CMS SOM App. G, Tag J-0084

(4) The staff may also include ancillary personnel who are supervised by the

professional staff.

Interpretative Guidelines § 491.8(a)(4)

The clinic’s staff may include personnel who are not practitioners but who provide

clinical services, for example, registered nurses, licensed practical nurses, laboratory

technicians, etc. In all cases personnel must hold current State licenses when required.

All such personnel must be supervised at all times by a practitioner, either a physician or

a non-physician practitioner, on the RHC’s professional healthcare staff. Supervisory

responsibilities may be shared among practitioners. For example, an NP on the RHC’s

staff may be the official supervisor who conducts regular performance reviews, but when

that NP is not on duty, the RHC’s physician or another NP or other non-physician

practitioner may provide supervision.

Survey Process § 491.8(a)(4)

• Determine whether all clinical staff members who are not practitioners have a current

State license or certification, as required.

• Ask clinical staff members who are not practitioners to identify their supervisor(s). .

• Is there someone responsible for supervising non-practitioners on the clinical staff at

all times the RHC is providing services? Request the name of that individual.

Interview other clinical staff to confirm.