RHC Provider Staffing 50 Percent Coverage Log

Inspection log documenting that a nurse practitioner (NP), physician assistant (PA), or certified nurse-midwife (CNM) is available to furnish patient care at least 50 percent of the time the Rural Health Clinic (RHC) operates, as required by 42 CFR 491.8.

Clinic & Review Period Identification

• RHC Facility Name
  Legal name of the Rural Health Clinic as it appears on the CMS certification.
• CMS Certification Number (CCN) / NPI
  Enter the clinic's CMS Certification Number or National Provider Identifier.
• Review Period Start Date
  First date of the staffing coverage period being documented.
• Review Period End Date
  Last date of the staffing coverage period being documented.
• Log Completed By (Name and Title)
  Full name and title of the person completing this coverage log.
• Date Log Completed
  Date this log entry was finalized.

Clinic Operating Hours for Review Period

• Total Clinic Operating Days in Review Period
  Number of days the clinic was open and providing patient care services.
• Total Clinic Operating Hours in Review Period
  Cumulative hours the clinic was open for patient care across all operating days in the review period.
• Standard Daily Operating Hours (e.g., 8:00 AM – 5:00 PM)
  Record the clinic's standard daily hours of operation. Note any deviations in comments.
• Were there any unplanned clinic closures during the review period?
  Indicate if the clinic experienced unexpected closures (e.g., weather, emergency). Document dates and reasons in comments.

NP / PA / CNM Provider Coverage Documentation

• Primary Qualifying Provider Name and Credential
  Full name and credential (NP, PA, or CNM) of the primary mid-level provider covering this period.
• Primary Provider: Total Hours On-Site and Available for Patient Care
  Total hours the primary qualifying provider was physically present at the RHC and available to furnish patient care during the review period.
• Secondary Qualifying Provider Name and Credential (if applicable)
  If a second NP, PA, or CNM contributed to coverage, enter their name and credential. Leave blank if not applicable.
• Secondary Provider: Total Hours On-Site and Available for Patient Care
  Total hours the secondary qualifying provider was on-site and available. Enter 0 if not applicable.
• Combined NP/PA/CNM Coverage Hours (All Qualifying Providers)
  Sum of all qualifying provider on-site hours across the review period. This figure is used to calculate the coverage percentage.
• Were qualifying providers available to furnish patient care (not just administratively present)?
  Confirm that documented hours reflect clinical availability for patient care, not administrative-only time, per 42 CFR 491.8(a) intent.
• Provider Schedule or Time Records Attached
  Confirm that supporting documentation (e.g., schedules, sign-in logs, EHR time records) is attached or on file to substantiate hours claimed.

50 Percent Coverage Calculation and Compliance Determination

• Calculated NP/PA/CNM Coverage Percentage
  Enter the calculated coverage percentage: (Combined NP/PA/CNM Hours ÷ Total Clinic Operating Hours) × 100. Must be ≥ 50% to meet 42 CFR 491.8(a).
• Does the RHC meet the ≥ 50% NP/PA/CNM coverage requirement for this period?
  Based on the calculated percentage above, confirm whether the clinic is in compliance with 42 CFR 491.8(a) for this review period.
• If coverage is below 50%, identify the root cause
  If the coverage percentage is below 50%, document the reason (e.g., provider vacancy, leave of absence, recruitment gap). Required if non-compliant.
• Corrective Action Plan Documented for Coverage Deficiency
  If coverage fell below 50%, confirm that a corrective action plan has been initiated and documented. Include target date for resolution in comments.

Waiver Status (If Applicable)

• Does the RHC currently hold an approved waiver of the 50% NP/PA/CNM coverage requirement?
  Indicate whether a CMS-approved waiver is in effect for this review period per 42 CFR 491.8(d).
• Waiver Approval Date (if applicable)
  Date the waiver was approved by CMS. Leave blank if no waiver is in effect.
• Waiver Expiration Date (if applicable)
  Date the current waiver expires. The clinic must ensure renewal is initiated before expiration.
• Waiver Documentation On File
  Confirm that the official CMS waiver approval letter is retained on file and available for survey review.
• Is a new waiver application pending?
  If the clinic is out of compliance and a waiver application has been submitted to CMS, document the submission date in comments.

Administrator and Medical Director Sign-Off

• Clinic Administrator Attestation: Information is accurate and complete
  The clinic administrator confirms that all hours, provider names, and compliance determinations documented in this log are accurate to the best of their knowledge.
• Clinic Administrator Signature
  Signature of the RHC clinic administrator attesting to the accuracy of this log.
• Medical Director Review Completed
  Confirm that the RHC medical director has reviewed this coverage log for the period.
• Medical Director Signature
  Signature of the RHC medical director confirming review of this staffing coverage log.
• Date of Final Sign-Off
  Date the log was finalized and signed by authorized personnel.
• Additional Notes or Observations
  Document any additional context, staffing changes, pending hires, or survey preparation notes relevant to the 50% coverage requirement.