operational site visit guide hrsa

An official website of the United States government

Here’s how you know

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

U.S. Dept. of Health & Human Services

Health Center Program Site Visit Protocol

Guidance for health centers to understand the tool HRSA uses for assessing compliance with Health Center Program requirements during operational site visits and look-alike initial designation site visits.

Download the Guidance Document

Issued by: Health Resources and Services Administration (HRSA)

Issue Date: February 27, 2020

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

Updated Site Visit Protocol, PCHP Community

April 18, 2023

HRSA-funded National Training and Technical Assistance Partners (NTTAPs) host or developed many of these events and resources. For more from the NTTAPs, visit the Health Center Resource Clearinghouse .

Enrolling a New FQHC Site in Medicare

Last week, we talked about Medicare revalidation for FQHC sites, which is required every five years, and shared tools and guidance. If you missed it, see the article .

If you are enrolling a new FQHC site (i.e., when a new service site is approved by HRSA through the change in scope process or through a funded application), you must provide the Notice of Award or Notice of Look-alike Designation that documents approval for the new site. Unlike with revalidation , when you are enrolling a new site you cannot use the health center’s Form 5B: Service Sites list downloaded from HRSA’s Electronic Handbooks (EHBs). You must complete the initial enrollment process with CMS. For more information, see CMS’ Become a Medicare Provider or Supplier website .

Act Now to Ensure Continued Access to EHBs

Beginning Friday, May 26, you will have to use Login.gov to access EHBs. That site employs two-factor authentication, which creates an extra layer of security beyond just a username and password.

• If you have an existing Login.gov account with the same email address you use in EHBs, you do not need to create a new account.
• If you have an existing Login.gov account with a different email address than what you use for EHBs, you will need to create a new account using the email you use for EHBs.
• If you do not have an account on Login.gov, create one now to ensure continued access. Be sure to use the same email address that you use to access EHBs.

See HRSA's instructions webpage for setting up and verifying a Login.gov account.

National Prescription Drug Take Back Day is Saturday

Visit the Department of Justice’s Take Back Day website for resources to promote this event in your community. Our March 24 bulletin includes other resources.

HHS COVID-19 Vaccination Operational Planning Guide

Last week, we shared updated CDC guidance in a bulletin. See the bulletin if you missed it.

Health Partner Order Portal Updates Delayed

If you order COVID-19-related products through HRSA’s COVID-19 Response Programs, the planned update of the Health Partner Order Portal (HPoP) is delayed. See messages in the HCPC for more information.

New Point-of-Care Test Available Soon Through HRSA

Beginning Wednesday, April 19, health centers participating in HRSA’s COVID-19 Testing Supply Program will be able to order the Abbott BinaxNOW COVID-19 Ag Card test in HPoP. Health centers can order a minimum of  15 units but are not to exceed 50   units.

This product is used to test only SARS-CoV-2 through a dual nasal swab. These FDA resources provide more information:

• Emergency Use Authorization (PDF)
• Fact Sheet for Healthcare Providers (PDF)
• Insert Instructions (PDF)

The manufacturer’s website also provides information.

If you are not currently participating in the HRSA COVID-19 Testing Supply Program and would like to begin ordering the Abbott BinaxNOW, at-home self-test kits, and/or Cepheid Xpert Xpress cartridges, submit a request via the BPHC Contact Form .

Behavioral Health

Integrating behavioral health care into clinical workflow.

Join to see how your health center can apply lessons learned in developing an integrated care workflow, describe the roles of key team players in integrated care, and understand how issues with role clarity may impact successful workflow design.

Wednesday, May 10 2:30-3:00 p.m. ET Registration page

Community of Practice: Behavioral Health Integration Skills and Practices for Health Centers

Over a series of eight 1.5-hour sessions, participants will learn about the most promising practices for effective integrated behavioral health care in primary care settings. Visit the registration page for dates and times.

Coordinating Care and Safety for Patients Experiencing IPV at the Intersection of Mental and Behavioral Health

Health Partners on IPV + Exploitation and the HHS-funded National Center on Domestic Violence, Trauma & Mental Health invite you to examine the intersections of intimate partner violence (IPV) and exploitation, mental and behavioral health, and substance use coercion. You will hear from a panel of survivors and gain strategies on assessing for abuse and coercion. Visit the registration page to apply by midnight, Friday, April 21.

SAMHSA Alert about Xylazine

In a Dear Colleague letter (PDF), SAMHSA shares information about xylazine – a non-opioid agent increasingly being found in combination with opioids such as fentanyl. Xylazine has not been approved by the FDA for use in humans and can cause devastating medical problems. Because it’s not an opioid, naloxone does not reverse its effects.

Substance Use Prevention Services in Primary Care Challenge Competition

Through a new challenge, NIH’s National Institute on Drug Abuse seeks creative, visionary, and actionable plans to implement substance use prevention interventions in primary care. Learn more or submit your plan by Friday, May 19, by visiting the challenge webpage on Challenge.gov .

Register for the Region 6 Workforce Workshop

HRSA is hosting Regional Workforce Workshops for Primary Care Associations (PCAs) and health centers. Registration is open for the Region 6 workshop, which takes place on Tuesday, April 25. See BHW’s recent bulletin for information and to register. We will share date and registration information for other regions in the coming months.

National Health Service Corps Scholarship Program Applications

The 2023 National Health Service Corps (NHSC) Scholarship Program application cycle is open. Providers serve at least two years at NHSC-approved sites in underserved communities. Funding is available for up to four years. Apply by Thursday, April 27, on HRSA’s webpage .

See the announcement above .

Virtual 2023 Biennial Workforce Summit

The Association of Clinicians for the Underserved’s (ACU's) STAR 2 Center, and the National Association of Community Health Centers (NACHC) will host this opportunity for health centers, Health Center Controlled Networks, and PCAs. Share and elevate best practices in addressing workforce challenges and needs. Participants are eligible to receive CE credits. Visit the registration page .

NTTAP Learning Collaboratives

Visit the registration pages for dates, times, and more information:

• House Asset Mapping Interested in learning more about housing and the homeless response system in your community? Join this Corporation for Supportive Housing (CSH) opportunity to learn what resources are available to you and your patients, how to navigate the housing system, and about best practices in health and housing partnerships. Registration page .
• Coordinating Care and Safety for Patients Experiencing IPV at the Intersection of Mental and Behavioral Health See the announcement above .

Additional Resources

Agworker health 102: supporting agricultural worker health.

Join the Farmworker Health Network (FHN, a group of six HRSA-funded NTTAPs) to hear about the most relevant current agricultural worker policy issues and explore effective service delivery models. Presenters will also highlight training and technical assistance opportunities and share resources and promising practices.

Tuesday, May 23 2:00-3:00 p.m. ET Registration page

Equitable Diabetes Prevention: Keys to Success from a Pacific Islander Community

A blog post from the National Nurse-Led Care Consortium (NNCC) and the Association of Asian Pacific Community Health Organizations supplements a related podcast episode. Both focus on the rollout of a Pacific Islander Diabetes Prevention Program and the positive outcomes of providing a tailored prevention program.

In case you missed it: Visit the Primary Health Care Digest archive .

Do you forward the Digest to others? Encourage them to subscribe .

Through April 25

Celebration of SDOH Innovation Webinar Series Hosted by multiple NTTAPs Tuesday, April 18 2:00-3:00 p.m. ET Registration page

Beyond the Bar Chart: Blending Data and Storytelling Session 1 in the Learning to Love Your Data: Health Center Data for Everyone Webinar Series Hosted by the Health Information Technology, Evaluation, and Quality (HITEQ) Center Tuesday, April 18 2:00-3:30 p.m. ET Registration page

How the End of the COVID-19 Public Health Emergency Will Impact Residents of HUD-Assisted Housing Hosted by the National Center for Health in Public Housing (NCHPH) Wednesday, April 19 1:00-2:00 p.m. ET Registration page

Innovations in Mobile Health to Increase Health Access for Domestic Violence and Human Trafficking Survivors (with live interpretation in ASL and Spanish) Hosted by Health Partners on IPV + Exploitation Wednesday, April 19 1:00-2:00 p.m. ET Registration page

Utilizing Community Health Workers for SDOH Screening and Housing Navigation Hosted by the CSH Wednesday, April 19 3:00-4:30 p.m. ET Registration page

HRSA Virtual Job Fair Wednesday, April 19 6:00-9:30 p.m. ET Job seeker registration

Community-Centered Approaches to Racial and Social Justice: Change from the Outside In With CCHH Hosted by the National Health Care for the Homeless Council Thursday, April 20 3:00-4:00 p.m. ET Registration page

Preparing Mental Health Leaders Hosted by ACU Monday, April 24 4:00-5:00 p.m. ET Registration page

COVID-19 Response Program Office Hours Tuesday, April 25 1:00-2:00 p.m. ET Registration page

Screening for Public Housing Community-specific Safe Sleep Risks Hosted by NCHPH Tuesday, April 25 1:00-2:00 p.m. ET Registration page

The Federal Telehealth Policy Landscape After the PHE: What’s Staying (For Now) and What’s Going Hosted by the HITEQ Center Tuesday, April 25 2:00-3:00 p.m. ET Registration page

Exploring Promising Practices on Diabetes Management and Prevention Hosted by NCHPH Tuesday, April 25 3:00-4:00 p.m. ET Registration page

Effective Referrals in Integrated Care Wednesday, April 26 11:00 a.m.-noon ET  Registration page **1.0 CE available**

Strategies to Support Survivors Experiencing Intimate Partner Violence or Exploitation and How to Promote Prevention (in Spanish with live interpretation in English) Hosted by Health Partners on IPV + Exploitation Wednesday, April 26 1:00-2:30 p.m. ET Registration page

Traditional Food, Culture, and Diabetes in the U.S. Hosted by NCHPH Wednesday, April 26 2:00-3:00 p.m. ET Registration page

Eyes on Access: Billing for Vision Services Hosted by NACHC Thursday, April 27 3:00-4:30 p.m. ET Registration page Note: There will be follow-up office hours on Thursday, May 18.

Training the Next Generation Hosted by CHCI and Northwest Regional PCA Thursday, April 27 3:30-4:30 p.m. ET Registration page

Diabetes 101 (in Spanish with live English interpretation) Hosted by the National Center for Farmworker Health Tuesday, May 2 2:00-3:00 p.m. ET Registration page

Screening for Safe Infant Sleep Habits in Public Housing Hosted by NCHPH Wednesday, May 3 1:00-2:00 p.m. ET Registration page

Placing Lived Expertise at the Center of Diabetes Prevention Hosted by CSH Wednesday, May 3 1:00-2:00 p.m. ET Registration page

Today with Macrae: Health Center Program Updates Thursday, May 4 2:00-3:00 p.m. Join the day of the session Join by phone: 833-568-8864 Webinar ID: 161 554 9350

Academic Partnerships to Foster Multidirectional Learning and Reinforce our Health Center Workforce Hosted by NCHPH Tuesday, May 9 1:00-2:00 p.m. ET Registration page

Integrating Behavioral Health Care into Clinical Workflow Wednesday, May 10 2:30-3:00 p.m. ET Registration page

Infection Prevention and Control for Dental Hygienists and Dental Assistants Hosted by the National Network for Oral Health Access Wednesday, May 10 3:00-4:30 p.m. ET Registration page **1.5 CDE available**

UDS Mapper Advanced Topic: Food Insecurity and Opportunities for Health Centers Tuesday, May 16 2:00-3:00 p.m. ET Registration page

Cybersecurity for Health Centers Hosted by NACHC Tuesday, May 16 2:00-3:30 p.m. ET Registration page

Webinars are hosted by HRSA unless otherwise noted.

• Bureaus and Offices
• Contact HRSA
• Current NHSC Sites

How to Prepare for an NHSC Site Visit

National Health Service Corps (NHSC) site visits strengthen relationships between our program personnel, your site, and the NHSC clinicians working at your site.

Once a date is set, the Bureau of Health Workforce (BHW)’s Division of Regional Operations (DRO) staff will request you provide them with the following documents:

Policies on Non-Discrimination. Submit a copy of the site’s policies on non-discrimination of patients based upon the individual’s inability to pay; whether payment for services would be made under Medicare, Medicaid, or CHIP; and the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity.

Sliding Fee Discount Program Documents. Submit the following:

• Applies to all residents of your site’s HPSA(s)
• Definitions of income and family size
• Patient eligibility procedures
• Frequency of re-evaluation of eligibility
• Advertisement of the sliding fee discount program to the patient population
• Nominal charge, if applicable
• Collections policy, if applicable
• Based on most current Federal Poverty Guidelines (FPG)
• It is calculated based on Family Size/Income
• Goes up to at least 200% of FPG
• Offers full discount for families with income at or below 100% of FPG
• Adjust fees based on family size and income for families with incomes above 100% and at/below 200% of the FPG.
• Patient Application for Sliding Fee Discount Program.
• The first photograph must show the sign prominently displayed in a common area visible to patients.
• The second photograph must be a close-up photo so the text is legible.
• Sites may not use the NHSC poster and/or logo until after they are approved by the NHSC.
• Online Signage Notifying Patients about the Sliding Fee Discount Program. Submit a document with the screenshot and link to the published online statement on  the site’s official website (if one exists) and social media platforms (if applicable.) The screenshot must explicitly state that “no one will be denied access to services due to inability to pay; and there is a discounted/sliding fee schedule available based on family size and income,” in accordance with the NHSC Site Agreement item #2e.

Note, if the Sliding Fee Discount Program does not apply to your site, you must provide documentation explaining that no one is charged or billed for services, and individuals are not denied service because of inability to pay.

Proof of Access to Ancillary, Inpatient, and Specialty Care . Submit proof of referral arrangements not available on-site. Behavioral health sites must also submit documents outlined in item #4 below.

• Signed Memorandums of Understanding (MOU)
• Signed Memorandums of Agreement (MOA)
• Signed contracts with ancillary, inpatient, and specialty facilities
• If formal referral arrangements do not exist, the applicant site should provide a dated and signed description of how it refers patients to ancillary, inpatient, and specialty care.

NHSC Comprehensive Behavioral Health Services Checklist and Supporting Documentation.  Submit the following:

• NHSC Comprehensive Behavioral Health Services Checklist (PDF - 245 KB)
• Documentation that verifies all information included in the Checklist. Site policies or other internal documents must be submitted to reflect services provided directly on-site. In addition, sites must submit formal affiliation agreements for all other services provided off-site by a third party.

NHSC Site Data Tables.  Submit NHSC Site Data Tables (PDF - 348 KB) with information on the individual site location that:

• Includes data from the previous six continuous months
• Demonstrates site’s sound fiscal management policies

Substance Use Disorder (SUD) Documentation.  Facilities providing opioid treatment and/or SUD treatment must provide the following documentation:

• Opioid Treatment Programs (OTPs): SAMHSA OTP certificate; OR
• Office-based opioid treatment (OBOT): documentation of services and medication assisted treatment (MAT) attestation letter describing size of MAT patient panel for last 6 months; OR
• Non-opioid outpatient SUD facilities: documentation of services.

Clinician Recruitment and Retention Plan.  The document must clearly state the policies and processes to recruit and maintain clinical staffing levels needed to appropriately serve the community, including specific strategies aimed at promoting clinician resiliency and reducing burnout.

DRO staff reviews these materials in advance of the actual site visit.

What should you do prior to the site visit?

• With a few exceptions, the site should expect to be contacted by our Division of Regional Operations (DRO) at least two weeks in advance.
• The site is expected to submit the required NHSC documents in advance of the NHSC site visit. 

What should you expect during a site visit?

We evaluate your site’s understanding and implementation of all the requirements we lay out in the NHSC Site Agreement (PDF - 291 KB) and Site Reference Guide (PDF - 808 KB) .

During a visit, the DRO staff will answer your questions and ensure compliance so your site remains an NHSC-approved site.

Our priority is to meet with NHSC clinicians, either individually or in a group to:

• Assure they are meeting NHSC requirements; and
• Evaluate how the site supports their retention at the site.

How often do we conduct site visits?

You should expect periodic site visits as long as you maintain status as an NHSC-approved site.

We may visit certain types of sites as part of the Site Application review.

Also, we may schedule a site visit before approving a site. This applies to any NHSC-eligible site type.

Why do we conduct site visits?

Along with an evaluation of the site’s understanding and implementation of the NHSC site and NHSC participant requirements, the site visit also provides the following:

• A setting where DRO staff and State PCO staff can provide site-specific technical assistance on NHSC program requirements;
• An opportunity for DRO staff to share NHSC recruitment and retention resources available to NHSC sites; and
• A venue where DRO staff can meet with NHSC clinicians to assess any technical assistance needs and receive feedback about the clinicians’ participation in the NHSC program.

Who conducts site visits?

BHW’s Division of Regional Operations (DRO) performs site visits in coordination with your site and your state’s Primary Care Office .

We send you notifications for most visits through the BHW Customer Service Portal .

Related Resources

Site guidance.

• Site Reference Guide (PDF - 808 KB)
• Site Opt-In Instructions (PDF - 808 KB)
• NHSC Site Agreement (PDF - 291 KB)
• Behavioral Health Services Checklist (PDF - 245 KB) *
• Site Data Tables (PDF - 348 KB)
• Site Points of Contact User Guide (PDF - 4 MB)

*If you use assistive technology, you may not be able to access information in this file. For help, contact us at 800-221-9393.

Provider Recruitment

• Health Workforce Connector
• Virtual Job Fairs

Fact Sheets

• NHSC LRP Fact Sheet (PDF - 215 KB)
• NHSC SUD Workforce LRP Fact Sheet (PDF)
• NHSC Rural Community LRP Fact Sheet (PDF - 362 KB)
• NHSC S2S LRP Fact Sheet (PDF)

Spanish Fact Sheets

• NHSC S2S LRP Fact Sheet - Spanish (PDF - 76 KB)

Support Network

• Division of Regional Operations (DRO) State Leads
• State Primary Care Offices (PCOs)
• Primary Care Associations (PCAs)
• Area Health Education Centers (AHECs)
• State Offices of Rural Health (SORHs)
• NHSC 11x17 Poster (PDF - 1 MB)
• NHSC 8.5x11 Poster (PDF - 932 KB)

Our Networks:

RCPN - Respite Care NCAB - Consumers HCHCN -Clinicians

Preparing for HRSA Operational Site Visits

Webinar Slides(PDF)

A HRSA Operational Site Visit (OSV) is an onsite evaluation of a health center’s ability to meet the 19 health center program requirements including a clinical and financial performance review. ‘Not Met’ health center program requirements found during the HRSA OSV could lead to a condition on the health center’s grant.

This anxiety inducing 2.5-day onsite evaluation process has Health Care for the Homeless grantees seeking recommendations on what to expect and how they can best prepare for their visits. Two Health Care for the Homeless grantees that have recently and successfully completed their HRSA OSV have volunteered to share how they prepared for their visit and will offer tips and suggestions to grantees expecting a OSV this year. There will be an opportunity for Q&A at the end of the presentation.

• Jenny Metzler, MPH , Executive Director, Albuquerque Health Care for the Homeless
• Nilesh Kalyanaraman, MD , Chief Medical Officer, Health Care for the Homeless – Baltimore
• Fran Pruce, MBA , Chief Operating and Financial Officer, Health Care for the Homeless – Baltimore

HRSA Operational Site Visits

Hrsa operational site visits – what are they, what you can expect, and how you can prepare as a health center..

So what is the point of the HRSA OSV anyways?

These visits are designed to perform a full organizational assessment in all operational areas (fiscal, clinical, administration/ governance). Every health center will have an operational assessment at least once per project period (read every 3 years). Operational assessments are usually 3 days on site and are attended by Consultant Reviewers contracted by HRSA and a HRSA Representative.

The key to remember here is that the entire focus of the OSV is to ensure that your health center is meeting all the elements detailed in the  Program Compliance Manual . This link provides a breakdown of each of the components and how to comply with each.

The compliance elements are divided into 18 categories:

• Needs Assessment
• Required and Additional health Services
• Clinical Staffing
• Accessible Locations and Hours of Operation
• Coverage for medical Emergencies During and After Hours
• Continuity of Care and Hospital Admitting
• Sliding Fee Discount Program
• Quality Improvement/Assurance
• Key management Staff
• Contracts and Sub awards
• Conflict of Interest
• Collaborative Relationships
• Financial management and Accounting Systems
• Billing and Collections
• Program Monitoring and Data Reporting Systems
• Board Authority
• Board Composition

NOTE: Portions of program compliance elements indicate regulatory requirements that are recommended but not required for grantees that receive funds solely for Health Care for the Homeless (section 330(h)) and/or the Public Housing Primary Care (section 330(i)) Programs.

So what can you expect?

Pre site visit conference call:.

The purpose of this call is to introduce the site visit team, made up of and Administrative/Governance Consultant; Financial Management/Information Management Consultant; and the Clinical Consultant. It will also include a  HRSA Representative , who will not be the health center’s designated Project Officer.

The health center’s PO will arrange a pre-site visit call with the health center, the site visit consultant team, and the individual who will serve as the on-site HRSA Representative; however, a health center’s designated PO will not attend the site visit, nor will they have a role in the determination of compliance.

The call will describe the purpose of the site visit (Program Requirement compliance/technical assistance where possible); the on-site process (entrance and exit conferences, agenda, management staff availability, document list (hard copy/digital); the Board member interview/meeting; site tour; and onsite logistics including work area. You will confirm the site visit location and they will answer any questions.

CHC’s Pre Site Visit Preparation:

OK, now you know when the site visit is happening – how do you prepare?

• Ensure all staff are aware of the site visit date and their roles in a successful visit
• Review the  Health Center Program Compliance Manual  with Board and staff
• Skim the  Health Center Program Site Visit Protocol : Frequently Asked Questions for a quick review.
• Ensure management team/board member(s) are available for first and last day of site visit
• Ensure CMO/Providers allocate time to meet with the Clinical Consultant
• Prepare documents and send to site visit team as requested prior to their visit

What to expect – a sample agenda:

• 9:00 AM – 10:00 AM – Entrance Conference: (the on-site HRSA Representative leads if present); Introduce Consultant Team/Purpose of the site visit; Health Center Overview- Senior Management Team/ Executive Director
• 10:00 AM – 12:00 PM – Meet with Members of Senior Management Team on individual basis (CFO, Medical Director, Exec. Director, Board Representative, etc.)
• 12:15 PM – 1:30 PM – Lunch with Board Members (at least members of the Executive Committee) CHC’s may be asked to arrange this lunch.
• 2:00 PM – 3:00 PM – Tour Facility
• 3:00 PM – 5:00 PM Continue Meeting with Senior Management Team and Center Staff
• 9:00 AM – 4:00 PM – Continue Meeting with Senior Management Team and Center Staff, Information Gathering/ Document Review
• 9:00 AM – 11:00 AM – Continue Meeting with Senior Management Team and Center Staff, Information Gathering/Document Review
• 11:00 AM-12:00 PM – Finalize Technical Assistance recommendations
• 12:00 PM –1:00 PM – Exit Interview (on-site HRSA Representative leads if present); Consultants summarize findings
• 1:00 PM – Team departs

What to expect – Visit Entrance Conference:

• Lead by the Consultant team
• Describes onsite process and outcome
• Lasts about an hour
• Team/staff introductions
• Set onsite expectations
• Reviewers are expecting CHC Leadership/Board to describe successes, challenges and opportunities for improvement, organizational priorities, and potential technical assistance needs. (Can be done in Powerpoint or Prezi).
• Reviewers are also looking for promising practices – an activity, procedure, approach or policy that leads to or is likely to lead to improved outcomes or increased efficiency for health centers. This is the time to share these practices.

What to expect – Interviews & Document Review:

• The Consultant team’s approach may vary where one member may read first and talk later – others may not
• Consultant team will seek clarification of policies and procedures
• What do you do
• Who reports to whom
• Verifies practices are consistent with policy
• Assesses job tasks, duties and responsibilities are consistent with observed practices
• Who’s running the organization
• Consultant team obtains an overall impression of grantee financial and operational performance and status based on expertise and available documentation
• Consultant team determines compliance with the  Health Center Program Compliance Manual  and identifies areas for performance improvement
• Identifies best practices

Health Center Board’s Role during HRSA OSV:

• Board members are requested to attend the entrance and exit conferences
• Usually there is an additional, separate meeting with Board
• Assessment of Center financial, operational and clinical performance
• Program Requirements
• Strategic Plan
• Financial Reporting and Status
• Quality Assurance Plan
• Information systems/informatics
• Performance reporting
• Overall management performance
• Board performance and self-evaluation

The on-site HRSA Representative Role during HRSA OSV:

• The on-site HRSA Representative does not manage the visit, work flow, process and or product
• Opens & closes the site visit (entrance & exit conference) & explains post-onsite process
• Observes (shadows) consultants’ work process (interviews) but is not a participant except in cases of specific findings set forth in the Notice of Award (NOA)
• The on-site HRSA Representative’s presence at interviews can change the dynamic and sometimes puts a brake on health center staff openness. If this occurs the Consultant may do a follow up interview
• If team performance issues arise on-site, consults with the Team Leader for resolution
• Consults with Team about the application/interpretation of HRSA policy, but ultimately it is the Consultant’s decision as what goes in the initial report

Consultant Team’s Roles during HRSA OSV:

• Manages the site visit
• Ensures the agenda is followed and that all Program Requirements are addressed
• Facilitates effective communication among the Consultant Team regarding findings and recommendations
• Resolves onsite performance issues
• Leads/facilitates entrance and exit conferences
• Consultant Team introductions
• Establishes order of presentation of preliminary findings and recommendations at exit conference
• Completes document review and interviews (board, management and other staff – consultant choice) within their disciplines
• Prepares preliminary report addressing demonstrated Program Compliance Elements; performance improvement recommendations and Technical Assistance (TA) recommendations

Oregon Primary Care Association’s (OPCA) role during HRSA OSV:

• OPCA is available over the phone to answer questions as well as provide data, available to OPCA, that may offer some context during the OSV
• We can have data available that compares your CHC to state and national quality metric averages
• Listen and learn! Site visits are a great forum for us to learn and share our learning with other sites that are preparing for site visits
• During the exit interview there is a review of suggested/required opportunities for improvement. OPCA can support you as needed around areas of noncompliance.       if needed or desired. We have a network of clinics that are able and willing to share policies, procedures, workflows so that you may not need to re-create the wheel
• If OPCA’s presence on the phone during the exit conference is in any way uncomfortable to the organization, we do not need to attend – it’s completely up to the health center. It’s OPCA’s intention to be invited in and be value added, as needed

What to expect – Exit Conference:

• Identifies post-onsite process including report preparation and distribution
• program requirement compliance
• findings and recommendations
• The on-site HRSA Representative describes post onsite process

Demonstrating Compliance Elements

The demonstrating compliance elements within the Compliance Manual include a list of items that must be addressed in order to demonstrate compliance. Nearly all of the elements within the  Health Center Program Compliance Manual  are assessed during an OSV.

Each of the 18 Program Compliance Elements will be designated as either ‘Yes’, ‘No’ or ‘NA’ based on the consultant’s review and judgment of the grantee’s operational/implementation response to the  Health Center Program Compliance Manual .

If a compliance element receives a ‘No’, the consultants will provide information on the grantee operations that shows why the element was not compliant.

Although a compliance element may be designated as “Yes”, there still may be a recommendation that provides performance improvement guidance to the grantee on a way to further improve some aspect of the grantee’s operation.

If the designation of the element is “No”, there will be a finding that specifically addresses what part of the program element is non-compliant (some of the requirements have multiple parts) and a recommendation that specifically provides guidance to the grantee on what action(s) need to be taken to bring that portion of the operation back into compliance.

What is in the report?

HRSA will develop and present a site visit report to the health center within 45 days after the site visit. The report will convey the site visit findings and final compliance determinations.

• Basic information-grantee name, and address, consultant(s) and their review areas
• Overview of the grantee- some history, population and target area demographics, information relevant to the grantees current operations
• Participants and if they were interviewed and attended entrance and exit conferences
• List of documents reviewed
• List of documents left with the grantee
• Primary Compliance Issues, Concerns, and/or Performance Improvement Opportunities Addressed During Visit
• Each section is populated with the applicable Program Requirements and Performance Improvement recommendations

Compliance Resolution Opportunity:

The HRSA Compliance Resolution Opportunity, or CRO, supports the timely resolution of areas of non-compliance found on-site during an OSV. CRO provides health centers an opportunity to address non-compliance findings prior to HRSA issuing the site visit report and placing conditions on the award/designation due to a failure to demonstrate compliance.

Specifically, CRO provides a 14 calendar day window for health centers to address OSV findings by submitting evidence of compliance via the HRSA Electronic Handbook (EHBs). CRO submission(s) will be reviewed and assessed before the final site visit report is issued.

Following the OSV process, health centers will be able to take advantage of the new CRO process and submit documentation via an Urgent Site Visit Report Request task in EHBs to demonstrate compliance. This new feature is designed to be a uniform and efficient way to help health centers demonstrate compliance while maintaining the objectivity and integrity of the OSV on-site review process. Learn more about the  CRO process .

OSV Follow Up Visit:

If HRSA determines that a health center has not demonstrated compliance with one or more of the elements reviewed via the OSV, as indicated in the final site visit report, a corresponding condition will be placed on the award/designation.  Get more information and a full list of conditions .

If a health center submits a response before the 14 calendar day timeframe has expired and compliance is still not demonstrated for all or some of the findings, the Urgent Site Visit Report Request task will be returned to the health center for additional information/clarification on the remaining non-compliance findings. No deadline extension will be provided beyond 14 calendar days. Information shared via methods other than the EHBs Urgent Site Visit Report Request task submission (e.g., phone calls, e-mails) will NOT be considered in HRSA’s final compliance assessment.

Following the release of the site visit report, the health center will work with the designated Project Officer. The designated Project Officer will discuss with the on-site HRSA Representative the findings from the OSV, including any findings that were not addressed/resolved through the CRO process and resulted in conditions.

The designated Project Officer will call the health center about conditions within 15 days of the release of the Notice of Award/Notice of Look-alike Designation communicating any conditions.

Bottom Line for the Health Center:

• Cooperate with the on-site HRSA Representative and Consultant Team
• Be transparent! Communicate! Prepare!
• If you receive a ‘No’ on any Compliance Elements, then work aggressively and expeditiously to resolve. OPCA can help!
• Show yourself off – Brag a little!

Further questions? Contact OPCA’s  Sonya Howk .

Leading the transformation of primary care to achieve health equity for all.

Programs & services, contact information.

623 SW Oak St., Suite 300 Portland, Oregon 97205

Phone: (503) 228-8852 Fax: (503) 228-9887 Email: [email protected]

© Copyright 2023. Oregon Primary Care Association. Privacy Policy . Designed and Powered by diamonddog Strategic Marketing Services .

Stay informed.

Sign up for the opca newsletter.

Jump to content

Feldesman Training Solutions

Bookmark/search this post.

You are here

Deciphering the operational site visit: legal requirements and practical tips for a successful osv.

• Presenter(s)
• Continuing Education
• Register/Take course

Please Note:  This training is limited to community health centers and look-alikes. If you are not affiliated with a health center and would like to attend, please  contact us .

As a result of the COVID-19 pandemic, HRSA has transitioned and re-focused its compliance efforts for Federally Qualified Health Centers (FQHCs) to a virtual compliance assessment process.  As of April 2021, HRSA has indicated that the virtual Operational Site Visit (OSV) will be in place for the foreseeable future.  Despite this change to a virtual platform, the review process itself strives to mirror the onsite process. As such, compliance with health center program requirements is still a vital component of a health center’s daily operations.

Whether conducted virtually or on-site, the OSV revolves around the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance, and the Site Visit Protocol, a “hands-on” compliance assessment tool that is a “living document” continually modified by HRSA to reflect updated practices and feedback from the field. The most recent update of the Protocol (the  2021 Site Visit Protocol ) a summary of which was published in April 2021, will be effective for all OSVs that start after May 28, 2021.

The Manual incorporates a new approach to “everyday compliance” by addressing each requirement’s statutory and regulatory basis, the key elements of compliance that collectively form the framework of every health center’s project, and areas for which health centers maintain discretion.  Aligning with and complementing the Manual, the Protocol reflects an objective review guidance used by HRSA reviewers and health centers alike.

While the Protocol strives to clarify the documentation requirements and assessment methodologies used by HRSA to verify compliance, confusion regarding review-related processes still exists. Further, as in the past, there is an expectation of 100% ongoing compliance with the Health Center Program Requirements.  Is your health center prepared to meet this challenge? Have you reviewed the most recent HRSA guidance and assessment processes with an eye towards shoring up your own operations and establishing your HRSA compliance work-plan? For example,

• Is your Form 5A up to date, based on HRSA’s service definitions and correct modes of delivery?
• Do you have written contracts and referral agreements in place for services listed in columns II and III of Form 5A, and do they include all required provisions, such as sliding fee discounts and provisions under 45 CFR Part 75?
• Are members of your clinical staff (including staff members such as dental assistants, medical assistants, and community health workers) appropriately credentialed and privileged?
• Does your quality improvement system meet all current standards?
• Do you have systems in place to assess all patients for income and family size? Have you implemented mechanisms to inform patients about the sliding fee discount program and to conduct an effectiveness evaluation of the program?
• Do you have billing and collection policies that address the waiver / reduction of payments and other processes that help strike the balance between maximizing reimbursement and maintaining optimum access?
• Is your financial management system sufficient for federal accountability purposes?
• Is your Board of Directors independently exercising all required authorities, and do you have documentation to verify compliance?

Join FTLF for this training exploring:

• The key challenges of the virtual OSV process and how they differ from (and are the same as) the onsite process;
• How to use the Compliance Manual, the new 2021 Site Visit Protocol and other HRSA-issued compliance guidance to prepare for your OSV, including discussion of the elements of the programmatic requirements and the documentation and assessment methodologies required to verify compliance with each, as well as areas where health centers retain explicit discretion and flexibility;
• How the legal requirements intersect with the reviewers’ interpretations;
• Key high-risk areas from recent compliance reviews; 
• A concentrated examination of credentialing and privileging, governance, contracts and referral agreements, sliding fee discount program, and financial management in a choice of breakout sessions; and 
• Compliance tips from our presenters’ years of experience working first-hand with hundreds of health centers prior to, during, and after their OSVs.

Target Audience

• Health Center Executive Staff
• Clinical Leadership
• Quality and Credentialing/Privileging Staff
• Financial Leadership and Staff
• Compliance Officers
• Administrative / Operations Leadership and Staff
• Board members
• Other Staff assisting with HRSA compliance and/or OSV preparation

Please Note: This training is limited to community health centers and look-alikes. If you are not affiliated with a health center and would like to attend, please contact us

Learning Objectives

After this training, you will be able to:

• Identify the key elements of the HRSA program requirements addressed in the Manual and the Protocol.
• Describe the specific documentation and assessment processes necessary to demonstrate compliance and areas where health centers retain discretion.
• Discuss the newest compliance tips for all phases of the HRSA compliance review (before, during, and after) and use such tips to establish your health center’s HRSA compliance workplan.
• 12.00 Certificate of Attendance
• Add to google calendar
• Add to yahoo calendar
• Add to iCalendar
• Add to Outlook

NOTE: The two sessions listed below will  NOT  be addressed in the workshop and will be provided via pre-recorded webinar prior to the on-site training. Please review the webinars prior to arrival and come prepared with your questions! The webinars can be accessed by clicking the gray "Take Course" button on either the "Overview" or "Register" tab once you have registered for the course.

• Introduction to the Health Center Program Compliance Manual and HRSA Review Process
• Working within the “Box”: Key Elements and Requirements of Scope of Project

FTLF'S VIRTUAL CLASSROOM

This live, interactive training will take place in FTLF's Virtual Classroom, hosted by Zoom.  Should you have any technical questions or would like more information, please contact us at  [email protected]  or 1-855-200-3822.

MOLLY EVANS  

A Partner in the firm’s health law practice group, Molly advises health centers on the management of clinical, employment and workforce related risks, with a particular focus on professional liability, Federal Tort Claims Act, and HIPAA matters. From her experience as both a private attorney and in-house counsel, Molly knows the importance of managing liability and risk issues in mission-driven organizations. [ Full Bio ]

Serving as Managing Partner of the firm since 2003, and a member of the Health Law and Federal Grants practices since 1992, Ted is a national authority in the area of federal grants, particularly in the health and community service spheres. He advises clients on all aspects of program requirements, including issues such as cost-based reimbursement, governance and the never-ending list of grant administration matters. Ted’s expertise in financial, cost reporting, reimbursement, and administrative issues is widely recognized and he routinely handles government audits, internal investigations, and litigation. [ Full Bio ]

MARCIE ZAKHEIM

A Partner at the firm, Marcie specializes in health care law, particularly in the areas of federal grants, grant-related requirements and grants management related to the federal health center program. Health centers turn to Marcie as a resource for knowing not only the letter of the law, but also the likely interpretation of requirements by federal policymakers, including the Health Resources and Services Administration (HRSA). [ Full Bio ]

Conference participants can earn   up to 14.40 CPE credits   in Specialized Knowledge and Applications.

ADDITIONAL INFORMATION

• Prerequisites: None 
• Target Audience: Health Center Executive Staff, Clinical Leadership, Quality and Credentialing/Privileging Staff, Financial Leadership and Staff, Compliance Officers, Board members, Other Staff assisting with HRSA compliance and/or OSV preparation
• Advanced Preparation: None  
• Program Level: All
• Delivery Method: Group Internet Based

Available Credit

Registration fees:, group discounts.

Bring your team! Discounts are available for groups of three (3) or more individuals from the same organization. Please  contact us  to process your registration.

Registration Instructions

Each registration must be in the name of the individual(s) who will attend. This allows FTLF to communicate important course information to the actual attendee(s), add training materials and handouts to the right account, and properly assign certificates of attendance or CPE credits. 

To register for this training:

• For yourself: login to your account and register with your personal information
• For someone else: login with the  ATTENDEE’S  login information or create an account for the  ATTENDEE  and register from the  ATTENDEE's  account
• For a group: email [email protected] to complete group registration

If you encounter problems or have questions Contact us .

We accept payment by PayPal, credit card, and check. Payment for any live training is due upon registration. If payment is not received in full prior to the start of the event, FTLF reserves the right to cancel your order and deny you entrance to the training.

Cancellation/Transfer Policy

All cancellation or transfer requests must be received in writing at  [email protected] . Requests for refunds or transfers for in-person events will be granted according to the following schedule:

• 30 or more days prior to the event,  requests for a full refund   or a transfer without a fee will be granted.
• Between 11 to 29 days prior to the event,  requests for cancellations will be granted a 50% refund and requests for transfers will be granted, space permitting and subject to a transfer fee.
• Within 10 days of the event start date , no requests for refunds or credits will be granted. At FTLF's discretion, late transfers may be granted, space permitting and subject to a transfer fee.

If there are extenuating circumstances regarding your cancellation, please reach out to the FTLF Training Team directly at  [email protected] .

Required Hardware/Software

Google Chrome or Mozilla Firefox are the preferred browsers.

Training & Events

• Training & Events >

Webinar Series: Preparing for HRSA’s Operational Site Visit

NACHC announces its annual webinar series for 330-Funded and Look-Alike Health Center leaders and staff preparing for HRSA’s Operational Site Visit (OSV) and creating a culture of  continuous compliance within your health center.

This unique 3-part webinar series features the perspective of three independent OSV reviewers with years of experience conducting HRSA OSVs, including virtual OSVs during the COVID-19 pandemic. Each faculty member – a current fiscal, governance, and clinical reviewer – will provide practical tips and promising practices for ensuring not just a successful OSV but for achieving and maintaining a state of continuous compliance.

This webinar series will provide:

• A practical overview of the Health Center Program requirements, HRSA’s  Health Center Program Compliance Manual , and HRSA’s  Site Visit Protocol  (updated in May 2023)
• An overview of the three types of OSV visits (on-site, virtual and the Health Center Compliance & Engagement Site Visit)
• Tips for navigating the Virtual and on-site OSV process;
• Potential pain points and common areas of conditions/findings;
• Strategies for preparing your board and health center and steps that your health center can take to ensure continuous compliance
• Insights and tips from a reviewer’s perspective

Learning Objectives

As a result of this webinar, participants will be able to:

• Describe HRSA’s process and tools for assessing compliance with the Health Center Program Requirements.
• Identify at least three pain points and/or areas of conditions found through the OSV.
• Implement a specific strategy or process for ensuring continuous compliance.

This webinar series is aimed at health center operational staff involved with preparing for the OSV. This includes compliance officers, practice/site administrators, CEOs, CFOs, COOs, CMOs, board members, and other staff involved with OSV preparation.

Webinars in this Series

• Date:  Tuesday, July 25, 2023  |   1:00 – 3:00 PM ET
• Description:  This webinar will begin with an overview of HRSA’s compliance program, including the Compliance Manual and the Site Visit Protocol. Faculty will provide an overview of the pre-planning process for operational site visits (OSVs) and share strategic tips and insights having a successful OSV while moving toward continual compliance. This webinar will also provide an in depth overview of the newest mode of the Operational Site Visit;  the Health Center Compliance & Engagement Site Visit also known as the “Pilot Program”. This webinar will highlight how compliance is assessed via the Site Visit Protocol and identify key pain points and areas where health centers often face challenges. In addition to providing an overview of the OSV, this webinar will provide an overview of the Governance requirements. Strategies and tips for preparing the Board of Directors and organizing materials and documents for the site visit will also be reviewed.  Time will be reserved for Questions and Answers. Representatives of your Board are encouraged to participate in this session.
• Speaker:  Jennifer Genua, CEO, Genua Consulting
• Moderator:  Ted Henson, MS, NACHC
• Date:  Wednesday, July 26, 2023  |  1:00 – 3:00 PM ET
• Description:  This webinar will provide an in-depth overview of the financial program requirements, how compliance is assessed via the Site Visit Protocol, and ways to build your financial systems for continuous compliance.  
• Speaker:  Renee Filson, Principal, Fiscal Solutions
• Moderator:  Ted Henson, NACHC
• Date:  Thursday. July 27, 2023   |  1:00 – 3:00 PM ET
• Description:  This webinar will provide an in-depth overview of the clinical program requirements, promising practices, and the Federal Tort Claims Act (FTCA) deeming requirements. Faculty will also highlight key strategies for building a system and culture of continuous compliance. Time will be reserved for Q&A.
• Speaker:  Kyle Vath, BSN, MHA, RN, CEO & Co-Founder, RegLantern

Webinar recording and presentation materials will be available to all registrants.

Not Found LocalTime

Delivery Methods

Not Found Map

Not Found Speakers

Not Found Data

Related Events

The cyberattack on change healthcare.

Frequently Asked Questions for Health Centers LEARN MORE