Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

D. Preparing for the Certification Inspection
This section will help your clinic prepare for the certification inspection. In Arizona, the Arizona
Department of Health Services, Division of Licensing Services, Office of Medical Facilities Licensing
is the state agency that conducts the inspection. The four key elements to preparing for the
RHC Certification inspection are: 1) Policy and Procedure Manual Review, 2) Medical Records
Review, 3) Facility Inspection, and 4) Program Evaluation.
The following is an excerpt from Starting a Rural Health Clinic - A How-To Manual, published by
the U.S. Department of Health and Human Services, Health Resources and Services Administration,
Office of Rural Health Policy. The complete manual is available online at: http://ruralhealth.
hrsa.gov/RHC/RHCmanual.htm. The form used by the surveyor during the inspection can be
referenced in Appendix G. Rural Health Clinic Survey Report.
The RHC Policy and Procedure Manual
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 Manual 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 for Rural Health Clinics], State and Federal Laws, State Public Health 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 for the RHC program and the RHC Interpretive Guidelines [see the following
website for the Code of Federal Regulations: http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr491_
02.html; see section II.B. Interpretive Guidelines for Rural Health Clinics) 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 for physician assistants, nurse practitioners and certifi ed nurse midwives. The
29