HRSA Site Visit Protocol Updates: November 2025

On November 20, 2025, HRSA released an updated Health Center Program Site Visit Protocol (SVP), the tool reviewers use to assess compliance during Operational Site Visits (OSVs).

Behind the scenes, HRSA made more than a thousand edits; when you strip out formatting, you’re still left with hundreds of meaningful changes that affect how compliance is tested and documented.

Please note: As of the initial publication of this blog post, the digital, web-based SVP is not yet updated. Only the PDF version has been updated at this time.

At a high level, the revised SVP:

• Removed sections. Removes Federal Tort Claims Act (FTCA) and “Promising Practices” sections from the SVP, focusing it strictly on statutory and regulatory compliance rather than best-practice guidance.

• Links and references. Reduces references to specific systems (like HRSA’s Electronic Handbooks or “EHBs”) and some specific agencies, leaning on more generic language and updated links to scope-of-project and Compliance Manual resources.

• Numbering & structure. The SVP is now numbered starting with Chapter 1 (Needs Assessment), which means the chapter numbers are offset from the Compliance Manual (whose “Introduction” is Chapter 1).

• Uniform Guidance alignment. Aligns more tightly with the October 2025 Compliance Manual update and the shift from 45 CFR to 2 CFR for Uniform Guidance.

• Terminology shifts. Cleans up terminology (for example, “awardee” changed to “recipient”, references to “special populations” changed to “medically underserved populations”) to better mirror statutory language in Section 330 and the revised federal grants rules.

• Less demographic detail, more local judgment. The protocol removes some prescriptive examples of demographic factors (race, ethnicity, gender) and instead pushes health centers to articulate how their boards and services reflect their own patient population and community. Again, this language more closely aligns with statutory language: The board “is composed of individuals, a majority of whom are being served by the center and who, as a group, represent the individuals being served by the center”.

How HRSA will run OSVs

What changed

• OSV timing and method. The SVP now explicitly allows HRSA flexibility in when and how OSVs are conducted, including more explicit room for in-person or virtual formats within an approximate timing range (SVP, p. 1).

• Document names are not compliance. HRSA reiterates that documents don’t need a specific title (“Board Governance Policy,” “Sliding Fee Policy,” etc.) to be compliant; what matters is content, not naming convention. Check out our previous blog post about this topic (SVP, p. 3).

• Patient samples and record review options.
  Health centers may choose to provide samples of patient records before or during the site visit. If patient records will be provided during the site visit, this should be communicated to the site visit team before the site visit to avoid any disruption or delay in the site visit process (SVP, p. 3).

• Key staff, board, and special cases.
  The SVP notes that some “key staff” and “board” elements may not apply to certain LALs or tribes, signaling more tailored OSV expectations.

Chapter 1: Needs Assessment (Compliance Manual Ch 3)

What changed

The November 2025 SVP update did not introduce major methodology changes specific to the Needs Assessment chapter. Most updates affecting this area are global (terminology, references, and the 3-year cycle emphasis already built into the Compliance Manual).

What leaders should do now

• Confirm your Needs Assessment schedule still meets the “at least every 3 years” requirement, even if your period of performance is 4 years.

• Make sure any references to demographics or special populations in your Needs Assessment materials align with the updated terminology (“medically underserved populations”) used across HRSA guidance.

Chapter 2: Required and Additional Health Services (Compliance Manual Ch 4)

What changed

1. Public agency services clarified as Column I.
   The SVP now clarifies that services furnished by either the co-applicant or the public agency’s own employees can be treated as Column I (direct employment) on Form 5A. This means some relationships previously placed under Column II or III (contracts/referrals) may actually belong in Column I if staff are employees of the public agency.

2. Agreements must be “Fully executed”.
   There is now an explicit requirement that each contract/agreement for services must be current and executed by all parties, but gives several ways to execute including: a signed paper copy, electronically-signed documents, or emails documenting acceptance.

3. Slight change in “cultural competency” language.
   The old SVP used the words “cultural sensitivity”, and the new SVP uses “culturally appropriate” language. This now aligns more directly with statute language.

4. Patient sample format and reuse.
   The protocol now explicitly allows health centers to use live, prepared, or recorded patient samples – and reuse the same sample data across multiple chapters where relevant. Just make sure to notify the reviewers of your plans.

What leaders should do now

• Public Agencies / Co-Applicants: Re-evaluate Form 5A:

• Move services performed by public agency employees (supporting your approved project) into Column I, and clean up unnecessary Column II/III entries.

• Confirm full execution of contracts/agreements:

• Confirm you have clear documentation of agreement (signature, e-signature, or email trail), even if not a “traditional” executed contract.

• Keep your cultural and linguistic access practices, but:

• Expect reviewers to focus on outcomes and accessibility rather than adherence to a specific external standard (like CLAS).

• Create a patient-sample strategy you can reuse across Chapters 2, 5, 6, and 8 (e.g., one well-designed sample set for service delivery, after-hours, continuity, and QI).

Chapter 3: Clinical Staffing (Compliance Manual Ch 5)

What changed

1. Credentialing & privileging for roles with on-the-job training.
   For roles that do not require prior training under state law, education/license verification is no longer required – but your policy must clearly define how you assess clinical competence for those individuals.

2. NPDB checks narrowed.
   The SVP clarifies that NPDB queries are required for NPDB-reportable provider types, implying leeway for not running NPDB on non-reportable categories (like some OCS roles). However, we still recommend running NPDB queries on all clinical staff (LIPs, OLCPs, and OCS). Please check out our blog posts we’ve written about this in the past.

3. Communicable disease standards are local decisions.
   HRSA is now explicit that health centers set, document, and apply their own communicable disease standards (e.g., TB testing, vaccination policies) in credentialing/privileging.

4. Fitness for duty added as a reason to modify privileges.
   The SVP adds fitness for duty to existing reasons (like clinical competence) for modifying or removing privileges.

5. C&P files don’t have to have ID
   C&P files no longer need to include a copy of a government ID in every sampled file; reviewers just need evidence that identity was verified, even if the specific document isn’t in the sample. However, our recommendation is to include a copy of the government-issued picture ID if you have it.

What leaders should do now

• Update your C&P policy to:

• Spell out how you establish clinical competence for positions filled through on-the-job training.

• Clarify which provider types require NPDB queries and which do not. Again, our recommendation is to still query the NPDB for all LIPs, OLCPs, and OCS.

• Add fitness for duty as an explicit basis for modifying privileges.

• Ensure communicable disease expectations (e.g., vaccines, TB, mask use when ill) are:

• Clearly defined, documented, and consistently applied across providers.

• Check that identity verification is:

• Documented somewhere reliable (e.g., HR onboarding checklist), if a physical ID copy isn’t retained in every C&P file.

Chapter 4: Accessible Locations and Hours of Operation (Compliance Manual Ch 6)

What changed

1. Carceral settings and restrictions.
   HRSA explicitly asks reviewers to look at whether in-scope sites overlap with carceral environments or are limited by correctional contracts or agreements.

2. Prioritizing recent sites.
   The SVP instructs reviewers to prioritize sites added within the last 12 months when evaluating how locations and hours reduce barriers to care.

3. Reusing patient satisfaction data.
   Patient experience/satisfaction results can be reused between this chapter and QI/QA (Chapter 8) so you don’t need multiple separate surveys.

What leaders should do now

• Review any jail, prison, or corrections-related arrangements to ensure:

• In-scope sites are consistent with HRSA’s expectations for access and patient autonomy.

• Limitations imposed by corrections partners are clearly documented and understood.

• For new sites (last 12 months):

• Be ready to explain how those locations and hours were chosen to reduce barriers (distance, transportation, safety, language, etc.).

• Align your patient satisfaction strategy:

• Use a single survey (or set of measures) that can speak to both access/location barriers and overall QI/QA.

Chapter 5: Coverage for Medical Emergencies During and After Hours (Compliance Manual Ch 7)

What changed

1. After-hours contact types clarified.
   After-hours coverage was clarified to be via phone, telehealth, or in-person clinical contact; other “light touch” formats (e.g., email-only) won’t meet expectations.

2. Patient samples may be viewed live or prepared.
   As noted earlier, you may use prepared or medical record samples to demonstrate after-hours workflows.

What leaders should do now

• Confirm your after-hours messages and workflows:

• Direct patients to a phone line, telehealth, or in-person option with clinical decision-making – not just a voicemail instructing them to call 911.

• Prepare clean process maps or sample recordings that walk through after-hours calls from start to disposition.

Chapter 6: Continuity of Care and Hospital Admitting (Compliance Manual Ch 8)

What changed

• The main change here is methodological: HRSA explicitly encourages the reuse of patient samples and prepared/recorded scenarios across chapters to demonstrate continuity.

What leaders should do now

• Use the same patient sample set from Chapters 2 and 5 to show how hospital discharges, referrals, and follow-up appointments are handled.

• Make sure your continuity documentation (e.g., referral tracking, hospital discharge reports) is structured so reviewers can easily follow one patient’s journey end-to-end.

Chapter 7: Sliding Fee Discount Program (SFDP) (Compliance Manual Ch 9)

What changed

1. Pharmacy dispensing fees are services and qualify for the SFDP.
   Pharmacy dispensing fees are now explicitly treated as services that must appear on your fee schedule and be included in SFDP considerations – not just pass-through “supplies.”

2. SFDP eligibility based only on income and family size.
   The SVP clarifies that SFDP eligibility must be based solely on income and family size, not on insurance status.

3. Frontline staff interviews for SFDP.
   Reviewers are instructed to interview frontline staff who actually assess SFDP eligibility to verify operational understanding, not just review policies.

4. Clarified difference between fee schedule and SFDS.
   The SVP clarifies that the fee schedule is the list of standard charges, and the sliding fee discount schedule (SFDS) is the schedule of discounts applied to those fees, and that billing policies extend beyond the SFDP alone.

What leaders should do now

• Review your pharmacy billing:

• Ensure dispensing fees are on your fee schedule and appropriately discounted under the SFDP, both for in-house and contract pharmacies.

• Audit your SFDP policy and workflows:

• Confirm eligibility is never conditioned on insurance status (or lack thereof).

• Train frontline staff (registrars, eligibility workers, pharmacy staff) on:

• Exactly how eligibility is determined.

• How discounts are applied to the fee schedule.

• Make sure your written materials and talking points clearly distinguish:

• “What we charge” (fee schedule) vs. “how we discount” (SFDS).

Chapter 8: Quality Improvement / Quality Assurance (QI/QA) (Compliance Manual Ch 10)

What changed

1. Security expectations broadened beyond PHI.
   The SVP now emphasizes that security policies should protect all patient information, even when it’s not technically PHI under HIPAA.

2. Reuse of patient satisfaction data.
   As noted in Chapter 4, you can reuse the same patient satisfaction data for both QI/QA and accessibility evaluations.

3. “Service utilization” defined.
   The SVP now explicitly defines “service utilization” as the quantity of health center services and trends in the types of services – clarifying what reviewers are looking for in your QI/QA and data reports.

What leaders should do now

• Ensure your information security policies:

• Clearly apply to any patient-related data (e.g., scheduling notes, care management logs), not just PHI in the EHR.

• Use your existing patient experience surveys:

• As evidence for both access and quality improvement discussions.

• Build QI dashboards or reports that:

• Track utilization trends (by service type, site, provider) and show how you use that data to drive improvement.

Chapter 9: Key Management Staff (Compliance Manual Ch 11)

What changed

1. Alternate CEO structures recognized.
   The SVP now acknowledges co-CEO or other non-traditional executive structures, as long as responsibilities are clearly delineated.

2. Applicability for LALs and tribes.
   Certain “key staff” expectations may not apply to Look-Alikes or Indian tribes; the SVP instructs reviewers to confirm applicability rather than assume a one-size-fits-all structure.

What leaders should do now

• If you have a shared or co-CEO model, ensure:

• Role descriptions and board resolutions clearly lay out who is responsible for each required CEO/project director function.

• For LALs and tribes:

• Confirm which key management elements apply and be ready to explain alternative structures that still meet program intent.

Chapter 10: Contracts and Subawards (CM Ch 12)

What changed

1. Fully executed documents – requirement and flexibility.
   As noted earlier, the SVP no longer requires every contract to look like a classic fully executed document; electronic signatures or documented agreement may suffice.

2. Focus on Health Center Program federal funds.
   Financial and contract oversight questions specifically focus on Health Center Program federal funds, not all possible federal (e.g. COVID-era funds).

3. 2 CFR citations and expectations.
   The SVP clarifies that it’s not enough to cite 2 CFR or GAAP/GASB – reviewers are instructed to assess whether you are actually complying with the requirements.

4. Performance monitoring in contracts.
   Performance monitoring requirements do not have to be spelled out in each contract; it’s sufficient to have a contract monitoring policy and evidence you follow it.

5. Column III agreements not assess for required contract/agreement certain language.
   The contract language requirements in this chapter apply only to Column II arrangements on Form 5A, not Column III referrals.

6. Contract list and sampling clarified.

• The “list of contracts” must include both contracts that support Column II services and other major contracts.

• Sample selection prioritizes contracts with the highest dollar amounts, regardless of whether they include Health Center Program funds.

What leaders should do now

• Review your contract/agreement list:

• Ensure it includes both Column II service contracts and other major operational contracts.

• Document your contract/agreement monitoring process:

• Have a policy (and evidence) showing how you review performance, even if individual contracts don’t spell it out.

• Check that you:

• Understand which relationships are Column II vs Column III – and don’t waste time adding grant-style language to pure referral relationships. 

• Have required language in contracts/agreements that cover both Column II and Column III relationships.

• Make sure finance and compliance teams are actually carrying out 2 CFR and GAAP/GASB requirements, not just referencing them.

Chapter 11: Conflict of Interest (Compliance Manual Ch 13)

What changed

• The main update is thematic: the SVP emphasizes focusing COI oversight on relationships involving Health Center Program federal funds, and it cross-connects with board composition and contracts (for example, board members with income from the health care industry).

• There was a strengthening in the language, now requiring that written codes of conduct require disciplinary actions for violating the conflict of interest requirements.

What leaders should do now

• Ensure your COI policies and disclosure forms:

• Clearly cover board members, officers, employees, and key agents.

• Capture whether non-patient board members earn more than 10% of their income from the health care industry (as flagged in the SVP).

• Require disciplinary actions for violating the conflict of interest requirements.

Chapter 12: Collaborative Relationships (Compliance Manual Ch 14)

What changed

• Language shifts from “special populations” toward “medically underserved,” aligning with the Compliance Manual revision.

• There was a change in the reference to the UDSMapper to now reference GeoCare Navigator.

What leaders should do now

• Make sure your collaboration narrative reflects how you work with other providers to serve medically underserved people broadly (not just formally designated special populations).

• Update any public-facing descriptions and board materials that still lean heavily on older “special populations only” terminology.

• Ensure your health center is using the GeoCare Navigator tool to complete your needs assessment and to determine where other health centers are in their service area that they need to collaborate with.

Chapter 13: Financial Management and Accounting Systems (Compliance Manual Ch 15)

What changed

1. Single Audit threshold updated.
   The SVP now reflects the updated Single Audit threshold: entities must have a Single Audit if they expend $1,000,000 or more in federal awards in a fiscal year (up from $750,000), consistent with the revised 2 CFR 200.501.

2. Reinvestment of out-of-scope funds.
   The SVP reiterates that funds generated from in-scope activities (even if not supported by grant dollars) must be used to benefit the target population and not for prohibited purposes.

3. Unaudited financials allowed if audit incomplete.
   If your annual audit isn’t finished at the time of OSV, HRSA will accept unaudited financial statements to support certain questions.

What leaders should do now

• Work with your finance team and auditors to determine whether your federal expenditures are likely to be above or below $1M and plan audit scope accordingly.

• Ensure your use-of-funds documentation clearly shows how program income and other revenues from in-scope activities are reinvested into your approved project.

• If your audit timeline runs late, have interim financial statements ready for OSV use, with clear reconciliation to your final audited numbers.

Chapter 14: Billing and Collections (Compliance Manual Ch 16)

What changed

1. Alternate payment methods must be universal and subject to payers and other billing requirements.
   Any alternate payment method (e.g., prompt-pay discounts, payment plans, membership models) must be universally available to all patients, and cannot override other legal or contractual obligations.

2. Discounts above 200% of FPL allowed but not grant-funded.
   The SVP reiterates that you may extend discounts above 200% FPL, but those discounts cannot be financed with Health Center Program grant dollars.

3. Billing samples prioritize top payers.
   Billing samples must prioritize claims from your largest payers and must include Medicare, Medicaid, and CHIP.

4. Clarified SFDP vs billing policies.
   Billing policies are clarified to be broader than SFDP alone; they cover fee schedule, SFDS, and overall billing practices (including non-SFDP discounts and payment plans).

What leaders should do now

• Review alternate payment offerings:

• Verify they’re offered equitably to all patients, and assess whether any need to be restructured to comply with payer or legal requirements.

• If your third-party payer contracts have restrictions you will need to update procedures to honor those restrictions or negotiate changes in the contracts.

• Ensure your SFDP and billing policies:

• Clearly separate grant-funded discounts from those funded by other revenue.

• For OSV prep, pull billing samples that:

• Include your largest commercial payer, Medicare, Medicaid, CHIP – and show accurate application of fee schedule and discounts.

Chapter 15: Budget (Compliance Manual Ch 17)

What changed

• The key change here ties back to financial management: If your Single Audit isn’t complete, unaudited financials can be used for certain budget-related questions.

What leaders should do now

• Make sure budget narratives and financial statements can be understood from either audited financials or clearly labeled unaudited statements, depending on timing.

Chapter 16: Program Monitoring and Data Reporting Systems (Compliance Manual Ch 18)

What changed

• Service utilization explicitly defined.
  “Service utilization” is now described as the quantity of health center services and trends in the types of health care services, tightening expectations for the data you present.

What leaders should do now

• Ensure your dashboards and reports to leadership and the board clearly show volumes and trends by service type, site, and key subpopulations.

• Connect these utilization trends to Needs Assessment findings and your QI/QA work so reviewers see an integrated story.

Chapter 17: Board Authority (CM Ch 19)

What changed

1. Public agency governance boundaries reinforced.
   Public agencies cannot veto or impose dual approval over co-applicant board decisions in core authority areas.

2. Board approves competitive applications only.
   The SVP clarifies that the governing board is required to approve competitive applications (e.g., SAC, RD, Supplemental Funding), not routine BPRs/annual certifications.

3. Quorum and proxy voting left to local rules.
   HRSA explicitly relies on local law and bylaws to determine what constitutes a valid quorum and proxy voting; the SVP doesn’t impose a uniform standard.

4. CEO in co-applicant arrangements.
   Even when a public agency retains personnel policy oversight, it cannot override the co-applicant board’s authority to select, evaluate, and terminate the CEO/project director.

5. Board minutes not required to be signed.
   HRSA clarifies that signed board minutes are not required for compliance.

6. Competitive application timing.
   The SVP acknowledges that the last competitive application may not fall within the last 12 months, even though the question doesn’t offer “N/A.”

7. Board-approved financial and personnel policies clarified.
   The SVP clarifies exactly what “financial policies” and “personnel policies” must be board-approved (e.g., selection/dismissal, salary scales, grievance procedures).

8. Look-Alike (LAL) board minutes expectation.
   If a LAL has fewer than 12 months of minutes, reviewers should review as many as are available.

What leaders should do now

• For public agency/co-applicant models, confirm your agreements and practice clearly preserve co-applicant authority over CEO selection, evaluation, and termination.

• Make sure your board calendar and minutes reflect:

• Approval of competitive applications, annual budget, scope changes, and required policies – even if not every operational item goes to the board.

• Approval of required policies according to the updated list (especially for personnel policies).

• Review your bylaws and local law:

• Ensure quorum and proxy rules are clear and consistently followed; you don’t need signed minutes, but you do need complete, accurate ones.

• If it doesn’t exist, clarify how documents are formally approved and retained.

• For LALs, organize whatever minutes you have, even if it’s fewer than 12, and be ready to show governance is functioning as expected.

Chapter 18: Board Composition (Compliance Manual Ch 20)

What changed

1. Patient members must reflect the patient population.
   The SVP now asks health centers to assess whether patient board members reflect the patient population, using criteria the health center defines (e.g., UDS data).

2. Reduced disclosure burden on non-patient board members.
   Non-patient board members now only need to disclose if they earn more than 10% of their income from the health care industry, not their full income details. This also applies to subrecipient boards.

3. Outside influence on board membership constrained.
   Third parties can only remove the board member they originally designated, and only within the bounds of the co-applicant/board relationship.

What leaders should do now

• Develop a written policy and/or procedure to define how you will determine that patient board members are reflective of the patient population (e.g., by geography, language, payer mix, special populations) and document your assessment.

• Update your board COI and disclosure forms to ask non-patient board members if more than 10% of their income comes from the health care industry, rather than requesting full income breakdowns.

• For co-applicant and subrecipient governance, check your agreements to ensure third-party removal rights are tightly limited and don’t erode true local control.

Chapter 19: Eligibility Requirements for Look-Alike (LAL) Initial Designation Applicants (Compliance Manual Ch 1)

What changed

1. Operational requirements for the LAL site.
   The SVP now expects at least one site to be:

• Open 40 hours per week,

• Permanent,

• Year-round (with accommodations for school-based sites open to the public and seasonal MSAW locations).

2. Focus on general primary care.
   LAL review focuses on general primary care in Column I/II, not Column III services, to determine eligibility.

3. Independence and corporate structure scrutiny.
   The SVP adds multiple questions to test whether the LAL is truly independent:

• Sole corporate member or subsidiary relationships

• Outsourced administrative or executive teams

• Limits on board authority

• Substantial financial support from another organization

4. Residents of public housing input.
   If applying as a LAL targeting residents of public housing, there must be evidence of resident input into site planning and operations.

What leaders should do now (prospective LALs)

• Confirm that at least one site meets the 40-hour, permanent, year-round standard (or clearly document how a school-based or seasonal site meets HRSA expectations).

• Ensure your corporate structure:

• Demonstrates real independence (board authority, control of substantive work, independent executive leadership).

• For public housing-focused LALs:

• Document genuine engagement with residents (listening sessions, advisory groups, surveys) in planning and operations.

Pulling it together: How to prioritize your next steps

If you’re an FQHC leader staring at this long list of changes, here’s some practical steps to begin working on tomorrow:

• Review your Form 5A. If you are a public entity or a co-applicant, you will likely need to update how your services are documented.

• Update Needs Assessment language. Make sure any references to demographics or special populations in your Needs Assessment materials align with the updated terminology (“medically underserved populations”) used across HRSA guidance.

• Ensure contracts are fully executed. There is now an explicit requirement that each contract/agreement for services must be current and executed by all parties.

• Review credentialing and privileging policies. Update language to include fitness for duty and clinical competence as reasons for modifying or removing privileges.

• Review corrections-related agreements. Review any jail, prison, or corrections-related arrangements to ensure in-scope sites are consistent with HRSA’s expectations for access and patient autonomy and that limitations imposed by corrections partners are clearly documented and understood.

• Review your Sliding Fee Discount Program (SFDP): Review your pharmacy billing to ensure dispensing fees are on your fee schedule and appropriately discounted under the SFDP, both for in-house and contract pharmacies. Confirm eligibility is never conditioned on insurance status (or lack thereof). Ensure frontline staff (registrars, eligibility workers, pharmacy staff) are trained to appropriately determine eligibility and how discounts are applied to the fee schedule. Make sure your written materials and talking points clearly distinguish “what we charge” (fee schedule) vs. “how we discount”.

• Review security policies. Ensure policies state how the health center will protect all patient information, even when it’s not technically PHI under HIPAA.

• Review Quality Plan. Ensure the plan addresses “service utilization” as falling under the Quality Program, and that the program measures the quantity of health center services and trends in the types of services used.

• Review co-CEO arrangements. If you have a shared or co-CEO model, ensure role descriptions and board resolutions clearly lay out who is responsible for each required CEO/project director function.

• Review financial practices. Ensure your health center is complying with all requirements (2 CFR or GAAP/GASB).

• Create a Contract Performance Monitoring policy. Performance monitoring requirements no longer have to be spelled out in each contract; it’s sufficient to have a contract monitoring policy and evidence that you follow it.

• Review Column III (Form 5A) agreements. The contract language requirements in SVP Chapter 10 now state that they apply only to Column II arrangements on Form 5A, not Column III referral agreements.

• Review contract list and samples. Ensure the “list of contracts” includes both contracts that support Column II services and other major contracts. Sample selection should prioritize contracts with the highest dollar amounts, regardless of whether they include Health Center Program funds.

• Review COI policies. Ensure your COI policies and disclosure forms clearly cover board members, officers, employees, and key agents. Capture whether non-patient board members earn more than 10% of their income from the health care industry (as flagged in the SVP). Require disciplinary actions for violating the conflict of interest requirements.

• Review Single Audit threshold. Work with your finance team and auditors to determine whether your federal expenditures are likely to be above or below $1M and plan audit scope accordingly.

• Use-of-funds documentation. Ensure your use-of-funds documentation clearly shows how program income and other revenues from in-scope activities are reinvested into your approved project.

• Review alternate payment offerings. Verify they’re offered equitably to all patients, and assess whether any need to be restructured to comply with payer or legal requirements. If your third-party payer contracts have restrictions, you will need to update procedures to honor those restrictions or negotiate changes in the contracts.

• Review your SFDP and billing policies. Clearly separate grant-funded discounts from those funded by other revenue.

• Review program reports. Ensure your dashboards and reports to leadership and the board clearly show volumes and trends by service type, site, and key subpopulations. Connect utilization trends to Needs Assessment findings and your QI/QA work so reviewers see an integrated story.

• Review public agency/co-applicant agreements. Ensure agreements and operations clearly preserve co-applicant authority over CEO selection, evaluation, and termination.

• Review board calendar and board minutes. Ensure documentation of approval of competitive applications, annual budget, scope changes, and required policies. Ensure approval of required policies according to the updated list (especially for personnel policies) is noted.

• Review bylaws and local law. Ensure quorum and proxy rules are clear and consistently followed; you don’t need signed minutes, but you do need complete, accurate ones. If it doesn’t exist, clarify how documents are formally approved and retained. For LALs, organize whatever minutes you have, even if it’s fewer than 12, and be ready to show governance is functioning as expected.

• Develop a patient board representation policy. Create a written policy and/or procedure to define how you will determine that patient board members are reflective of the patient population (e.g., by geography, language, payer mix, special populations) and document your assessment.

• Update your board COI and disclosure forms. Ensure these documents ask non-patient board members if more than 10% of their income comes from the health care industry, rather than requesting full income breakdowns.

• Review co-applicant and subrecipient agreements. Check your agreements to ensure third-party removal rights are tightly limited and don’t erode true local control.

• Review LALs operations. Confirm that at least one site meets the 40-hour, permanent, year-round standard (or clearly document how a school-based or seasonal site meets HRSA expectations). Ensure your corporate structure demonstrates real independence (board authority, control of substantive work, independent executive leadership). For public housing-focused LALs, document genuine engagement with residents (listening sessions, advisory groups, surveys) in planning and operations.

If you treat the November 2025 SVP revision as an opportunity to clean up policies, sharpen documentation, and align your OSV prep process, you won’t just “pass the visit” – you’ll make it easier for your team to stay in continual compliance while focusing on what actually matters: caring for your community.

Need help navigating these changes? RegLantern is here to help. Contact us today to learn about our consulting services, mock HRSA OSVs, or continuous compliance software tools.