2025 Site Visit Protocol: Summary of Updates

The Health Center Program Site Visit Protocol (SVP) gives site visit teams instructions for conducting operational site visits (OSVs). It includes what teams review and how they check for compliance. These instructions align with current programmatic guidance, including the Health Center Program Compliance Manual (Compliance Manual). 

As part of our ongoing continuous quality improvement efforts, we analyze feedback about the SVP and site visit process from stakeholders, including health centers, site visit team reviewers, and HRSA staff. Your feedback helps us update and improve the site visit process. This page provides a summary of the 2025 SVP updates.

Substantial updates

  • Eligibility Requirements for LAL ID Applicants: We revised this section of the SVP to align with the Look-Alike Initial Designation (LAL-ID) Application Instructions. Visit the Look-Alike Initial Designation (LAL ID) webpage for more information on the LAL ID application process. 

Crosscutting updates 

HRSA made the following general updates throughout the SVP: 

  • Aligned language, methodology, and questions with current programmatic guidance, including updates to HHS Grants Policies and Regulations.
  • Added chapter numbers. NOTE: The chapter numbers for the SVP are different from the chapter numbers in the Compliance Manual, as there is no corresponding section of the OSV for Chapter 1: Health Center Program Eligibility and Chapter 2: Health Center Program Oversight. When possible, we noted the corresponding Compliance Manual chapter for each section of the SVP.
  • Added a link to Scope of Project Resources in each chapter
  • Clarified and streamlined methodology and questions. This includes improving plain language, formatting, and consistency. We also improved “skip patterns” that will allow site visit teams to skip questions that are not applicable to the site visit.
  • Updated and improved consistency of common terms and references.

Updates by SVP section

Throughout this summary, we use “Element” as the abbreviation for “Demonstrating Compliance Element,” and we use “questions” as the abbreviation for SVP sections containing “Site Visit Findings questions.”

Introduction

  • Clarified that OSVs usually take place around the mid-point of each health center’s period of performance.
  • Updated the Structure section to address both structure and terminology and clarified flexibilities with documentation.

SVP Chapter 1: Needs Assessment 

Corresponds to Compliance Manual Chapter 3: Needs Assessment

SVP Chapter 2: Required and Additional Health Services 

Corresponds to Compliance Manual Chapter 4: Required and Additional Health Services

  • Added guidance for providing the site list and selecting sites for tours.
  • Element a. Added clarifying notes and improved questions to distinguish how service delivery methods are assessed.
  • Element b. Added clarifying notes and streamlined methodology.
  • Element c. Streamlined methodology and aligned question to match the element.

SVP Chapter 3: Clinical Staffing 

Corresponds to Compliance Manual Chapter 5: Clinical Staffing

  • Added examples, notes, and a link to Health Center Program Site Visit Protocol: Examples of Credentialing and Privileging Documentation to guide health centers in uploading the right documentation.
  • Element b. Clarified questions to ensure that site visit teams thoroughly assess the staffing mix.
  • Element c. and Element d. Added clarifying notes on demonstrating compliance with credentialing and privileging requirements, particularly highlighting health center flexibilities.
  • Element d. Updated question to more thoroughly assess criteria and processes for modifying and removing privileges.
  • Element e. Clarified how review of identification documentation can occur.
  • Element f. Clarified options health centers have for ensuring that contracted and referral providers are credentialed and privileged.

SVP Chapter 4: Accessible Locations and Hours of Operation 

Corresponds to Compliance Manual Chapter 6: Accessible Location and Hours of Operation

  • Element a. Updated methodology to focus interviews on sites that have been added within the past 12 months (if the health center has added sites in the last 12 months.)
  • Element c. Added methodology and question regarding sites or activities in carceral settings. 

SVP Chapter 5: Coverage for Medical Emergencies During and After Hours 

Corresponds to Compliance Manual Chapter 7: Coverage for Medical Emergencies During and After Hours

  • Element a. Updated methodology to acknowledge basic life support training may be completed through licensure or certification.
  • Element c. Clarified different ways the site visit team may be connected to an individual for after-hours calls.
  • Element d. Added an example to clarify the types of follow-up the health center may be providing.

SVP Chapter 6: Continuity of Care and Hospital Admitting 

Corresponds to Compliance Manual Chapter 8: Continuity of Care and Hospital Admitting

  • Element a.
    • Updated methodology and question 1 to ask about “all health center patients” to ensure OSV team addresses any gaps.
    • Added footnote clarifying that the use of the term “formal arrangements” is specific to this chapter and does not refer to Form 5A: Services Provided, Column III (Formal Written Referral Arrangements.)

SVP Chapter 7: Sliding Fee Discount Program 

Corresponds to Compliance Manual Chapter 9: Sliding Fee Discount Program

  • Documents the Health Center Provides: Added note explaining the difference between the sliding fee discount schedule (SFDS) and “fee schedule.”
  • Updated methodology, questions, and inserted notes to emphasize that the sliding fee discount program (SFDP) policy applies uniformly to all patients and is based only on patient income and family size.
  • Element a. Added note to methodology clarifying that pharmaceutical dispensing fees are a service and therefore on the fee schedule.
  • Element b. Added note to methodology that “Nominal charges cannot reflect the actual cost of the service being provided.”
  • Element j. Removed mention of “sliding fee” before discounts in methodology and questions to allow for flexibility in discounts provided in Column III arrangements. To demonstrate compliance with Element j, the health center either ensures that Column III services are discounted consistent with Element c. Sliding Fee for Column I Services, or meets the sub-bullets of Element j.

SVP Chapter 8: Quality Improvement/Assurance 

Corresponds to Compliance Manual Chapter 10: Quality Improvement/Assurance

  • Element f. Updated reference in “protected health information” to “patient information, including protected health information” to align with element language. Also made this change in “Documents the Health Center Provides.”
  • Element c. Clarified flexibilities the health center has in conducting periodic Quality Improvement/Quality Assurance (QI/QA) assessments.

SVP Chapter 9: Key Management Staff 

Corresponds to Compliance Manual Chapter 11: Key Management Staff

  • Added gateway question tagging if this is a LAL ID site visit, so that questions on prior approval are automatically marked Not Applicable.
  • Added gateway question tagging whether this is a site visit for an Indian/tribal organization, so that the Element d: CEO Responsibilities question on whether the Project Director /Chief Executive Officer (PD/CEO) reports to board is automatically marked Not Applicable.
  • Element d. Added guidance to methodology addressing how to assess health centers with more than one CEO-level position.

SVP Chapter 10: Contracts and Subawards 

Corresponds to Compliance Manual Chapter 12: Contracts and Subawards

  • Documents the Health Center Provides:
    • In the list of contracts provided by the health center, added a requirement to note whether the contract supports a Column II service.
    • For the sample of contracts that do not use Health Center Program award funds, clarified that the selected contracts should be those that use the largest amounts of funds.
    • Clarified the following:
      • The health center needs to submit a total of two to three contractor reports/records.
      • Contracts outside the scope of project (other lines of business) should not be submitted for the OSV.
    • Updated and clarified documentation used by the health center to assess subrecipient compliance in order to align with current Board Composition element language. This includes requesting subrecipient analysis used to assess whether patient board members, as a group, represent the individuals who are served by the health center.
  • Element a. Added notes explaining what level of detail is expected related to federal cost principles references.
  • Element b. Added footnote clarifying allowability of non-competitive proposals.
  • Element f.
    • Updated methodology and questions to narrow site visit team’s focus to the most relevant contracts and their supporting documentation.
    • Clarified that Column III Formal Written Referral Agreements are not reviewed as part of this element.
    • Added footnote clarifying applicability of property management, record retention/access, and audits in contracts.
  • Element i. Updated methodology and questions to align with current Board Composition element language.

SVP Chapter 11: Conflict of Interest 

Corresponds to Compliance Manual Chapter 13: Conflict of Interest

  • Element a. Added footnote clarifying applicability to public agency and co-applicant employees.

SVP Chapter 12: Collaborative Relationships 

Corresponds to Compliance Manual Chapter 14: Collaborative Relationships

SVP Chapter 13: Financial Management and Accounting Systems 

Corresponds to Compliance Manual Chapter 15: Financial Management and Accounting Systems

  • Element a. Added note explaining how Generally Accepted Accounting Principles (GAAP) / Government Accounting Standards Board (GASB) principles can be demonstrated.
  • Element d. Increased the single audit threshold to $1,000,000.
  • Element e. Added note explaining health center flexibility in determining use of non-grant funds.

SVP Chapter 14: Billing and Collections 

Corresponds to Compliance Manual Chapter 16: Billing and Collections

  • Documents the Health Center Provides:
    • Added note explaining the difference between SFDS and “fee schedule.”
    • Clarified billing and collections policies are different from policies related to SFDP.
    • Removed “if available” after revenue cycle management metrics.
    • Clarified claims sample should be from “most common” third-party payors, and that it must include Medicare, Medicaid, and CHIP.
  • Clarified through updated notes, methodologies, and questions that policies and procedures are applicable to all patients and subject to legal/contractual restrictions.
  • Element a. Added note clarifying that pharmaceutical dispensing fees are a service and therefore on the fee schedule, but that prescription drugs are a supply.
  • Element g. In alignment with the Compliance Manual Chapter 16, Related Considerations, added note clarifying that discounts may be provided to patients with incomes over 200% of the Federal Poverty Guideline (FPG) if discounts are funded through other sources.
  • Element h. Added footnote with examples of circumstances and criteria for waiving or reducing fees.
  • Element i. Added note to provide additional examples when billing for supplies or equipment.
  • Element j. Updated questions to guide a clearer assessment of refusal to pay policy.

SVP Chapter 15: Budget

Corresponds to Compliance Manual Chapter 17: Budget

  • Documents the Health Center Provides: Clarified what to provide when audits are not available.

SVP Chapter 16: Program Monitoring and Data Reporting

Corresponds to Compliance Manual Chapter 18: Program Monitoring and Data Reporting Systems

  • Documents the Health Center Provides: Added note defining service utilization.

SVP Chapter 17: Board Authority

Corresponds to Compliance Manual Chapter 19: Board Authority

  • Element a. Added note clarifying public agency powers over co-applicant.
  • Element c. Added notes clarifying use of proxies, signatures, specific applications needing board approval, and budget/application overlap. Added footnote defining service utilization.
  • Element d. Emphasized that updates should result from board’s evaluation of policies.
  • Element e. Emphasized that updates should result from board’s evaluation of policies, specified what financial management/accounting policies and personnel policies include, clarified how a public agency/co-applicant’s PD/CEO is addressed in this element, and added new question asking about board updates to policies (to align with element language; mirror question structure for Element d.)

SVP Chapter 18: Board Composition 

Corresponds to Compliance Manual Chapter 20: Board Composition

  • Updated documents to match current element language and Form 6A, including requesting the health center analysis used to assess whether patient board members, as a group, represent the individuals who are served by the health center.
  • Added note at top of questions: “For public agencies that elect to have a co-applicant, all board composition requirements apply to the co-applicant board. For public agencies that do not elect to have a co-applicant, all board composition requirements apply to the public agency’s governing board”
  • Added “Not Applicable” in several questions, for cases where the health center has an approved waiver and no patient board members.
  • Element a. Added note in methodology clarifying how to review a public agency with a co-applicant board.
  • Element b.
    • Added note clarifying how to review for a public agency with a co-applicant
    • Updated questions to align with current element language.
  • Element c. Updated methodology and questions to align with current element language.

Eligibility requirements for look-alike initial designation applicants 

Site Visit resources

  • Required Documents and File Naming Convention: In response to your feedback, we developed Required Documents and File Naming Convention. (PDF - 1 MB) This resource provides detail and clarity on which documents health centers are required to upload, what samples to select, and how to organize and label the documents for OSVs. 
     
Date Last Reviewed: