Continuous HRSA Compliance: Right After Your OSV (33-36 Months Out)

The HRSA Reviewers just left your building (either literally or figuratively in the virtual-age) – congratulations! You no-doubt worked really hard to get all of your documents ready and the process was likely exhausting for everyone involved. Your team probably learned a bunch as well – there is nothing that will teach you compliance like an Operational Site Visit (OSV). Grab a cold drink and celebrate with the team – you earned it!

But after a quick celebration, it’s important to turn your focus to transitioning your health center to a continuous HRSA compliance mindset. Maybe you were already in that mindset for this last OSV. But if you are like the majority of health centers across the county, you might have begun your preparation a little later than you would have liked and the months and weeks leading up to your OSV were a little less-than-peaceful.

Anticipate The Fires…Start Early!

If there is one phrase I hear more often than any other it is, “When things calm down, we’ll focus on HRSA compliance.” I hate to be the bearer of bad news, but after two decades in healthcare, I haven’t seen a time when things “calm down”. “Fires” that need to be put out always come up…EHR go-lives, staffing challenges, global pandemics…there is always something that comes up. We can’t always prevent them or even know when the fires will need our attention. But we can anticipate that they will happen. So, the first recommendation after your OSV is to anticipate that there will be numerous “fires” that will steal your team’s attention through the next three years be leading up to your next OSV. And if you are anticipating them, this means you will need to get started early so you have plenty of flexibility to adjust to those crises when (not if) they arise.

Start While The Information is Fresh!

We know how exhausting the site visit preparation process was. The tendency is to shut-down, relax, and push compliance to the back burner – “mission accomplished” and “we’ll think about this again later”. But right after your OSV, the information you learned is fresh and front-of-mind. If you wait to look back at your notes in a few years, there is a strong likelihood that you won’t remember some of the specifics of recommendations that reviewers made (many of them will not be in any written report) and the opportunity to act on their advice will be lost. Also, the fact is that some of your health center staff who were involved in this OSV, might move on to other jobs and leave your organization between now and then. If your team does not systematize some of the lessons learned during this OSV, when those staff leave, they will also take with them many of those valuable lessons learned. The time and money invested in those staff is not something you can afford to lose.

Compliance Resolution Opportunity

Back in the “old days”, HRSA would allow what they called “quick fixes” during the Operational Site Visit. If a reviewer noted that there was some key language missing in a policy or procedure, commonly, they would allow the staff to quickly update the policy, call an emergency board meeting to get it approved, and present the changes to the review team before they left your health center. Today, “quick fixes” are no longer permitted, and the “Compliance Resolution Opportunity” is the process that replaces it. Now, if the health center had any findings of non-compliance recommended by the reviewers, they will receive a “Correspondence Request Task” through their Electronic Handbook (EHB). From the time the health center receives this request, they will have 14 days to submit documentation demonstrating compliance in the EHB. If health centers submit sufficient documentation demonstrating that findings have been corrected before the end of the 14-day period, HRSA will not carry the recommended findings over to the final report. If you need a little help quickly correcting these findings, we can help as well. So, an investment during those 14 days will save you time in the long-run!

Update Your Documents

The reviewers will likely provide you a great deal of advice and recommendations to improve your operations while they are working with you. If you used RegLantern to organize and share your documents with the reviewing consultants, now is the time to make changes to your documents and re-upload them to the platform. When you do this, you will establish new “expiration dates” that will proactively remind you that the documents need to be reviewed, so use this time to set systems in place to check back in with these documents prior to your next OSV. If you update your documents at this time while it is fresh in your mind, you will be using the RegLantern platform to help your health center to turn into a continuous compliance machine!

Subscribe to HRSA Updates

Each day, it is not uncommon for our team to talk with health centers who are not using the most-current HRSA Health Center Program Site Visit Protocol or HRSA Health Center Program Compliance Manual. These documents are frequently updated and contain invaluable information. If your health center is subscribed to our compliance platform, you don’t need to worry – we keep our system updated with the very most-up-to-date info. However, if you are not, we recommend you subscribe to the HRSA newsletters and keep an eye out for key compliance updates and changes.

Develop a Continuous HRSA Compliance Plan

You may have had a rather chaotic preparation period right before your OSV and you likely don’t want to do that again. RegLantern has created a Continuous HRSA Compliance Road Map that can be customized to your health centers and the date of your next OSV. If you would like for us to create a customized plan for you and your health center, please set-up a quick 15-minute call with our team so we can quickly gather the date of your next OSV and some other basic information.

Has it been a little while since your last OSV? No problem! In the coming weeks, we will be providing recommendations for how to move toward being continuously HRSA compliant…at whatever point you find yourself in the health center project period life cycle.