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

March 6, 2024 to March 7, 2024

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.

HRSA’s compliance assessment efforts for Federally Qualified Health Centers (FQHCs) are a “mainstay” of the Health Center Program (HCP).  Conducted at least once per project period, all health centers are subject to an Operational Site Visit (OSV) to determine their ongoing compliance with the HCP Requirements that establish the foundation and framework of every health center’s particular project. In addition to the traditional 3-day OSV, HRSA has begun a limited roll-out of the Compliance & Engagement Operational Site Visit (CE-OSV), which combines aspects of the “live” (virtual or in-person) OSV with substantial desk audits. 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 HCP Requirements and the Site Visit Protocol (SVP), document review including health center-self assessments based on the SVP, and traditional interviews for the most common areas of non-compliance.   

Whether your assessment follows the new CE-OSV process or the traditional 3-day OSV, compliance with HCP 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 HCP 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.

Similarly, all assessment processes are guided by the SVP, which aligns with the HCP Compliance 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.

Regardless of any changes to the assessment process, HRSA maintains an expectation of 100% ongoing compliance with the HCP 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 distinctions and similarities between the traditional 3-day OSV and the CE-OSV process;
  • How to use the Compliance Manual, the SVP, and other HRSA-issued compliance guidance to prepare for your compliance assessment, including discussion of the elements of the HCP 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 HCP Requirements addressed in the Manual and the SVP.
  • 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
Available credit: 
  • 12.00 Certificate of Attendance
Course opens: 
Course expires: 
Event starts: 
03/06/2024 - 10:00am EST
Event ends: 
03/07/2024 - 5:30pm EST


Virtual Classroom
Wednesday, March 6 - Thursday, March 7, 2024
*Agenda times are all ET and subject to change*

Day 1

Wednesday, March 6, 2024
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 - 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, March 7, 2024
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.Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement – Part 1 (Chapters 16 & 9)
11:30 - 11:45 a.m.Break
11:45 - 1:00 p.m.Ensuring the Core Mission: Making Care Affordable While Maximizing Reimbursement – Part 2 (Chapters 16 & 9)
1:00 - 2:00 p.m.Break
2:00 - 3:30 p.m.Building Blocks of Fiscal Viability and Internal Controls: Contracts, Subawards and Standards of Conduct (Chapters 12, 13) 
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

Virtual Classroom

This live, interactive training will take place in the Feldesman Training Solutions Virtual Classroom, hosted by Zoom.  Should you have any technical questions or would like more information, please contact us at or 1-855-200-3822.

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]

Scott Sheffler

Scott Sheffler is a Partner with the firm in the Federal Grants and Health Care practice groups. He advises clients on matters of federal grant law, government contract law, and health care law. Scott assists clients with the myriad requirements that apply upon acceptance of federal grant funding, including the administrative requirements and cost principles established in the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), the Office of Management and Budget (OMB) Circulars that preceded the Uniform Guidance, and program-specific statutory and regulatory funding conditions. [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 13.50 CPE credits in Specialized Knowledge and Applications upon completion of all course requirements.


  • 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, Other Staff assisting with HRSA compliance and/or OSV preparation
  • Advanced Preparation: None  
  • Program Level: All
  • Delivery Method: Group Internet Based

Feldesman Leifer 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

Available Credit

  • 12.00 Certificate of Attendance


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Training Is Not Recorded

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