Monthly Archives: April 2018

2019 FTCA Re-Deeming Application Outline

The new FTCA application provides some challenges to organizing it in a cohesive and coordinated outline to support our clients’ understanding of the application elements and attachments.  The attestations provide for some healthy discussions around their established risk management policies, procedures, plans, and program.

We came up with the attached document that we are beginning to use.  Take a look at it and let me know your thoughts. If you would like, use the outline to support your own application process.

Have a great week!

– Eileen

2019 FTCA Documents 4-30-18

CEO/CMO – Combined Position OK with HRSA

Today, I received confirmation that the CEO can in fact also be the Chief Medical Officer/Medical Director.  It has been the practice in the past that we separate these two – however, there is no need “as long as the grantee/LAL applicant can present a proposal to HRSA that is logical and reflects their scope of project, the combination of CEO/CMO could be allowable.” (BPHC Answers <>) This is a great opportunity for some of the smaller health centers that are managed by physicians to continue the practice of their CEO also providing the clinical oversight. Also, remember that HRSA is changing the option of contracting for the CEO/Project Director. FQHCs can no longer contract for the CEO position as explained in the manual on Page 46 – “The health center’s governing board determines under what circumstances it is appropriate and necessary to contract for the Project Director/CEO position rather than directly employ this individual.” The revised manual is expected out shortly.

Sign up for email updates with FQHC Source, we will continue to post information as we get it.

Have a wonderful weekend!


Define and Annually Review Service Area – Chapter 3: Needs Assessment


Since our annual review of data (UDS and OSHPD Alirts) is still fresh in our minds, I am currently completing the annual review of my clients “catchment area.” This second “Needs Assessment” requirement mandates that we do the following from Element a, Chapter 3, page 20:

“The health center identifies and annually reviews its service area 1 based on where current or proposed patient populations reside as documented by the ZIP codes reported on the health center’s Form 5B: Service Sites. In addition, these service area ZIP codes are consistent with patient origin data reported by ZIP code in its annual Uniform Data System (UDS) report (for example, the ZIP codes reported on the health center’s Form 5B: Service Sites would include the ZIP codes in which at least 75 percent of current health center patients reside, as identified in the most recent UDS report).”

Has anyone done this review in the past? I have to some extent as part of the Needs Assessments completed every three years, but this is a little more in-depth. Here’s what I’m currently doing for my clients:

  • Pulling the health center’s zip codes off their Form 5B – from every site and copying them over to a spreadsheet. This is your recognized service area;
  • Printing out the pages of the UDS report that gives me the zip codes;
  • Going right down the list and plugging in the totals from the report for each of the zip codes; and
  • Comparing this data to the 2016 UDS data for any significant changes.

The remaining assessment is unique for each health center. Depending upon the data at hand, you can put forth the recommendation to add any zip codes to your service area that have more than 20 patients, 50 patients, 75 patients, whatever number you think is logical. Or you can think about removing zip codes from your service area that have a very low patient count. These types of decisions will be discussed at the management level – and remember, the Board needs to be in on the discussion and always provide the approval.

I have also developed some statistics to support the review:

  • Percentage of patients who come from the service area – HRSA wants at least 75%.
    Totals by County.
  • Totals by site. This has helped my clients to know if there is any site based in- or out-migration of patients.
  • Additional zip codes that HRSA added to your UDS this year. Also – those that were deleted.

Keep in mind these are my thoughts on the assessment right now, but it will change as my clients start using it. I’ll keep you posted if we make any great discoveries.

Good luck!


FTCA Deeming – Don’t forget the Compliance Manual!


I’ve been thinking about our annual FTCA deeming application lately – actually my clients have been helping me with that as some are sending emails anxiously anticipating the submission. Just an FYI, HRSA EHB sent out a notice on March 29th stating that it will reopen and resume accepting applications on May 4th, 2018. But really, there’s no need to wait until then if you are ready to get going – which I would recommend. We just don’t know when those grants they’ve been talking about will be posted and, if we’ve got our act together on FTCA we can focus on expanding our programs and services when they are released, instead of trying to figure out how to document your quarterly risk management assessments.

Speaking of risk management assessments – did anyone get stumped on that last year? The Compliance Manual has a chapter on FTCA, Chapter 21, and included in the Related Considerations items the following: “The health center determines how to conduct and document the completion of quarterly risk management assessments.” P. 85. Yea, so this is HRSA tell you that they aren’t going to tell you what to include. Here’s a thought…

My clients and I had quite a lively discussion about this list last year and after some debate we decided to start asking ourselves what we do to assess the clinics’ performance in any area. Literally, we started from January and worked our way through the past year and the upcoming year listing everything we do to review, assess, track, and survey our patients, our staff, our EHRs, and our work. In the end, we were amazed at how many things we were doing that met our thoughts on what the quarterly risk assessments should include. Keep in mind that not all the assessments have to be completed quarterly, you are just required to complete quarterly assessments. We combined semi-annual, annual, bi-annual, quarterly, and monthly assessments to make up our final list. Here’s a partial list of the areas we looked at and found assessments being conducted or opportunities for assessment that we added to our risk management quarterly assessment quarterly calendar.

  • Patient Complaints and Grievances
  • Hazard Vulnerability Assessment
  • Meaningful Use
  • Compliance Review
  • Review of Forms 5A, 5B, 5C
  • Employee Survey
  • 340B Program Compliance
  • Billing – Aging reports

Let me know if you would like the complete list. And remember, FTCA is covered extensively in Chapter 21 of the Compliance Manual – it’s worth a read!

– Eileen


Continuous Compliance – An Affordable Solution to HRSA’s Compliance Mandate


“Continuous Compliance” is a term used today by Jim Macrae, Associate Administrator Bureau of Primary Health Care Health Resources and Services Administration U.S. Department of Health and Human Services on the BPHC All-Programs Webcast. He was speaking about health centers and how they need to adopt a practice of compliance with their FQHC program throughout the year, not just before you have an Operational Site Visit. It makes sense to me!

In support of health centers as you transition from the old PINS and PALS to the new Compliance Manual and as you develop your “continuous compliance” program, TCG has developed a consulting service that is affordable and ongoing. With an initial review followed by ongoing support and consulting services, the program will enable you to work with highly-skilled consultants through the year.

The Tremaine Consulting Group’s FQHC Continuous Compliance Package will provide expert consulting for the following:
A. Section 330 Compliance Risk Assessment – Initial Review of 18 Program Requirements
B. Develop Action Plan for completion of the identified risks.
C. Conduct Quarterly FQHC Compliance Meetings.
D. Provide 20 hours of consulting support per quarter to support the development of needed processes or documents to correct deficiencies identified in the Risk Assessment. Any other needed consulting can be accessed up to the 20 hours per quarter.

  • Initial Program Development – Items A and B listed above: Consulting includes a 2-Day Onsite Visit and the development of Action Plan for identified risks. $10,000/one-time cost
  • Ongoing Program – Items C and D listed above: Consulting support for 20 hrs/quarter. $4,000/quarter

The program kicks off with a two-day site visit providing a Compliance Manual overview and the completion of the Compliance Risk Assessment that identified key areas of improvement and a timeline for completion of the work. The program continues with quarterly FQHC Compliance Meetings to update program status and complete random audits should there not be any current identified areas of improvement.

Call me today to get your health center enrolled – (530) 524-5420. I’m only taking ten health center clients for this program so don’t wait until the slots are gone!