Developing a Continuous Compliance Policy and Plan

Over the past few years, the health center movement has been moving quickly into an era of expected “Continuous Compliance”. HRSA has both explicitly stated this expectation and implicitly moved the health center community into this era by fine-tuning the Operational Site Visit (OSV) process to be more objective and initiating the “One, One & Done” rule in which one or more conditions remaining on the health center’s record at the time of the service area competition (SAC) grant application results in a one-year (versus three) project period.

With the HRSA Program Requirements now being clearly spelled out in the HRSA Compliance Manual and the HRSA Site Visit Protocol, health centers have a defined end result. To move your health center now into “Continuous HRSA Compliance”, we recommend each health center develop a “road map” to get to that defined end result in the form of a “Continuous Compliance Policy and Plan”.

This policy should be individualized to the unique situations your health center encounters and the roles should be personalized to the roles your health center employs. However, we recommend that your health center Continuous Compliance Policy and Plan contain several key features:

  • The health center should develop a new, three-year Continuous Compliance Plan (CCP) every three years.
  • The CCP should be reviewed and a progress update should be reported to the Board of Directors (BOD) at least annually.
  • This CCP should schedule the review of all key HRSA Program Requirements at least once every three years.
  • The CCP should include at least one full review of HRSA Program Requirements (pertinent to the BOD) for the health center BOD at least once a year.
  • The health center leadership team should briefly discuss progress in relation to the CCP at least monthly, visually displaying the live dashboard (via projector) and discussing barriers and updating on progress.
  • At least three health center staff members (Example: CEO, COO, and Chief Compliance Officer) should be subscribed to the HRSA email newsletter subscriptions as well as the state Primary Care Association email list at all times.
  • These designated staff members will review email newsletters frequently to remain aware of any regulatory changes or updates.

For those using the RegLantern Continuous Compliance Tools:

  • Designated staff members should utilize the RegLantern HRSA Compliance web-based tools (as they are updated when regulatory changes occur).
  • The health center should assign at least one User Manager who has full administrative rights to add and delete users.
  • The User Manager should add at least six health center staff members to the RegLantern platform to ensure assignments are divided among the staff.
  • The User Manager should assign documents to upload in the Site Visit Protocol Checklist to various health center staff.
  • When documents are uploaded, the user should assign an “Expiration Date” to each document.
  • The RegLantern platform should be updated any time a policy or contract is updated.
  • All users should “Follow” relevant chapters pertinent to their position on RegLantern’s Community Forum.

When a health center implements a “Continuous Compliance Policy and Plan”, last-minute cramming-for-the-test chaos will be reduced, and staff will be calmer and better-prepared. There should no longer be a need for eleventh-hour Mock Site Visits priced at a premium for the rush and your Board of Directors will be less frustrated and overwhelmed if they can approve one to two policies for every Board meeting rather than 42 right before your OSV.

If you are interested in a sample “Continuous Compliance Policy and Plan”, please request a sample document from our team here.