Rural Health Clinic Conditions for Certification Self-Survey

Self-assessment survey organized by 42 CFR Part 491 conditions for certification to support RHC readiness review ahead of a state or federal survey.

Clinic Location and Staffing (42 CFR 491.5 & 491.8)

• The clinic is located in a non-urbanized area designated as a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA) as required under 42 CFR 491.5.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The clinic employs at least one physician assistant (PA), nurse practitioner (NP), or certified nurse midwife (CNM) who is available to see patients at least 50% of the clinic's operating hours (42 CFR 491.8(a)(1)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• A physician is present at the clinic at least once every two weeks to provide medical direction, consultation, and supervision (42 CFR 491.8(b)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• All clinical staff (physicians, PAs, NPs, CNMs, nurses) hold current, valid licensure or certification in the state in which the clinic operates.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• If any staffing or licensure gaps exist, please describe them and any corrective actions underway.
  Provide detail if you rated any item in this section 3 or below.

Provision of Services and Patient Care Policies (42 CFR 491.9)

• The clinic provides the required basic primary care services: physician, PA, NP, or CNM services; nursing services; clinical laboratory services; and referral arrangements for other necessary health services (42 CFR 491.9(a)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Written patient care policies are established, reviewed at least annually, and signed by the physician medical director and a PA, NP, or CNM as required under 42 CFR 491.9(b).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Policies address the scope of services offered, patient scheduling, after-hours coverage, emergency procedures, and referral and transfer protocols.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The clinic has documented arrangements for emergency medical care and hospital admissions, including a written agreement with at least one hospital (42 CFR 491.9(b)(1)(iv)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• After-hours coverage arrangements are documented and communicated to patients, ensuring 24/7 access to care or triage guidance.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Please describe any gaps in service provision or patient care policy documentation, and any planned remediation steps.
  Provide detail if you rated any item in this section 3 or below.

Clinical Records (42 CFR 491.10)

• A clinical record is maintained for every patient seen at the clinic, containing sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the results (42 CFR 491.10(a)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Clinical records include, at minimum: patient identification data, problem list, medication list, allergies, past medical and surgical history, physical examination findings, diagnostic test results, and progress notes (42 CFR 491.10(a)(2)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Records are protected against unauthorized access, loss, destruction, and tampering, with access limited to authorized personnel (42 CFR 491.10(b)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The clinic has a written records retention policy consistent with state law and CMS requirements, and records are retained for the required period.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Please describe any clinical records deficiencies identified and steps being taken to address them.
  Provide detail if you rated any item in this section 3 or below.

Patient Rights (42 CFR 491.10(c) & General CMS Expectations)

• Patients are informed of their rights in a language and manner they can understand, including the right to be informed about their care, to participate in treatment decisions, and to refuse treatment.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• A written patient rights notice is posted prominently in the clinic and provided to patients upon registration or first visit.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The clinic has a formal patient grievance and complaint process, and patients are informed of how to file a complaint with the state agency.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Patient confidentiality and privacy protections are in place and consistent with HIPAA requirements and 42 CFR 491.10(b).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Please describe any patient rights or privacy gaps identified and corrective actions planned.
  Provide detail if you rated any item in this section 3 or below.

Environment of Care and Safety (42 CFR 491.6)

• The clinic maintains a safe, sanitary, and functional environment for patients and staff, free of hazards that could cause injury or illness (42 CFR 491.6(a)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Pharmaceutical storage, handling, and disposal practices comply with applicable state and federal requirements, including controlled substance regulations (42 CFR 491.6(b)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Infection control policies and procedures are in place, current, and followed by all clinical staff, including hand hygiene, PPE use, and sterilization/disinfection of instruments.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Laboratory services provided on-site meet CLIA certificate requirements, and the clinic's CLIA certificate is current and posted (42 CFR 491.9(a)(3)).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Emergency equipment (e.g., AED, oxygen, crash kit) is present, maintained, and staff are trained in its use.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• Please describe any environment of care or safety deficiencies and the corrective actions being taken.
  Provide detail if you rated any item in this section 3 or below.

Quality Assurance and Performance Improvement (42 CFR 491.11) & Open Feedback

• The clinic has an active, documented Quality Assurance and Performance Improvement (QAPI) program that reviews clinical and administrative performance on a regular basis (42 CFR 491.11).
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• QAPI activities include review of patient care outcomes, adverse events, patient complaints, and medical record audits, with documented findings and corrective actions.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The QAPI program involves the physician medical director and mid-level practitioners, and findings are used to update policies and training.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• The clinic has completed a mock survey or internal readiness review within the past 12 months and has addressed identified deficiencies.
  Rate your compliance: 1 = Strongly Disagree / Not in place, 5 = Strongly Agree / Fully in place
• What are the top 1-3 compliance risks or readiness gaps your clinic faces ahead of the next state or federal survey?
  Be specific — identify the regulatory citation (e.g., 42 CFR 491.8(b)) if known, and describe the gap and your plan to close it.
• Is there anything else about your clinic's certification readiness that you would like to document or flag for follow-up?
  Use this space for any additional observations, concerns, or context not captured in the sections above.