CMS SOM App. G, Tag J-0124

(3) The policies include:

(i) A description of the services the clinic . . . furnishes directly and those furnished

through agreement or arrangement.

(ii) Guidelines for the medical management of health problems which include the

conditions requiring medical consultation and/or patient referral, the maintenance

of health care records, and procedures for the periodic review and evaluation of the

services furnished by the clinic . . .

Interpretative Guidelines § 491.9(b)(3)(i) & (ii)

The written RHC patient care policies must include:

Description of Services

The written policies must provide a description of the services the RHC furnishes,

whether directly using RHC staff or through an agreement or arrangement. The services

furnished by the clinic must be described in sufficient detail to permit understanding of

the scope of all services furnished in the RHC, and the scope/type of agreement or

arrangement they are furnished through if applicable. An example of services under

arrangement might be provision by a contractor of additional laboratory services beyond

those required to be performed by RHC staff. Such statements as the following may

sufficiently describe services: Taking complete medical histories, performing complete

physical examinations, assessments of health status, routine lab tests, diagnosis and

treatment for common acute and chronic health problems and medical conditions,

immunization programs, family planning. Statements such as “complete management of

common acute and chronic health problems” standing alone, would not sufficiently

describe services.

Guidelines for Medical Management

The clinic’s written guidelines for the medical management of health problems include a

description of the scope of medical care that may be furnished by a PA, NP, or CNM,

including the extent and nature of required supervision. The guidelines would also

include standard protocols for diagnosis and treatment of common conditions or for

provision of preventive care. Acceptable guidelines may follow various formats. Some

guidelines are collections of general protocols, arranged by presenting symptoms; some

are statements of medical directives arranged by the various systems of the body (such as

disorders of the gastrointestinal system); some are standing orders covering major

categories such as health maintenance, chronic health problems, common acute self-limiting health problems, and medical emergencies. The manner in which these

guidelines describe the criteria for diagnosing and treating health conditions may also

vary. Some guidelines will incorporate clinical assessment systems that include

branching logic. Others may be in a more narrative format with major sections covering

specific medical conditions in which such topics as the following are discussed: The

definition of the condition; its etiology; its clinical features; recommended laboratory

studies; differential diagnosis, treatment procedures, complications, consultation/referral

required; and follow-up. Guidelines also may be based on guidelines of nationally

recognized professional organizations, which are referenced and reproduced, such as the

immunization guidelines developed by the Centers for Disease Control and Prevention

Advisory Committee on Immunization Practices. However, the guidelines must include

information on actions non-physician practitioners in the RHC are permitted to take, as

well as circumstances warranting referral.

Even though approaches to describing guidelines may vary, acceptable guidelines for the

medical management of health problems must:

• Be comprehensive enough to cover most health issues covered in a primary and

preventive care setting;

• Describe the actions a NP, PA or CNM may initiate or implement, consistent with

State scope of practice requirements; and

• Describe the circumstances that require consultation with the RHC’s MD or DO, as

well as external referral.

Guidelines may be in electronic or paper format, but should be readily accessible to RHC

practitioners, all of whom must be familiar with them.

Survey Procedures § 491.9(b)(3(i) & (ii)

• Ask the RHC to provide a copy of its description of services. Is it consistent with

services advertised on the RHC’s website or via other media?

• Ask the RHC’s medical director to show one or more medical management guidelines

and explain their source/how they were developed, as well as how they are used. Do

the examples include the required elements?

• Ask one or more RHC practitioners to demonstrate how they access the RHC’s

medical management policies. Are they familiar with the guidelines applicable to

their practice?