Section 491.8 - Staffing and staff responsibilities(a)Staffing.(1) The clinic or center has a health care staff that includes one or more physicians. Rural health clinic staffs must also include one or more physician's assistants or nurse practitioners.(2) The physician member of the staff may be the owner of the rural health clinic, an employee of the clinic or center, or under agreement with the clinic or center to carry out the responsibilities required under this section.(3) The physician assistant, nurse practitioner, certified nurse-midwife, clinical social worker, clinical psychologist, marriage and family therapist, or mental health counselor member of the staff may be the owner or an employee of the clinic or center, or may furnish services under contract to the clinic or center. In the case of a clinic, at least one physician assistant or nurse practitioner must be an employee of the clinic.(4) The staff may also include ancillary personnel who are supervised by the professional staff.(5) The staff is sufficient to provide the services essential to the operation of the clinic or center.(6) A physician, nurse practitioner, physician assistant, certified nurse-midwife, clinical social worker, clinical psychologist, marriage and family therapist, or a mental health counselor is available to furnish patient care services at all times the clinic or center operates. In addition, for RHCs, a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services at least 50 percent of the time the RHC operates.(b)Physician responsibilities. The physician performs the following:(1) Except for services furnished by a clinical psychologist in an FQHC, which State law permits to be provided without physician supervision, provides medical direction for the clinic's or center's health care activities and consultation for, and medical supervision of, the health care staff.(2) In conjunction with the physician assistant and/or nurse practitioner member(s), participates in developing, executing, and periodically reviewing the clinic's or center's written policies and the services provided to Federal program patients.(3) Periodically reviews the clinic's or center's patient records, provides medical orders, and provides medical care services to the patients of the clinic or center.(c)Physician assistant and nurse practitioner responsibilities.(1) The physician assistant and the nurse practitioner members of the clinic's or center's staff: (i) Participate in the development, execution and periodic review of the written policies governing the services the clinic or center furnishes;(ii) Participate with a physician in a periodic review of the patients' health records.(2) The physician assistant or nurse practitioner performs the following functions, to the extent they are not being performed by a physician: (i) Provides services in accordance with the clinic's or center's policies;(ii) Arranges for, or refers patients to, needed services that cannot be provided at the clinic or center; and(iii) Assures that adequate patient health records are maintained and transferred as required when patients are referred.57 FR 24983, June 12, 1992, as amended at 61 FR 14658, Apr. 3, 1996; 68 FR 74817 , Dec. 24, 2003; 71 FR 55346 , Sept. 22, 2006; 79 FR 25480 , May 2, 2014; 79 FR 27156 , May 12, 2014; 86 FR 61626 , Nov. 5, 2021; 88 FR 36510 , June 5, 2023; 88 FR 79553 , Nov. 16, 2023 86 FR 61626 , 11/5/2021; 88 FR 36510 , 8/4/2023; 88 FR 79553 , 1/1/2024