HRSA Operational Site Visit Preparation Checklist

Pre-visit inspection checklist for FQHCs to organize policies, files, and documentation ahead of a HRSA Operational Site Visit (OSV), aligned to the site visit protocol and readiness expectations.

Visit Logistics and Document Control

• HRSA OSV date, location, and reviewer contact information documented
• OSV agenda, protocol, and requested document list reviewed by leadership
• Central document repository established with version control
• Point of contact assigned for HRSA reviewers and document retrieval

Governance and Corporate Compliance

• Current bylaws, articles of incorporation, and board roster available
• Board meeting minutes show required oversight of operations and quality
• Conflict-of-interest disclosures completed for board members and key staff
• Sliding fee schedule, discount policy, and related approvals available
• Policies for compliance reporting, corrective action, and issue escalation current

Clinical Operations and Access to Care

• Credentialing and privileging files current for all licensed clinicians
• Scope of practice and supervision requirements documented and followed
• Appointment access, triage, and after-hours coverage policies available
• Referral tracking and follow-up process documented with recent examples
• Patient complaint and grievance logs current and retrievable

Quality Improvement and Performance Management

• Quality Improvement plan current and approved
• Recent QI committee minutes show data review and action items
• Clinical quality measures tracked with current performance data
• Corrective actions documented for measures below target
• Patient satisfaction or access feedback reviewed and trended

Human Resources and Staffing Files

• Personnel files contain licenses, certifications, and job descriptions
• Annual training records completed for required compliance topics
• Background checks, references, and onboarding documentation retained as required
• Staffing schedule reflects adequate coverage for services offered
• Emergency contact list and leadership coverage plan current

Facilities, Safety, and Emergency Preparedness

• Emergency preparedness plan current and accessible
• Fire drill, evacuation, and incident logs available for review
• Fire extinguishers, exits, and egress routes unobstructed and clearly marked
• Hazardous materials, eyewash, and SDS access reviewed
• Any open facility deficiencies or corrective actions documented