2025 HRSA Site Visit Protocol Updates Refine Compliance Expectations

The Health Resources and Services Administration (HRSA) has released its 2025 updates to the Health Center Program Site Visit Protocol, refining how Operational Site Visits are conducted for Federally Qualified Health Centers (FQHCs) and Look-Alikes. Many revisions align language and methodology with current program guidance. Several changes, however, provide clearer direction in areas where documentation and day-to-day operations often receive close review.

Key Takeaways:

• HRSA 2025 Site Visit Protocol updates clarify how Operational Site Visits are conducted for FQHCs and Look-Alikes, with visits generally scheduled at the midpoint of the period of performance.
• Clinical staffing, credentialing and privileging, and oversight of contracted providers will receive closer review, with documentation required to support consistent implementation.
• Sliding Fee Discount Program compliance remains a high-risk area. Discounts must be applied consistently based only on income and family size and kept separate from billing and collections policies.
• Contracts and subawards, billing and collections, and board authority and composition must align with current guidance, including required claims samples, monitoring records, and documented board oversight.
• Health centers may strengthen readiness through structured compliance assessments and mock Operational Site Visits to confirm that daily operations, documentation, and governance meet HRSA requirements.

2025 HRSA Site Visit Protocol Updates

HRSA clarified that Operational Site Visits (OSVs) are generally scheduled around the midpoint of a health center’s period of performance. For health centers, this reinforces the importance of maintaining steady compliance throughout the grant cycle. Policies, workflows, and documentation should consistently reflect how care is delivered and how oversight responsibilities are carried out.

The 2025 updates provide clear guidance on what site visit teams review and how compliance is measured. Health centers may benefit from understanding where expectations have been refined, so leadership, clinical teams, and board members feel prepared and supported well before an OSV occurs.

Key Operational and Governance Areas Drawing Closer Review

The 2025 updates place sharper focus on several areas that often require coordination across departments, sites, and governance structures. While the underlying requirements are familiar, methodology and documentation expectations are more clearly defined.

Clinical staffing is one such area. The revised protocol adds clarification around credentialing and privileging, assessment of staffing mix, and oversight of contracted and referral providers. Site visit teams are directed to look more closely at how health centers document processes for granting, modifying, and removing privileges. In practice, this means documentation must support not only written policy but consistent implementation.

The Sliding Fee Discount Program also receives added attention. The protocol emphasizes that the sliding fee discount policy applies uniformly to all patients and is based solely on income and family size. Updates distinguish between the sliding fee discount schedule and the fee schedule and clarify how nominal charges and pharmaceutical dispensing fees are treated. Health centers should expect reviewers to assess whether policies are applied consistently and whether documentation clearly supports those practices.

Contracts and subawards represent another area of refinement. The updated guidance narrows the review to the most relevant contracts and clarifies which agreements are within scope for the site visit. Documentation expectations for subrecipients now include clearer alignment with board composition elements, including analysis demonstrating that patient board members, as a group, reflect the population served. This new emphasis calls for coordination between finance, operations, and governance.

Billing and collections updates further reinforce consistency. The protocol clarifies distinctions between billing and collections policies and sliding fee policies, removes qualifiers such as ‘if available’ in connection with revenue cycle metrics, and specifies expectations for claims samples from common third-party payors, including Medicare, Medicaid, and CHIP. Policies and procedures must apply to all patients, subject to legal or contractual limits, and documentation must reflect actual practice.

Board authority and composition requirements also are more precisely framed. The updates emphasize documented board evaluation of policies, clarity around approval responsibilities, and alignment with current element language. For public agencies and co-applicant structures, additional notes clarify how requirements apply.

Finally, HRSA introduced a new resource outlining required documents and file naming conventions. While administrative in nature, this change signals increased attention to how materials are organized and submitted. Clear, consistent file naming and complete documentation may help streamline the review process and reduce follow-up requests.

Preparing for an Operational Site Visit

The updated protocol reinforces a practical point. Compliance is shown through consistent daily operations and accurate documentation. FQHCs may benefit from stepping back to confirm that written policies, workflows, and documentation align across clinical, financial, and governance functions.

Staff readiness is central. Clinical leaders should be comfortable describing credentialing and privileging processes. Revenue cycle teams should understand how billing and collections policies interact with sliding fee requirements. Governance leaders should be prepared to explain how the board evaluates and updates policies and how composition requirements are met. Consistency across interviews, documentation, and observed practice often shapes the overall site visit experience.

AAFCPAs advises that clients preparing for an OSV conduct a structured readiness assessment well in advance of the anticipated midpoint review. A mock OSV may help identify documentation gaps, workflow inconsistencies, or areas where staff would benefit from additional clarification. This focuses on confirming that daily operations, documentation, and governance meet HRSA requirements, rather than rewriting existing policies.

With the 2025 updates in place, awareness is key. Health Centers that understand where expectations have been clarified may approach their next OSV with greater confidence and a clear path to readiness.

How We Help

AAFCPAs has supported Federally Qualified Health Centers since 1973, providing practical CPA and advisory solutions tailored to the operational and financial needs of community health centers. Our team helps FQHCs maintain compliance and operational readiness across all aspects of care delivery, including analysis of staffing models (productivity, cost per visit, right‑sizing), governance, contracts, billing, and the Sliding Fee Discount Program. We offer a full range of services, from audits in accordance with Uniform Guidance and state-specific reporting requirements to outsourced CFO and controller advisory, revenue cycle management, and technology and process optimization. Our expertise extends to the federal 340B Drug Pricing Program, Medicaid and Medicare reimbursement, cost reporting, and strategic use of tax credits for capital initiatives. We work with leadership teams to streamline workflows, ensure documentation aligns with HRSA and regulatory expectations, and provide mock Operational Site Visits to assess readiness. By combining financial assurance, operational insight, and specialized healthcare knowledge, AAFCPAs helps FQHCs demonstrate compliance, optimize resources, and maintain sustainable, efficient operations.

These insights were contributed by Pauline Legor, CPA, MBA, Director, Healthcare Practice and Courtney McFarland, CPA, MSA, 340B Apexus Certified Expert™, Partner.

Questions? Reach out to our authors directly or your AAFCPAs partner.

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