Section 491.9 - Provision of services(a)Basic requirements.(1) All services offered by the clinic or center are furnished in accordance with applicable Federal, State, and local laws; and(2) The clinic or center is primarily engaged in providing outpatient health services and meets all other conditions of this subpart.(3) The laboratory requirements in paragraph (c)(2) of this section apply to RHCs, but do not apply to FQHCs.(b)Patient care policies.(1) The clinic's or center'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 or center staff.(3) The policies include: (i) A description of the services the clinic or center 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 or center.(iii) Rules for the storage, handling, and administration of drugs and biologicals.(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 RHC or FQHC.(c)Direct services -(1)General. The clinic or center staff furnishes those diagnostic and therapeutic services and supplies that are commonly furnished in a physician's office or at the entry point into the health care delivery system. These include medical history, physical examination, assessment of health status, and treatment for a variety of medical conditions.(2)Laboratory. These requirements apply to RHCs but not to FQHCs. The RHC provides laboratory services in accordance with part 493 of this chapter, which implements the provisions of section 353 of the Public Health Service Act. The RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including:(i) Chemical examinations of urine by stick or tablet method or both (including urine ketones);(ii) Hemoglobin or hematocrit;(iv) Examination of stool specimens for occult blood;(vi) Primary culturing for transmittal to a certified laboratory.(3)Emergency. The clinic or center provides medical emergency procedures as a first response to common life-threatening injuries and acute illness and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids.(d)Services provided through agreements or arrangements.(1) The clinic or center has agreements or arrangements with one or more providers or suppliers participating under Medicare or Medicaid to furnish other services to its patients, including: (i) Inpatient hospital care;(ii) Physician(s) services (whether furnished in the hospital, the office, the patient's home, a skilled nursing facility, or elsewhere); and(iii) Additional and specialized diagnostic and laboratory services that are not available at the clinic or center.(2) If the agreements are not in writing, there is evidence that patients referred by the clinic or center are being accepted and treated.57 FR 24983, June 12, 1992, as amended at 58 FR 63536, Dec. 2, 1993; 84 FR 51832 , Sept. 30, 2019