CMS SOM App. G, Tag J-0123

The physician performs the following:]

(2) In conjunction with the physician assistant and/or nurse practitioner

member(s), participates in developing, executing, and periodically reviewing the

clinic's . . . written policies and the services provided to Federal program patients.

[§ 491.8(c) Physician assistant and nurse practitioner responsibilities.]

(1) The physician assistant and the nurse practitioner members of the clinic's . . .

staff:

(i)

Participate in the development, execution and periodic review of the written

policies governing the services the clinic . . . furnishes;

[§ 491.9(b) Patient care policies . . .]

(1) The clinic's … health care services are furnished in accordance with appropriate

written policies which are consistent with applicable State law.

(2) The policies are developed with the advice of a group of professional personnel

that includes one or more physicians and one or more physician assistants or nurse

practitioners. At least one member is not a member of the clinic . . . staff.

(4) These policies are reviewed at least biennially by the group of professional

personnel required under paragraph (b)(2) of this section and reviewed as necessary

by the clinic . . .

Interpretative Guidelines § 491.8(b)(2) & (c)(1)(i), § 491.9(b)(1), (2) & (4)

The clinic must have written policies governing the clinical services provided. At least

one RHC physician and one RHC PA or NP must participate in the development of the

clinic’s written policies and providing advice to the RHC’s management on appropriate

clinical policies. In addition, there must be at least one physician, NP, or PA who is not

on the RHC’s staff who participates in the development of the clinical policies. The

clinic must identify in writing the names of all individuals involved in developing clinical

policies. The clinical practitioners who participate in the policy development provide

advice to the RHC’s leadership. The RHC’s leadership is not required to accept this

advice, but if it exercises its authority to reject or modify the patient care policy advice of

the practitioners it must be able to ensure that any changes it makes are clinically

appropriate and supportable.

The clinic’s patient care policies must be reviewed at least biennially or more frequently

when appropriate, by a group that also contains at least one RHC physician, one RHC NP

or PA, and one outside healthcare practitioner.

Survey Procedures § 491.8(b)(2) & (c)(1)(i), § 491.9(b)(1), (2) & (4)

• Review meeting minutes or other documentation to verify that the required types

of practitioners actually participated at least biennially in developing the policies

and recommending policies to the RHC’s leadership.

• Ask the RHC’s leadership if it ever rejects the advice of the practitioners. If yes,

how does it ensure that any changes made are clinically appropriate? Does it

document the rationale for its rejection of the advice? Is there documentation of

the policies recommended by the practitioners as well as of any changes made by

the RHC’s leadership?

•