FQHC Series: Staffing
Health centers are defined in the Public Health Services Act (“PHSA”) as “entities that serve a population that is medically underserved, or a special medically underserved population comprised of migratory and seasonal agricultural workers, the homeless, and residents of public housing.” These health centers enjoy many benefits, including Health Services Resources Administration (“HRSA”) grant money to fund operations, medical malpractice coverage through the Federal Tort claims Act, enhanced Medicare and Medicaid reimbursement and others. To maintain these benefits, they are also required to operate their centers in accordance with 19 HRSA program requirements. All 19 of the requirements can be found on HRSA’s website listed here.
The earlier parts in this series discussed how FQHCs and CHCs comply with HRSA’s requirements related to Needs Assessment and Services. We will now look at the requirements for and best practices to comply with the third compliance requirement “Staffing”.
Based on the scope of services, and sites where these services are provided, as documented in Form 5A and Form 5B respectively, the health center must be staffed appropriately. Section 330(a)(1), (b)(1)-(2), (k)(3)(C), and (k)(3)(I) of the PHS Act requires that the health center maintains a core staff as necessary to carry out all 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.
The health center would demonstrate compliance with these requirements by:
1 – Ensuring that it has clinical staff and/or contracts or referral arrangements with other service providers or provider organizations to carry out all required and additional services included in the scope of services approved by HRSA.
- Clinical staff include licensed independent practitioners (LIPs) such as physicians, dentists, and nurse practitioners. Other licensed or certified practitioners (OLCPs) include but are not limited to registered nurse, dietician and certified medical assistant. Other clinical staff who provide services include medical assistants or community health workers who do not require licensure or certification.
2 – Considering the size, demographics, and health needs of its patient population in the health center’s catchment area in determining the number and ratio of clinical staff necessary to ensure reasonable access to services.
3 – Establishing board approved operating policies and/or operating procedures for initial and recurring review of credentials and privileges for all LIPs, OLCPs and other clinical staff who are either health center employees, contractors or volunteers. Privileging is the process of authorizing a health care practitioner’s specific scope and content of patient care services.
- The procedures for credentialing would ensure verification of:
- Current licensure, registration or certification;
- Education and training for initial credentialing;
- Completion of a query through the National Practitioner Databank (NPDB);
- Identity using a government issued picture identification;
- Drug Enforcement Administration (DEA) registration; and
- Current documentation of basic life support training
- The procedures for privileging would ensure verification of:
- Fitness for duty, immunization and communicable disease status based on recommendations published by the CDC and state
- Clinical competence through education and training, and available reference reviews for initial privileging
- Current clinical competence via peer/supervisor review for renewal of privileges
- The procedure should also include a process for denying, modifying or removing privileges based on assessments of clinical competence and/or fitness for duty.
- Credentialing and privileging policies should be compliant with PIN 2002-22: “Clarification of Bureau of Primary Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16”. As per PIN 2002-22:
- the qualifications of all LIPs must be assessed and confirmed at a minimum of every two years
- For all licensed and certified practitioners, licensure must be primary source verified initially and on re-credentialing
- The qualifications of OLCPs must be confirmed upon hire by secondary source verification
4 – Based on the above procedures, maintaining clinical staff records that include documentation of licensure, credentialing verification, and applicable privileges
5 – If the health center has contracts or formal, written referral agreements with provider organizations, the health center should ensure that providers are:
- Licensed, certified, or registered as verified through a credentialing process, in accordance with applicable Federal, state, and local laws; and
- Competent and fit to perform the contracted or referred services, as assessed through a privileging process
Your focus on compliance should be to prepare for a site visit. The best way to prepare for a compliance review is to ask yourself the questions contained in the health center site visit guide. Is your clinical and non-clinical staff sufficient to serve the patient population consistent with your scope of project included on Form 5A and 5B? Are your providers all licensed or certified to perform the activities included in your approved scope of project? Do you have a staffing profile and privilege list? Do you have documented credentialing and privileging policies and procedures? Are the credentialing and privileging policies compliant with PIN 2002-22? Do you have contracts, agreements for arrangements with provider organizations to provide services included in HRSA approved scope?
A site visit contractor will perform review of your center’s documentation in advance of the site visit where applicable. The contractor will also conduct interviews with your staff to determine if those individuals have the qualifications to service your population. To prepare, ensure that your credentialing and staffing policy is compliant with PIN 2002-22, the organization has a process for tracking and maintaining current licenses in provider files, and staffing profile includes administrative and not-clinical support ratio as a percentage of full-time equivalent employees, among other things.
With the right amount of planning and attention to detail, you can put your FQHC or CHC in a good position to comply with this critical HRSA requirement.
Follow our FQHC and CHC Withum Weekly Pulse as we continue our series HRSA compliance requirements. Coming soon will be a discussion of the best practices related to the fourth compliance requirement “Accessible Hours of Operation/Locations”. If you have more questions, please fill out the form below and one of our experts will follow up with you.
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A copy of IRS Notice 2017-48 and News Release 2017-143 may both be accessed at the healthcare services section of our Firm’s Website.
