(Recorded Workshop) Deciphering the Operational Site Visit: Legal Requirements and Practical Tips for a Successful OSV

  • Session 1: 5.75 hrs
  • Session 2: 5.75 hrs
Recorded on: 9/7/2022 - 9/8/2022

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.

At the start of the COVID-19 pandemic, HRSA transitioned and re-focused its compliance efforts for Federally Qualified Health Centers (FQHCs) from an on-site compliance assessment to a virtual process that mirrors the in-person reviews.  Using lessons learned from the virtual Operational Site Visit (OSV), HRSA is currently “pilot testing” a new approach that strives for both compliance and excellence by combining aspects of the virtual process with desk audits and pre-OSV support through technical assistance sessions on the Health Center Program Requirements.  Regardless of the specific process used for your OSV, compliance with health center program requirements is still a vital component of a health center’s daily operations. . .and non-compliance findings may result in legal consequences impacting such operations and your ability to serve your patient populations and your community at large.

Whether virtual or on-site, the OSV process revolves around the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance. The Manual, which supersedes most (but not all) prior guidance, incorporates an “ongoing compliance” approach by addressing each requirement’s statutory and regulatory bases, the key elements of compliance that collectively form the framework of every health center’s project, and areas for which health centers maintain discretion.

To assist in conducting a “hands-on” compliance assessment, HRSA reviewers utilize the Site Visit Protocol, which aligns with the Manual and reflects a more objective assessment tool than prior review guides. HRSA’s most recent Protocol, which is effective for both the virtual OSVs and the new pilot program, clarifies the documentation requirements and assessment methodologies used by HRSA to verify compliance.

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, including 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? Does your sliding fee discount schedule apply to all in-scope services and have you implemented mechanisms to ensure input from your Board members when establishing the sliding fee discount schedule and nominal fee and conducting 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, without limitation, and do you have documentation to verify compliance?

Join FTLF for this training exploring:

  • The virtual OSV process and how it differs from (and is the same as) the onsite process;
  • How to use the Compliance Manual, the most recent 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; 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 elements of the HRSA program requirements addressed in the Manual and the Protocol.
  • Describe the specific documentation requirements and assessment methodologies, and the distinctive procedural processes, necessary to demonstrate compliance
  • Describe the areas where health centers retain discretion in implementing compliance.
  • 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.
Course summary
Available credit: 
  • 11.50 Certificate of Attendance
Course opens: 
Course expires: 

Session 1 (5.75 hrs)

  • The "Community" in Community Health Center: The Governing Board of Directors
    • Chapter 19: Board Authority
    • Chapter 20: Board Composition
  • The Heart of Your Health Center Project: Need, Services & Continuity of Care
    • Chapter 3: Needs Assessment
    • Chapter 4: Required & Additional Health Services
    • Chapter 6: Accessible Locations and Hours of Operation
    • Chapter 7: Coverage for Medical Emergencies During and After-Hours
    • Chapter 8: Continuity of Care & Hospital Admitting
    • Chapter 14: Collaborative Relationships
  • Quality is Key
    • Chapter 10: Quality Improvement/Assurance
  • Personnel Dynamics - Ensuring Appropriate Management and Staff
    • Chapter 11: Key Management Staff
    • Chapter 5: Clinical Staffing

Session 2

  • Internal Controls and Ensuring Fiscal Viability
    • Chapter 15: Financial Management & Accounting Systems
    • Chapter 17: Budget
    • Chapter 12: Contracts and Sub-awards
    • Chapter 13: Conflict of Interest Policy
  • Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement
    • Chapter 16: Billing and Collection
    • Chapter 9: The Sliding Fee Discount Program
  • It's All Up with Data 
    • Chapter 18: Program Monitoring and Data Reporting Systems


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]


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]

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Read more about maintaining an attendance record in our FAQs.

Available Credit

  • 11.50 Certificate of Attendance


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