C. See Addendum: Regulatory Guide: RHC/FQHC Proposed Rule 28
D. Preparing <strong>for</strong> the Certification Inspection This section will help your clinic prepare <strong>for</strong> the certification inspection. In <strong>Arizona</strong>, the <strong>Arizona</strong> Department of <strong>Health</strong> Services, Division of Licensing Services, Office of Medical Facilities Licensing is the state agency that conducts the inspection. The four key elements to preparing <strong>for</strong> the RHC Certification inspection are: 1) Policy and Procedure <strong>Manual</strong> Review, 2) Medical Records Review, 3) Facility Inspection, and 4) Program Evaluation. The following is an excerpt from Starting a <strong>Rural</strong> <strong>Health</strong> <strong>Clinic</strong> - A How-To <strong>Manual</strong>, published by the U.S. Department of <strong>Health</strong> and Human Services, <strong>Health</strong> Resources and Services Administration, Office of <strong>Rural</strong> <strong>Health</strong> Policy. The complete manual is available online at: http://ruralhealth. hrsa.gov/RHC/RHCmanual.htm. The <strong>for</strong>m used by the surveyor during the inspection can be referenced in Appendix G. <strong>Rural</strong> <strong>Health</strong> <strong>Clinic</strong> Survey Report. The RHC Policy and Procedure <strong>Manual</strong> The policy and procedure manual should cover key human resource policies, administrative policies, clinical procedures and protocols, and medical guidelines per RHC Code of Federal Regulations (CFR) §491.7(a)(2) [available online at: http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr491_02.html]. Each clinic’s policy and procedures manual should be drafted with that clinic in mind. This document should be an accurate refl ection of how the clinic truly intends to operate. The Policy and Procedures <strong>Manual</strong> section of the RHC Interpretive Guidelines states, “Written policies should consist of both administrative and patient care policies. Patient care policies are discussed under 42 CFR 491.9(b). In addition to including lines of authority and responsibilities, administrative policies may cover topics such as personnel, fi scal, purchasing, and maintenance of building and equipment. Topics covered by written policies may have been infl uenced by requirements of the founders of the clinic, as well as agencies that have participated in supporting the clinic’s operation.” When looking at developing human resource policies there are several laws, administrative rules, acts, and regulations that must be considered: RHC Code of Federal Regulations [available online at: http://www. access.gpo.gov/nara/cfr/waisidx_02/42cfr491_02.html], RHC Interpretative Guidelines [see section II.B. Interpretive Guidelines <strong>for</strong> <strong>Rural</strong> <strong>Health</strong> <strong>Clinic</strong>s], State and Federal Laws, State Public <strong>Health</strong> Code, and Professional Practice Standards. The Human Resource policies should include: • job descriptions • benefits, compensation and pay practice • employment criteria and conditions of employment • smoking, drug use/possession and distribution • appointment of providers/credentialing • confidentiality • personnel fi les (organization, management, and access) • harassment, and employee privacy The Code of Federal Regulations <strong>for</strong> the RHC program and the RHC Interpretive Guidelines [see the following website <strong>for</strong> the Code of Federal Regulations: http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr491_ 02.html; see section II.B. Interpretive Guidelines <strong>for</strong> <strong>Rural</strong> <strong>Health</strong> <strong>Clinic</strong>s) are often the best place to start when developing RHC policies. CFR Section 491.8 Staffi ng and staff responsibilities, outlines some of the program requirements <strong>for</strong> physician assistants, nurse practitioners and certifi ed nurse midwives. The 29