FQHC Associates Cheat Sheet - How to Prepare for a HRSA Operational Site Visit (OSV)

The goal of HRSA is that all health center program grantees will, at some point during their project period, get an on-site operational site visit to review grantee compliance with the 19 program requirements identified in the health center program legislation and federal regulations. The current HRSA target is to conduct the site visit at the mid-point for each project period (approximately 18 months). Here are some things you should do now to ensure that your organization does well during a HRSA operational site visit:

  • Review the 19 Health Center program requirements. The intent of the HRSA operational assessment is to assess compliance with statutory and federal regulations. These requirements should be shared across your organization, specifically with all key personnel and all board members. It is equally important that all key staff (e.g. dept. heads) associated with the 4 major areas outlined in the 19 program requirements be familiar with the expectations for their respective areas - clinical, fiscal, administrative, governance, etc. These are listed on the HRSA website at http://bphc.hrsa.gov/about/requirements/.
     
  • Review the HRSA site visit guide. The HRSA site visit guide is developed to familiarize your organization with the 19 program requirements, the specific HRSA program policies associated with each requirement, and the documentation that your organization is required to maintain to demonstrate compliance with the HRSA program requirements. To a large extent, the HRSA operational site visit will use the HRSA site visit guide for the 3 day operational assessment site visit, with each respective reviewer addressing the questions listed under each of the 19 program requirements. It is important that the pertinent staff members for each key area become familiar with the details in the site visit guide for their respective areas. It will assist them in gathering the appropriate documentation to demonstrate compliance with the 19 program requirements. The site visit guide can also be obtained on the HRSA website at http://bphc.hrsa.gov/policiesregulations/centerguide.html.
     
  • Gather and review documents or materials that demonstrate compliance with each related area. The HRSA reviewers will spend a large portion of their time on site and, prior to the visit, they will spend some time reviewing the documentation to support compliance with the program requirements. You will be notified prior to the visit of the specific documentation and/or materials to be reviewed, which will need to be made available by your organization. It is recommended that you establish a central repository (such as a Dropbox account or a smart drive) for all documentation related to the HRSA operational site visit. Directories or folders can be organized by the key areas - needs, clinical, governance, administrative, scope of project, etc. This will allow easy access to documents by the reviewers and your organization during the site visit.
     
  • Preparing for your site visit after you have been contacted by HRSA. To a large extent, HRSA sets the agenda for the 3 day site visit. The typical agenda will consist of an entrance conference, reviewer working time, and an exit conference. Here are some things you can do to prepare once your site visit has been scheduled:
  1. Contact your project officer. Your project officer will provide details on the HRSA site visit. These include dates for the site visit, HRSA team members involved, documentation to be reviewed, and any specific areas identified for HRSA review.
  2. Identify areas or issues requiring clarification. These should be discussed on the HRSA site visit planning call. This call will customarily occur after you are notified of the site visit and prior to the actual team site visit. 
  3. Inform key staff and board members. Key staff and board members should be informed about the program requirements related to their respective areas and prepared to meet with the HRSA team members. Board members, in particular, should participate in the entrance and exit conferences, as well as any time requested by the HRSA team.

If you have any questions or need further assistance in preparing for your HRSA Operational Site Visit, please feel free to contact me at jruiz@fqhc.org.

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John Ruiz is a Principal at FQHC Associates, a health care consulting firm specializing in the needs of established, new and potential Federally Qualified Health Centers (FQHCs).

Read more about John here.

To contact John, email him at JRuiz@FQHC.org.

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