[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR491.8]



[Page 965-966]

 

                         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 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



[[Page 966]]



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]