Lake County Community Health Center Governing Council Met March 9.
Here is the minutes provided by the council:
1. Call to Order
Chair Smith-Taylor joined the meeting at 5:42 p.m., after the vote on Action Item 6.1. With the addition of Chair Smith-Taylor, quorum plus 1 was present, therefore, Member Fornero, who prior to the meeting submitted notification that he would not be able to attend unless his presence was needed to make quorum, left the meeting at 5:44 p.m.
Vice Chair Brown called the meeting to order at 5:36 p.m.
Present 7 - Absent 4 -
Member Fornero, Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
2. Pledge of Allegiance
Vice Chair Brown led the Pledge of Allegiance.
3. Approval of Minutes
3.1 February 9, 2021 Meeting Minutes
A motion was made by Member Bejster, seconded by Member Washington, that the minutes be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Fornero, Member Washington, Vice Chair Brown, Member Tarter, Member Bejster and Member Lara
Absent: 4- Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Chair Smith-Taylor
4. Public Comment to the Council
None
5. Executive Director's Report
Mark Pfister, Executive Director, informed the Council that the HRSA site visit will take place August 3, 2021 through August 5, 2021, and at some point during that time they will be meeting with the Governing Council members. Prior to HRSA's visit, staff will be working with Council members to review the Corporate Compliance Manual and the questions that may potentially be asked. COVID-19 vaccine is starting to come in greater numbers. We anticipate receiving 11,000 first doses this week and 13,000 first doses next week. Over 164,000 doses have been administered to Lake County residents and 48% of residents age 65 and above have received at least one dose. The current 7-day rolling average is 5,228 doses per day. The daily average needed to vaccinate 560,000 people in six months is 6,137 doses. Lake County's positivity rate is down to 2.8% and we hope it continues to drop but we are concerned about the different variants of the virus such as the UK variant, the South African variant, and the Brazilian variant. At this point in time, all three vaccines have proven to be efficacious for all of those variants to some degree. We continue to recommend that people follow the three W's: wear a mask, watch your distance, wash your hands.
6. Action items
6.1 Provider Credentialing and/or Privileging - Dr. Zun
Dr. Les Zun, Medical Director, informed the Council that the privileging and credentialing information for the provider noted in the agenda packet was reviewed in the Personnel Committee meeting which took place just prior to this regular meeting and the Committee recommends approval.
A motion was made by Member Bejster, seconded by Member Washington, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Fornero, Member Washington, Vice Chair Brown, Member Tarter,
Member Bejster and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Chair Smith-Taylor
6.2 Provider Reappointment - Dr. Zun
Dr. Zun informed the Council that the reappointment information for the providers noted in the agenda packet was reviewed in the Personnel Committee meeting which took place just prior to this regular meeting and the Committee recommends approval.
*NOTE: After the vote on item 6.1, Vice Chair Brown turned the meeting over to Chair Smith who joined at 5:42 p.m. Member Fornero, who was in attendance in order to make quorum, left the meeting at 5:44 p.m.
A motion was made by Vice Chair Brown, seconded by Member Bejster, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
6.3 Change in FQHC Hours of Operation - Burke
Lake County Illinois Page 3 of 8
Lake County Community Health March 9, 2021
Meeting Minutes - Final
Center Governing Council
Attachments: BMB Hour Change
Kim Burke, Director of Healthcare Operations, reviewed the change in operating hours as outlined in the agenda packet. In addition to the construction plans noted, she added that a building-wide generator will also be installed.
A motion was made by Member Washington, seconded by Member Bejster, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
6.4 Sliding Fee Schedule of Discounts - Riley
Attachments: Sliding Fee Schedules March 2021
Pam Riley, Director of Finance, reviewed the information provided in the agenda packet, noting that this is an annual update. She added as a reminder that it is only the income that has been updated, the prior year nominal fees have not changed.
A motion was made by Member Tarter, seconded by Vice Chair Brown, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
6.5 2020 Annual Report - Nordstrom
Jerry Nordstrom, Director of Business Operations, informed the Council that the Annual Report was approved by the Board of Health at their meeting on February 24, 2021. He noted that the look of the report has changed quite a bit from prior years. The new format is intended to provide more of a "thirty thousand foot view" and allow people to get a sense of operations prior to COVID-19.
A motion was made by Vice Chair Brown, seconded by Member Washington, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
6.6 Annual Compliance Work Plan Review and Approval - Nordstrom
Jerry Nordstrom reviewed the information as provided in the agenda packet. Member Tarter noted that in the agenda item write-up it states, "These documents will be provided annually for review and approval by the Board of Health.....," and asked if the Governing Council shouldn't be included in that statement since they are expected to vote on it. Jerry agreed that the Governing Council can be added going forward but pointed out that the suggested motion is on behalf of the Governing Council, so other than the omission in the paragraph above the item still stands as the motion and vote will be from the Governing Council. Member Tarter then asked who requires this document, HRSA or The Joint Commission. Jerry stated that this is not something formally required of the Health Department. It is best practice on the part of the Health Department to ensure we are being proactive, have a work plan to present to the Board of Health and Governing Council, and it is consistent with what a compliance plan should include. Chair Smith-Taylor noted that in the "Complete" comments at the top of page 2, it states, "Several areas were identified as needing additional controls....," and asked if those several areas need to be spelled out. Jerry stated that they do not as assessments always contain areas which can potentially be improved and that they can vary.
A motion was made by Vice Chair Brown, seconded by Member Tarter, that this item be approved. Motion carried by the following roll call vote:
Aye: 6 - Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
6.7 Governing Council Member Reappointment - Pfister
Mark Pfister reviewed this item as provided in the agenda packet and pointed out that Member Argueta is also a consumer.
A motion was made by Vice Chair Brown, seconded by Member Bejster, that this item be approved. Motion carried by the following roll call vote:
6 - Aye: Member Washington, Vice Chair Brown, Member Tarter, Member Bejster, Chair Smith-Taylor and Member Lara
Absent: 4 - Member Withem-Voss, Member Cunningham, Member Vargas and Secretary Argueta
Not Present: 1 - Member Fornero
7. Presentations
None
8. Discussion Items
8.1 Uniform Data System (UDS) 2020 Submission Review - McMillan-Wilhoit
Jefferson McMillan-Wilhoit, Director of Health Informatics, reviewed the information on the 2020 submission for the Uniform Data System (UDS) as provided in the agenda packet. He noted that this is an annual requirement for our HRSA grant, which is what funds the FQHC. It is a way for us to submit our data to the national database, it is a way for HRSA to understand some of the national trends, and it is also a way for us to benchmark against our peers. He informed the Council that today's presentation is just an overview of what the submission looks like and that at their next meeting on April 13, 2021, the actual year-over-year comparisons as well as the comparisons to the benchmark will be provided. It usually takes HRSA 30-45 days after our submittal to get benchmarks for the entire country as well as to figure out the thresholds for national quality leaders (NQL). The submission was due by February 15, 2021, but the Health Department submitted it early on February 12, 2021. Vice Chair Brown noted that the new measure, HIV Screening, is patients 15 through 65, that 38,127 patients were reported for 2020, and asked if LCHD administered that many HIV tests in a year. Jefferson stated that in our UDS system for 2020, we administered an HIV test for 50.1% of our patient population age 15 through 65. Vice Chair Brown also commented that the alteration to the HIV Linkage to Care measure is needed and he looks forward to next month's report. Chair Smith-Taylor noted that she appreciates that the reporting on asthma will continue even though that measure has been removed. Christina Hayes, CQI Coordinator, clarified that the new measure, HIV Screening, requires patients 15 through 65 be screened at least once, not once every year.
This matter was presented
8.2 Clinical Risk and Patient Safety Management - Koppit
Attachments: Clinical Risk and Patient Safety Management Report
Denise Koppit, Clinical Compliance Manager, reviewed each section of the Clinical Risk and Patient Safety Committee report as provided in the agenda packet. Chair
Smith-Taylor noted that on page 3, Patient Report Form, the Medication category was 50 for 2019 and 47 for 2020, so not a lot of change, and asked if that was due to COVID-19.
Denise stated that much of it is due to the vaccine management component that they are working on. Many of those reported incidents are near misses in that staff identified that they pulled something the wrong way from the system, and it was initially documented incorrectly, rather than it having been given to the patient incorrectly. Chair Smith-Taylor then asked if overall a lot of the numbers are due to COVID-19. Denise stated she believes they are.
This matter was presented
9. Medical Director Report
9.1 Medical Director Report - Dr. Zun
Dr. Zun began by reviewing the highlights of his report as provided in the agenda packet. Shortly after, Dr. Zun was dropped from the meeting due to technical difficulties, so Kim Burke took over. When Dr. Zun rejoined the meeting, he resumed his review. Chair Smith-Taylor asked about the wait time from assessment to appointment with a psychiatrist, and if it has changed. Dr. Zun stated the it has changed, that it has improved, but he does not have the exact number and will get that information for her.
This matter was presented
10. Director of Healthcare Operations Report
10.1 Director of Healthcare Operations Report - Burke
Kim Burke informed the Council that since this is her first official report to them, her intent is to present a new operational metric every month and then build a dashboard so that they can see the numbers going forward. She then reviewed her report as provided in the agenda packet. She also announced that the Lake County Community Health Center FQHC was one of five in the State of Illinois selected by Governor Pritzker to receive direct shipment of COVID-19 vaccines from the State on a weekly basis. The first shipment, 400 doses of Johnson & Johnson vaccine, was received today and will be administered starting tomorrow to FQHC patients age 65 and above. FQHC patients age 65 and above and in the Phase 1a group have been receiving vaccinations since the beginning of February using vaccine received by the Lake County Health Department, but now that the FQHC is receiving direct shipment the Health Department can distribute that vaccine to other partners in Lake County, thereby expanding vaccination efforts. The FQHC can request as many as 500 doses per shipment, so requests will be increased as the other FQHC sites become mass vaccination clinics. The FQHC sites currently operating as mass vaccination clinics are 3010 Grand and Zion, with Midlakes being added next week, then Northshore in Highland Park, and then BMB by the end of March. Vaccinations are by appointment only and patients need to register and schedule using the AllVax system.
Temporary help will be hired to assist with outreach to those FQHC patients not registered in AllVax or who don't have access to a computer so that we can get them registered and an appointment scheduled. Chair Smith-Taylor congratulated the team on their great work. Mark thanked Kim, Dr. Zun, and Jefferson for all their hard work in getting this up and running. It's a great opportunity for us, as only one of five selected, to showcase what we can do. And the fact that it's Johnson & Johnson means it's only one dose rather than two so that we can ensure more of our patients are getting vaccinated in a timely manner thereby building herd immunity in our patient population.
This matter was presented
11. Director of Finance Report
11.1 Director of Finance Report - Riley
Pam Riley reviewed the information provided in the agenda packet. She noted that the information for FY2020 is preliminary and unaudited at this time.
This matter was presented
12. Added to Agenda
None
13. Old Business
None
14. New Business
None
15. Executive Session
None
16. Adjournment
Chair Smith-Taylor adjourned the meeting at 6:43 p.m.
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