have been improvements in the quality of clinical care and quality of service to clients, and assesses the overall effectiveness of the program. III. Goal The division's overarching goal is to demonstrate improvements in the clinical care and services provided to clients. IV. Scope of the Quality Management Program The QMP reviews and evaluates clinical and other service dimensions of the division's delivery system. In order to fulfill the goals and objectives of this program and to The program uses objective and measureable performance parameters. Areas reviewed may include: • Delivery system design • Administrative support services • Complaint/grievance review • Credentialing/Recredentialing • Chronic conditions • Client satisfaction • Medical records Results are communicated to the QM Committee and ultimately to the Director. VI. Supporting Committees and Personnel Director, Department of Public Health The Director ensures that the Quality Management Program is working effectively to monitor and improve the quality of care and services and promote the goals and objectives of the QMP. The Director meets this responsibility by reviewing reports and studies used to gauge the quality of care and services, and monitoring the continuous improvement of the care quality. Additionally, the Director recommends improvements in clinical and quality processes. Medical Director, Clinical Services The Medical Director, Clinical Services, provides feedback and facilitates implementation of corrective actions. The Medical Director meets with the Quality Management Committee at least twice each year to review quality activities and reports created by these activities. Clinical Services Quality Assurance Committee The Clinical Services Quality Assurance Committee is a standing committee comprised of program managers within the Clinical Services Division, Department of Public Health. The Clinical Services Quality Assurance Committee meets at least quarterly and reviews issues related to quality assurance throughout clinical services. The Clinical Services Quality Assurance Committee approves the program's Quality Assurance Plan and Quality Performance Indicators. The Administrator reports results of quarterly quality assurance audits to the Clinical Services Quality Assurance Committee, who will recommend improvements to administrative and medical operations and corrective action plans. • Adoption of indicators • Measurement of compliance with standards • Review of findings and issue identification • Identification of opportunities for improvement • Interventions and corrective actions • Reevaluation and follow-up XII. Integration/Coordination The division integrates QM activities throughout its operations. This vital exchange of information takes place through staff participation on committees, staff meetings, and through informal communications. Information from throughout the organization is also used in the recredentialing process. Healthcare for the Homeless Clinic Quality Assurance Program 2017 I. Purpose The purpose of the Quality Assurance Program (QAP) of the Healthcare for the Homeless Clinic (HCH) is to explain the clinic’s program and commitment to monitor, evaluate, and improve the quality of health care and case management services given to the homeless of Maricopa County. Focusing on the technical quality of care, the efficiency of care, and the quality service received by the clinic’s clients, the program objectively and systematically monitors and assesses the quality and appropriateness of care and services delivered in the clinic. Through these activities the program identifies opportunities for improvement, unresolved quality issues, client complaints, and inefficiencies in care and service delivery. The HCH QAP uses techniques of continuous quality improvement to correct deficiencies, improve care processes and improve service. II. Authority The authority and accountability for the program ultimately rests with the Director of the Department of Public Health of Maricopa County (Director). The Director delegates the development, implementation and evaluation of the program to the HCH Program Supervisor (Supervisor) through the Medical Director for Clinical Services (Medical Director). The Director will review and approve the overall program, the Quality Improvement (QI) initiatives, and the program’s annual evaluation. The Director will periodically evaluate the performance in quality of clinical care and quality of service, analyze whether there have been improvements in the quality of clinical care and quality of service to clients, and assess the overall effectiveness of the program. Additionally, the Director is responsible for assuring that there are appropriate resources to carry out the program. III. Goal The program’s overarching goal is to demonstrate improvements in the clinical care and case management services provided to clients. IV. Scope of the Quality Assurance Program The QAP reviews and evaluates clinical and case management services dimensions of the HCH health care delivery system. In order to fulfill the goals and objectives of this program and to efficiently use resources, the program functions as an integrated activity within HCH. It addresses, but is not limited to, the following areas: • Quality of medical care • Service availability • Patient’s rights • Policies and procedures • Medical records • Risk management o Infection control o Equipment o Safety o Security • Continuity of care • Drug Delivery System • Laboratory • Case Management • Substance Abuse Treatment • Mental Health Treatment • Housing Referral V. Objectives The QAP description is designed to achieve the following objectives: • Develop and maintain an integrated system to continuously identify, measure, assess, improve and re-measure aspects of care and service provided to clients • Assure that health care is available, accessible, and appropriate to the client’s needs • Support preventative health and health maintenance activities • Assure timely identification, assessment and resolution of known or suspected problems negatively affecting clients through prompt and fair responses to complaints, appeals and grievances of our clients • Communicate and report important quality findings and recommendations to appropriate parties • Maintain compliance with local, state, and national regulatory requirements and regulatory standards • Assure practitioner quality and skill through appropriate credentialing and re-credentialing • Peer review • Measure and maintain client and practitioner satisfaction The program uses objective, measurable, and statistically valid performance parameters. Areas reviewed may include: • Delivery System Design • Administrative support services • Behavioral health • Complaint/grievance review • Preventative health services • Credentialing/Re-credentialing • Chronic conditions • Client satisfaction • Medical records Results are communicated to the Quality Management Committee and to the Director. VI. Supporting Committees and Personnel Director, Department of Public Health The Director ensures that the QAP is working effectively to monitor and improve the quality care and services and to promote the goals and objectives of the QAP. The Director meets this responsibility by reviewing reports and studies used to gauge the quality of care and services, and by monitoring the continuous improvement of the quality of care. Additionally, the Director recommends improvements in clinical and quality processes at HCH. Medical Director, Clinical Services The Medical Director of Healthcare for the Homeless is actively engaged in this responsibility by providing direct care and interacting regularly with the providers and staff, reviewing reports and studies used to gauge the quality of care and services, and by monitoring the continuous improvement of the quality of care. Additionally, the Medical Director of Healthcare for the Homeless recommends improvements in clinical and quality processes and corrective action at HCH. The Medical Director of Healthcare for the Homeless meets with the Quality Management Committee quarterly to review quality activities and reports created by these activities. Supervisor reports regularly to Director who then provides feedback to HCH and facilitates implementation of corrective actions. The Director delegates the development, implementation and evaluation of the program to the HCH Program Supervisor (Supervisor) through the Medical Director for Clinical Services (Medical Director). Clinical Services Quality Assurance Committee The Clinical Services Quality Assurance Committee is a standing committee comprised of program managers within the Clinical Services Division, Department of Public Health. The Clinical Services Quality Management Committee meets at least quarterly and reviews issues related to quality assurance throughout clinical services. The Clinical Services Quality Management Committee approves the program’s Quality Assurance Plan and Quality Performance Indicators. The Supervisor reports results of quarterly assurance audits to the Clinical Services Quality Management Committee, who will recommend improvements to administrative and medical operations and corrective action plans. Quality Management Committee The Quality Management (QM) Committee is comprised of the members of the HCH management team and meets quarterly. The QM Committee is charged to: • Create the Quality Assurance Program • Review administrative and quality reports • Determine the priority of QAP activities • Determine Quality Improvement (QI) studies and projects • Review complaints and grievances and determine corrective actions • Oversee and implement changes to the QAP • Evaluate delivery systems • Report quarterly to the Director and the Clinical Services Quality Assurance Committee VII. Evaluation of Program The QAP is evaluated at least annually by the QM Committee and may be amended at any time. The QM evaluation reviews all aspects of the program with emphasis on determining the effect of the program on HCH’s quality of care and quality of service. Further, the Program evaluation assesses the overall effectiveness of the quality assurance processes. The QAP evaluation findings are used to develop the annual work plan for the upcoming year. The QM Committee reviews and approves the QAP evaluation. The QM Committee submits the evaluation to the Director for approval. VIII. Work Plan Based on the annual evaluation of the previous year’s QAP, the QM Committee formulates the QA Work Plan (Work plan) by the end of the first quarter of the following year. The plan identifies the activities and studies that are to occur in the next year. The Work plan includes target dates for completion and the responsible party(ies) for each QI activity. Previously identified issues are tracked and activities linked to the previous year’s plan. IX. Confidentiality All quality assurance worksheets, study results and meeting minutes are confidential information and are protected from discovery by state statute. All staff and committee members will respect this confidentiality and will not release information without obtaining prior consent. Everyone who has access to this material will sign a Confidentiality and Conflict of Interest statement. The findings of the QM Committee are considered part of the program. Such findings, if they contain identifiable personal information, will not be released to any outside agency (unless required by law or court order) without the assurance that the confidentiality of that data will be maintained, and without permission of the originating agency or affected party, as appropriate. X. Conflict of Interest No person may participate in the review, evaluation, discussion or final disposition of any issue or case in which he or she has been personally, professionally or financially involved, or in which his or her judgment may be compromised. XI. Quality Improvement Process The HCH Quality Improvement (QI) Process identifies opportunities to improve the clinical quality of care, the process of care delivery, and the quality of service to its clients. The QI Process consists of: • Adoption of indicators • Measurement of compliance with standards through indicators and peer review • Review of findings and issue identification • Identification of opportunities for improvement • Interventions and corrective actions • Reevaluation and follow-up XII. Integration/Coordination The clinic integrates QA activities throughout its operation. This vital exchange of information takes place through staff participation on committees, staff meetings, and through informal communications. Information from throughout the organization is also used in the re-credentialing process. PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 6 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #19 CONFLICT OF INTEREST POLICY Compliance Review Findings: MCPHD is a Section 330(h) grantee and has an approved waiver for 51 percent majority patients. In order to ensure patient input and participation, MCPHD: • Conducts monthly focus groups with patients. An attendance log is kept with discussion documented. Open-ended questions are asked to encourage participation and communication. • There is no process for formally communicating input directly to the MCPHD governing board as there is none. • Patient input is not being used by the governing board in areas such as: 1) selecting health center services areas, 2) setting health center operating hours, 3) defining budget priorities, 4) evaluating the organization’s progress in meeting goals, including patient satisfaction and 5) other relevant areas of governance that require and benefit from patient input. There is currently no governing board overseeing or advisory committee of the board overseeing Section 330(h) funding. • As a Section 330(h) grantee, the following program requirements are not required for compliance: – The board has at least 9 but no more than 25 members as appropriate for the complexity of the organization. – The remaining non-consumer members of the board shall be comprised of members with a broad range of skills, expertise, and perspectives. – No more than 50 percent of the non-patient representatives may derive more than 10 percent of their annual income from the health care industry. Action Recommended for Compliance: MCPHD must follow PIN 2014-01 and implement a board of directors in order for patient input to be used as participation in the organization, direction, and ongoing governance of the health center. Input of information from patient focus groups and surveys must be reported to the MCPHD board of directors and used for input in the following areas: • Selecting health center services • Setting health center operating hours • Defining budget priorities • Evaluating the organization’s progress in meeting goals • Other relevant areas of governance that require and benefit patient input Program Response: Introduction Maricopa County appreciates the opportunity to have participated in the Operational Site Visit conducted August 23, 2016 through August 25, 2016, and September 12, 2016 and September 16, 2016. Maricopa County has operated the Health Care for the Homeless Program under Section 330(h) for over 30 years. The Program has provided primary care and enabling services to hundreds of thousands of our most vulnerable community members during that period of time. It has been an honor and a privilege to have served our homeless population by providing exceptional, high quality health care services. HRSA released Policy Information Notice (PIN) 2014-01 in January 2014. The PIN provided detailed information about the governance requirements for Health Care for the Homeless Programs. Unfortunately, the new governance requirements are not conducive to the structural and operational nuances of a local government agency such as Maricopa County. Maricopa County operates under the jurisdiction of a locally elected Board of Supervisors as established by the Arizona Constitution, with powers and duties as delineated in Arizona Revised Statutes. Although the PIN offered two options to meet the governance requirements, by using either the current Board of Supervisors (with some modification) or the establishment of a co-applicant board, neither option will allow Maricopa County to continue providing high quality health care and enabling services to the homeless population without the Board of Supervisors accepting substantial financial risk coupled with loss of programmatic control and oversight from the County Manager and the Director of the Department of Public Health. Plan of Action Conditions related to compliance with PIN 2014-01 and governance of the Health Care for the Homeless Program are included in the most recent Notice of Award, dated January 5, 2017. The conditions, numbered 1 through 9, were all included in the final report of the Operational Site Visit conducted in August and September 2016. This plan is submitted and proposed for the condition as listed and numbered as 1. Conditions numbered as 2 through 6 (partial), 8 and 9, have been addressed separately. The conditions numbered as 6 (partial) and 7 are not applicable to programs funded solely through Section 330(h), and therefore, and in accordance with the PIN, the Maricopa County Health Care for the Homeless Program is exempt from these requirements. The exemption as allowed in the PIN includes portions of the condition numbered as 6 related to board members as employees of the health center, and the CEO serving only as a nonvoting exofficio member of the board and the condition numbered as 7, related to the composition of the governing board. Maricopa County is in the final year of the current project period. The project period will end December 31, 2017, and if it were to continue, Maricopa County would be submitting an application for a new project period through the 2017 Service Area Competition process. Because of its inability to meet the governance requirements under its current structure, Maricopa County does not intend to submit an application in the upcoming Service Area Competition solicitation. It should be noted that the Maricopa County Health Care for the Homeless Program is in compliance with conditions numbered as 2, 3, 4, 5, 6, 8 and 9, with the exception of approval of those items by a governing board established pursuant to PIN 2014-01. To remedy the governing board situation and to resolve the issue of noncompliance with PIN 2014-01, the Maricopa County Department of Public Health is proposing to work with another agency in the community to submit an application for funding under the upcoming Service Area Competition solicitation. In effect, the Maricopa County Department of Public Health will cease its operation of the Health Care for the Homeless Program on December 31, 2017, and another agency, if chosen by HRSA in their grant award process, will open a new Health Care for the Homeless Program on January 1, 2018. The County will seek to work with another community agency that will offer, at a minimum, the same level of quality services that are currently being provided to the homeless population and in the same location that services are currently being offered within the county. There are a number of agencies within Maricopa County that are currently providing services to the homeless community, and at least one of those agencies has expressed an interest in submitting an application to provide services within the area that the Maricopa County Health Care for the Homeless Program is currently serving. The agency that has expressed interest currently operates another Health Care for the Homeless Program in Maricopa County, and also recently underwent an Operational Site Visit which resulted in no unmet governance or compliance issues. The Department of Public Health will assist another agency with the preparation of its application through the Service Area Competition process, and will commit its full support and assistance to that agency. Once a new applicant is selected by HRSA to provide services within the service area, the Department of Public Health will commit the resources necessary to ensure a smooth transition of the program to the new grantee. Maricopa County intends to be "in compliance" with the governance requirements as set forth in PIN 2014-01 by January 1, 2018, by no longer operating a Health Care for the Homeless Program. Between now and January 1, 2018, the Maricopa County Department of Public Health will be working with another agency (or agencies) to develop a solid, robust application to be submitted under the upcoming Service Area Competition, and then working with HRSA's new grantee to ensure a smooth transition that is intended to be "invisible" to the homeless clients currently being served. We are hopeful that HRSA will be agreeable to continue funding the Maricopa County Health Care for the Homeless Program through the last year of the current project period (ending December 31, 2017). Attachments: • None PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 7 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #18 BOARD COMPOSITION Compliance Review Findings: MCPHD is a Section 330(h) grantee and has an approved waiver for 51 percent majority patients. In order to ensure patient input and participation, MCPHD: • Conducts monthly focus groups with patients. An attendance log is kept with discussion documented. Open-ended questions are asked to encourage participation and communication. • There is no process for formally communicating input directly to the MCPHD governing board as there is none. • Patient input is not being used by the governing board in areas such as: 1) selecting health center services areas, 2) setting health center operating hours, 3) defining budget priorities, 4) evaluating the organization’s progress in meeting goals, including patient satisfaction and 5) other relevant areas of governance that require and benefit from patient input. There is currently no governing board overseeing or advisory committee of the board overseeing Section 330(h) funding. • As a Section 330(h) grantee, the following program requirements are not required for compliance: – The board has at least 9 but no more than 25 members as appropriate for the complexity of the organization. – The remaining non-consumer members of the board shall be comprised of members with a broad range of skills, expertise, and perspectives. – No more than 50 percent of the non-patient representatives may derive more than 10 percent of their annual income from the health care industry. Action Recommended for Compliance: MCPHD must follow PIN 2014-01 and implement a board of directors in order for patient input to be used as participation in the organization, direction, and ongoing governance of the health center. Input of information from patient focus groups and surveys must be reported to the MCPHD board of directors and used for input in the following areas: • Selecting health center services • Setting health center operating hours • Defining budget priorities • Evaluating the organization’s progress in meeting goals • Other relevant areas of governance that require and benefit patient input Program Response: Introduction Maricopa County appreciates the opportunity to have participated in the Operational Site Visit conducted August 23, 2016 through August 25, 2016, and September 12, 2016 and September 16, 2016. Maricopa County has operated the Health Care for the Homeless Program under Section 330(h) for over 30 years. The Program has provided primary care and enabling services to hundreds of thousands of our most vulnerable community members during that period of time. It has been an honor and a privilege to have served our homeless population by providing exceptional, high quality health care services. HRSA released Policy Information Notice (PIN) 2014-01 in January 2014. The PIN provided detailed information about the governance requirements for Health Care for the Homeless Programs. Unfortunately, the new governance requirements are not conducive to the structural and operational nuances of a local government agency such as Maricopa County. Maricopa County operates under the jurisdiction of a locally elected Board of Supervisors as established by the Arizona Constitution, with powers and duties as delineated in Arizona Revised Statutes. Although the PIN offered two options to meet the governance requirements, by using either the current Board of Supervisors (with some modification) or the establishment of a co-applicant board, neither option will allow Maricopa County to continue providing high quality health care and enabling services to the homeless population without the Board of Supervisors accepting substantial financial risk coupled with loss of programmatic control and oversight from the County Manager and the Director of the Department of Public Health. Plan of Action Conditions related to compliance with PIN 2014-01 and governance of the Health Care for the Homeless Program are included in the most recent Notice of Award, dated January 5, 2017. The conditions, numbered 1 through 9, were all included in the final report of the Operational Site Visit conducted in August and September 2016. This plan is submitted and proposed for the condition as listed and numbered as 1. Conditions numbered as 2 through 6 (partial), 8 and 9, have been addressed separately. The conditions numbered as 6 (partial) and 7 are not applicable to programs funded solely through Section 330(h), and therefore, and in accordance with the PIN, the Maricopa County Health Care for the Homeless Program is exempt from these requirements. The exemption as allowed in the PIN includes portions of the condition numbered as 6 related to board members as employees of the health center, and the CEO serving only as a nonvoting exofficio member of the board and the condition numbered as 7, related to the composition of the governing board. Maricopa County is in the final year of the current project period. The project period will end December 31, 2017, and if it were to continue, Maricopa County would be submitting an application for a new project period through the 2017 Service Area Competition process. Because of its inability to meet the governance requirements under its current structure, Maricopa County does not intend to submit an application in the upcoming Service Area Competition solicitation. It should be noted that the Maricopa County Health Care for the Homeless Program is in compliance with conditions numbered as 2, 3, 4, 5, 6, 8 and 9, with the exception of approval of those items by a governing board established pursuant to PIN 2014-01. To remedy the governing board situation and to resolve the issue of noncompliance with PIN 2014-01, the Maricopa County Department of Public Health is proposing to work with another agency in the community to submit an application for funding under the upcoming Service Area Competition solicitation. In effect, the Maricopa County Department of Public Health will cease its operation of the Health Care for the Homeless Program on December 31, 2017, and another agency, if chosen by HRSA in their grant award process, will open a new Health Care for the Homeless Program on January 1, 2018. The County will seek to work with another community agency that will offer, at a minimum, the same level of quality services that are currently being provided to the homeless population and in the same location that services are currently being offered within the county. There are a number of agencies within Maricopa County that are currently providing services to the homeless community, and at least one of those agencies has expressed an interest in submitting an application to provide services within the area that the Maricopa County Health Care for the Homeless Program is currently serving. The agency that has expressed interest currently operates another Health Care for the Homeless Program in Maricopa County, and also recently underwent an Operational Site Visit which resulted in no unmet governance or compliance issues. The Department of Public Health will assist another agency with the preparation of its application through the Service Area Competition process, and will commit its full support and assistance to that agency. Once a new applicant is selected by HRSA to provide services within the service area, the Department of Public Health will commit the resources necessary to ensure a smooth transition of the program to the new grantee. Maricopa County intends to be "in compliance" with the governance requirements as set forth in PIN 2014-01 by January 1, 2018, by no longer operating a Health Care for the Homeless Program. Between now and January 1, 2018, the Maricopa County Department of Public Health will be working with another agency (or agencies) to develop a solid, robust application to be submitted under the upcoming Service Area Competition, and then working with HRSA's new grantee to ensure a smooth transition that is intended to be "invisible" to the homeless clients currently being served. We are hopeful that HRSA will be agreeable to continue funding the Maricopa County Health Care for the Homeless Program through the last year of the current project period (ending December 31, 2017). Attachments: • None PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 8 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #6 BOARD AUTHORITY Compliance Review Findings: Health center physicians have admitting privileges at one or more referral hospitals, or other such arrangement to ensure continuity of care. In cases where hospital arrangements (including admitting privileges and membership) are not possible, health center must firmly establish arrangements for hospitalization, discharge planning, and patient tracking. (Section 330(k)(3)(L) of the PHS Act). Action Recommended for Compliance: MCPHD must develop an MOU with at least one area hospital to ensure their patients have unrestricted access to emergency room and inpatient facilities. An MOU would also ensure that appropriate health information exchange takes place. Program Response: The program is currently working with Maricopa Integrated Health Systems to develop an MOU to meet this requirement. The program will finalize the agreement, and seek approval of the Board of Supervisors, prior to June 1, 2017. Attachments: • None PLAN OF ACTION FOR COMPLIANCE NOA CONDITION NO. 9 HRSA Notice of Award Date Issued: January 5, 2017 Project Period: November 1, 2001 through December 31, 2017 Project Title: Health Center Cluster Grant No.: H80CS00044 Award No.: 6 H80CS00044-16-01 Grantee: Maricopa County Department of Public Health 220 S. 12th Ave. Phoenix, AZ 85007 DUNS Number: 145454000 Submitted March 31, 2017 PROGRAM REQUIREMENT #16 SCOPE OF PROJECT Compliance Review Findings: Some changes are needed on Form 5A in order to bring it up to date. Form 5B needs a change to add another site, UMOM New Day Centers. This is a shelter that regularly offers services. This change had been submitted but not yet approved. Form 5C reflects both clinical and non-clinical outreach activities. It is accurate and up to date. Action Recommended for Compliance: MCPHD must submit a Change In Scope through the electronic Handbook to bring Form 5A up to date. Under required services, the following changes must be made: Column III services can be removed to reflect the services are given to the homeless through the Column II model, paid for by the health center. Any referral service made for an insured patient would be made to the provider the company dictated, making formal agreements with individual providers unnecessary. The one exception is the emergency service requirement, which should have an MOU with at least one hospital to accept MCPHD patients in the emergency room. For additional services, the same thing is true. MCPHSD must assure the mode of provision of services is accurately reflected. For specialty services, podiatry should be removed from Columns I and II as the service is no longer offered. Program Response: • Change of Scope requests were submitted on February 21, 2017. • Approved by the Maricopa County Board of Supervisors on _____________, 2017. Attachments: • Confirmation of Submission of Change in Scope Requests (2) Corinne Velasquez - PHSX From: HRSA EHBs System User <oitgems@hrsa.gov > Sent: Tuesday, February 21, 2017 12:55 PM To: Corinne Velasquez PHSX Subject: CIS Request Submitted (Tracking No: CIS00046376) This email is to notify you the change in scope request with tracking no CIS00046376 for grant H8OCS00044 has been successfully submitted. This request will be reviewed by IIRSA and you will be notified appropriately. Please note down the tracking mimber and use it for all future correspondence with HRSA related to this CIS request. You can view a copy of your CIS request in your grant handbook. If you have any questions related to the CIS request, please contact the Project Officer. This is a system generated message. Please do not respond to this message. Corinne Velasquez - PHSX From: HRSA EHBs System User <oitgems@hrsa.gov > Sent: Tuesday, February 21, 2017 12:46 PM To: Corinne Velasquez - PHSX Subject: CIS Request Submitted (Tracking No: CIS00046374) This email is to notify you the change in scope request with tracking no CIS00046374 for grant H8OCS00044 has been successfully submitted. This request will be reviewed by HRSA and you will be notified appropriately. Please note down the tracking number and use it for all future correspondence with HRSA related to this CIS request. You can view a copy of your CIS request in your grant handbook. If you have any questions related to the CIS request, please contact the Project Officer. This is a system generated message. Please do not respond to this message. C-86-02-073-2-49 ATTACHED TO AND A PART OF Governance and Compliance, Healthcare for the Homeless U. S. Department of Health and Human Services, Health Resources and Services Administration Health Center Cluster Notice of Award No. H80CS00044-15-00 IN WITNESS WHEREOF, the parties agree to enter into this Contract and its Amendments: FOR AND ON BEHALF OF MARICOPA COUNTY By Denny Barney Chairman, Board of Supervisors Date ATTEST: Clerk of the Board Date APPROVED AS TO FORM: Attorney for Maricopa County Date Page 8