HRSA Compliance: Appropriate Clinical Staffing Makeup

HRSA Compliance: Evaluating Thoughtful Clinical Staffing Makeup

The RegLantern team commonly receives questions regarding the HRSA Site Visit Protocol, Chapter 3: Clinical Staffing, Elements a and b:

• Question 1: Does the health center’s current clinical staffing makeup (such as employees, volunteers,

  contracted and referral providers) enable it to carry out the HRSA-approved scope of project

  on Form 5A?”

• Question 2: “Did the health center provide one to two examples of how the mix (for example, pediatric and

  adult providers) and number (for example, full or part-time staff, contracted providers) of

  clinical staff are responsive to the size, demographics, and needs of its patient population?”

• Question 3: “Based on the health center’s most recent UDS, is the number and mix of current staff

  (considering all sites and all service delivery methods) sufficient to ensure reasonable patient

  access to all health center services?”

Health centers often ask: “How do we demonstrate compliance for these three questions?”

Though many of the HRSA Site Visit Protocol questions have been revised to be more objective, this one could be classified as a rather subjective judgment call. So, the onus lies on the health center to make very clear why the reviewer should have no choice but to mark “Yes” to this question.

When ensuring your health center is continuously compliant and has the documentation to prove it, we recommend you do these four things:

Assign an accountable leader to every service on Form 5A (Column I)
On your health center’s Form 5A, Column I services are services that you are telling HRSA you’re providing directly and paying for out of health center funds. This means that your health center must show that you have the staff (employees, individual contractors, and volunteers) to handle administering and managing these services. If you are using the RegLantern web-based tools, this is easy–fill in the staff member title beside every Column I service. If you are not using our platform tools, at least make sure you create a document that lists the Column I services together with the staff member role accountable to the oversight of that service (i.e., “General Primary Medical Services-Chief Medical Officer”, “Pharmaceutical Services-Pharmacy Director”, etc.).

Evaluate patient access and clinical staff makeup
Create a document (or access our sample “Patient Access and Clinical Staff Evaluation” document on our RegLantern Resource page) that allows you to evaluate and review the size, demographics, and needs of the population you serve and compare it to the makeup of your clinical staff. Note any disparities and develop a plan with action steps to correct any areas where you discover your clinical staff resources may not be responsive to the community’s needs.

Provide other supporting documentation
Besides staff numbers and FTEs (full-time equivalents) that may be captured on your HRSA Form 2 (Staffing Profile), a health center may document other outcomes that may be indicative of a healthy clinical staff makeup. These may include Third Next Available Appointment tracking (to demonstrate there is plenty of access to your clinical providers), or maybe it is a list of staff vacancies. Another metric might be provider productivity rates (number of patients seen per hour) or patient panel size (per FTE). Together, these data points will paint a picture of how well your staff is covering your in-scope services.

Discuss with the Board
After compiling your staffing and supporting documentation, take the reports to your Board. Present your findings and state any recommendations you may have in areas where you need to shore up or diversify your staff. Make sure the person taking the minutes captures that a robust discussion was had and that this question was fully taken into consideration.

When you have done these four things, compile the documentation and Board meeting minutes into a document and provide the packet to the reviewers when the time comes for your Operational Site Visit. Health center leaders should always review the current HRSA Compliance Manual and the HRSA Site Visit Protocol as references to guide their work. When reviewing your credentialing and privileging systems, review the HRSA Program Requirements and consider having an FQHC mock site visit. As HRSA continues to work to align its key guidance documents, staying on top of the changes will keep you heading away from episodic compliance and toward HRSA Continual Compliance.

Reviewed & Updated: July 23, 2026