HRSA Requirements for Board Members and Employees

What steps should be taken when a material weakness is identified in the annual audit report?

Both the Health Center Compliance Manual and Site Visit Protocol outline the requirements that HRSA has between board members and employees. In review of Chapter 20-Board Composition, Element f, a health center board member may not be an employee of the health center, or an immediate family member of a current health center employee (i.e. spouses, children, parents or siblings through blood, adoption or marriage). Health centers can ensure compliance with this requirement by periodically evaluating whether the board does not include such prohibited board members. Industry best practice supports the inclusion of this requirement in any board member application or on the conflict of interest disclosure form. Board members can annually fill out the conflict of interest form to maintain continuous compliance. 

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Proving Program Effectiveness Under Regulatory Scrutiny

Regulators are no longer satisfied with documentation alone; they want evidence that your compliance program actively prevents, detects, and corrects risk. Investigators expect to see how issues are identified early, investigated thoroughly, corrected effectively, and monitored over time. Boards demand measurable insight, and leadership needs confidence that exposure is managed before it becomes a liability. The standard has shifted from activity to impact.