[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR491.8]

[Page 964-965]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                  HEALTH AND HUMAN SERVICES (CONTINUED)
 
PART 491_CERTIFICATION OF CERTAIN HEALTH FACILITIES--Table of Contents
 
Subpart A_Rural Health Clinics: Conditions for Certification; and FQHCs 
                         Conditions for Coverage
 
Sec. 491.8  Staffing and staff responsibilities.

    (a) Staffing. (1) The clinic or center has a health care staff that 
includes one or more physicians. Rural health clinic staffs must also 
include one or more physician's assistants or nurse practitioners.
    (2) The physician member of the staff may be the owner of the rural 
health clinic, an employee of the clinic or center, or under agreement 
with the clinic or center to carry out the responsibilities required 
under this section.
    (3) The physician assistant, nurse practitioner, nurse-midwife, 
clinical social worker, or clinical psychologist member of the staff may 
be the owner or an employee of the clinic or center, or may furnish 
services under contract to the center.
    (4) The staff may also include ancillary personnel who are 
supervised by the professional staff.
    (5) The staff is sufficient to provide the services essential to the 
operation of the clinic or center.
    (6) A physician, nurse practitioner, physician assistant, nurse-
midwife, clinical social worker, or clinical psychologist is available 
to furnish patient

[[Page 965]]

care services at all times the clinic or center operates. In addition, 
for RHCs, a nurse practitioner, physician assistant, or certified nurse 
midwife is available to furnish patient care services at least 50 
percent of the time the RHC operates.
    (b) Physician responsibilities. (1) The physician:
    (i) Except for services furnished by a clinical psychologist in an 
FQHC, which State law permits to be provided without physician 
supervision, provides medical direction for the clinic's or center's 
health care activities and consultation for, and medical supervision of, 
the health care staff.
    (ii) In conjunction with the physician's assistant and/or nurse 
practitioner member(s), participates in developing, executing, and 
periodically reviewing the clinic's or center's written policies and the 
services provided to Federal program patients; and
    (iii) Periodically reviews the clinic's or center's patient records, 
provides medical orders, and provides medical care services to the 
patients of the clinic or center.
    (2) A physician is present for sufficient periods of time, at least 
once in every 2 week period (except in extraordinary circumstances), to 
provide the medical direction, medical care services, consultation and 
supervision described in paragraph (b)(1) of this section and is 
available through direct telecommunication for consultation, assistance 
with medical emergencies, or patient referral. The extraordinary 
circumstances are documented in the records of the clinic or center.
    (c) Physician assistant and nurse practitioner responsibilities. (1) 
The physician assistant and the nurse practitioner members of the 
clinic's or center's staff:
    (i) Participate in the development, execution and periodic review of 
the written policies governing the services the clinic or center 
furnishes;
    (ii) Participate with a physician in a periodic review of the 
patients' health records.
    (2) The physician assistant or nurse practitioner performs the 
following functions, to the extent they are not being performed by a 
physician:
    (i) Provides services in accordance with the clinic's or center's 
policies;
    (ii) Arranges for, or refers patients to, needed services that 
cannot be provided at the clinic or center; and
    (iii) Assures that adequate patient health records are maintained 
and transferred as required when patients are referred.
    (d) Temporary staffing waiver. (1) CMS may grant a temporary waiver 
of the RHC staffing requirements in paragraphs (a)(1) and (a)(6) of this 
section for a 1-year period to a qualified RHC, if the RHC requests a 
waiver and demonstrates that it has been unable, despite reasonable 
efforts in the previous 90-day period, to hire a nurse midwife, nurse 
practitioner, or physician assistant to furnish services at least 50 
percent of the time the RHC operates.
    (2) CMS terminates the RHC from participation in the Medicare 
program, if the RHC is not in compliance with the provisions waived 
under paragraphs (a)(1) and (a)(6) of this section at the expiration of 
the waiver.
    (3) The RHC may submit its request for an additional waiver of 
staffing requirements under this paragraph no earlier than 6 months 
after the expiration of the previous waiver.

[57 FR 24983, June 12, 1992, as amended at 61 FR 14658, Apr. 3, 1996; 68 
FR 74817, Dec. 24, 2003]