Deciphering the Operational Site Visit: Legal Requirements and Practical Tips for a Successful Compliance Assessment

Washington, DC US
September 6, 2023 to September 7, 2023

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.

In a time of transition impacting the health care regulatory landscape, HRSA has begun transitioning its compliance assessment efforts for Federally Qualified Health Centers (FQHCs) as well.  By combining limited aspects of the “live” (virtual or in-person) Operational Site Visit (OSV) with substantial desk audits, HRSA has begun rolling out a new Compliance & Engagement Operational Site Visit (CE-OSV), which, for some health centers, will be conducted in lieu of the traditional 3-day OSV. The CE-OSV process streamlines the assessment process, striving for both compliance and operational excellence by blending together pre-site visit technical assistance sessions on the Health Center Program Requirements and the Site Visit Protocol (SVP), document review including health center-self assessments based on the SVP, and traditional interviews for the four most common areas of non-compliance.   

Regardless of whether your assessment follows the new CE-OSV process or the traditional 3-day OSV, compliance with Health Center Program Requirements in both documentation and practice is a vital component of a health center’s daily operations … and non-compliance findings may result in legal consequences that significantly impact operations and your ability to serve your patient populations and your community at large.

All compliance assessments – OSVs, CE-OSVs and FQHC Look-Alike certification site visits – focus on the Health Center Program Compliance Manual, a consolidated resource to assist FQHCs in understanding, demonstrating, and operationalizing compliance. The Manual 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.

The assessment process is guided by the SVP, which aligns with the Manual and forms the basis for review under all compliance assessments.  The SVP reflects an objective assessment tool that clarifies many of the documentation requirements and assessment methodologies used by HRSA to verify compliance.

As in the past, HRSA maintains an expectation of 100% ongoing compliance with the Health Center Program Requirements – both in your documentation and your daily operations. Is your health center prepared to meet this challenge? Have you reviewed the most recent HRSA guidance and assessment processes with an eye toward 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 definitions for services and 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 when conducting an effectiveness evaluation of the program overall?
  • 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, including but not limited to your procurement processes, sufficient for purposes of federal accountability and good stewardship of public funds?
  • Is your budget constructed to account for all expenses and revenues?
  • Is your Board of Directors independently exercising all required authorities, without limitation, and do you have documentation to verify compliance?

Join us for this training exploring:

  • The new CE-OSV process and how it differs from the traditional 3-day OSV;
  • How to use the Compliance Manual, the most recent Site Visit Protocol, and other HRSA-issued compliance guidance to prepare for your compliance assessment, regardless of its form and format, including discussion of the elements of the programmatic requirements, the documentation and assessment methodologies required to verify compliance with each, and 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

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 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
Course opens: 
Course expires: 
Event starts: 
09/06/2023 - 10:00am EDT
Event ends: 
09/07/2023 - 5:30pm EDT


Washington, DC or FTLF Virtual Classroom
Wednesday, September 6 - Thursday, September 7, 2023
*Agenda times are all ET and subject to change*

Day 1

Wednesday, September 6, 2023
10:00 a.m. - 5:30 p.m. ET
10:00-10:15 a.m.Welcome and Overview of the Training
10:15-11:30 a.m.The Heart of Your Health Center Project: Needs, Services & Continuity of Care – Part 1 (Chapters 4, 7, 8) 
11:30-11:45 a.m.Break
11:45 a.m.-12:45 p.m.The Heart of Your Health Center Project: Needs, Services & Continuity of Care – Part 2 (Chapters 3, 6, 14)
12:45-1:45 p.m.Break
1:45-2:45 p.m.Quality is Key (Chapter 10)
2:45-3:45 p.m. Personnel Dynamics – Ensuring Appropriate Key Management and Clinical Staff (Chapters 11 & 5)
3:45-4:00 p.m.Break
4:00-5:30 p.m. Building Blocks of Fiscal Viability and Internal Controls: Budgeting and Financial Management (Chapters 17, 15) 

Day 2

Thursday, September 7, 2023
10:00 a.m. - 5:30 p.m. ET
10:00-10:15 a.m.Day 1 “Parking Lot” and Other Outstanding Questions
10:15-11:30 a.m.Building Blocks of Fiscal Viability and Internal Controls: Contracts, Subawards and Standards of Conduct (Chapters 12, 13) 
11:30-11:45 a.m.Break
11:45 a.m.-1:00 p.m.Ensuring the Core Mission: Making Care affordable While Maximizing Reimbursement – Part 1 (Chapters 16 & 9)
1:00-2:00 p.m.Break
2:00-3:30 p.m.Ensuring the Core Mission: Making Care affordable While Maximizing Reimbursement – Part 2 (Chapters 16 & 9) 
3:30-3:45 p.m.Break
3:45-5:00 p.m.The “Community” in Community Health Center: The Governing Board of Directors (Chapters 19 & 20)
5:00-5:15 p.m.It's All About the Data (Chapter 18)
5:15-5:30 p.m.Q&A and Wrap-Up
FTLF Training Center
1129 20th Street NW
Suite 300
Washington, DC 20036
United States
+1 (855) 200-3822


AC Hotel by Marriott (0.1 mi)

1112 19th St NW

Washington, D.C. 20036



St. Gregory Hotel Dupont Circle** (0.2 mi)

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2033 M St NW

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Hyatt Place Washington DC/Georgetown/West End** (0.3 mi)

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2121 M St NW

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Hilton Garden Inn Washington DC/Georgetown Area** (0.3 mi)

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West End Washington DC, Tapestry Collection by Hilton (0.3 mi)

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Embassy Suites by Hilton Washington DC Georgetown (0.4 mi)

1250 22nd St NW

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** Discounted Rate available through FTLF link

Molly Evans

A Partner in the firm’s health care 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]

Ted Waters

Serving as Managing Partner of the firm since 2003, and a member of the Health Care 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]

Participants can earn up to 13.60 CPE credits in Specialized Knowledge and Applications upon completion of all course requirements.

Additional Information

  • Prerequisites: None 
  • 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; and Other Staff assisting with HRSA compliance and/or OSV preparation
  • Advanced Preparation: None  
  • Program Level: All
  • Delivery Method: Group-Live/Group Internet based

Feldesman Tucker Leifer Fidell LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website (formerly

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Training is Not Recorded

This training will not be recorded for later viewing, as we would like attendees to be comfortable and candid, sharing their experiences and asking scenario-based questions. The discourse between the attorneys and participants is a valued part of each training.

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