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Run: RHC Provider Staffing 50 Percent Coverage Log

Track whether your RHC had an NP, PA, or CNM available for patient care at least 50% of operating time during a review period. This log captures hours, cover...

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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 critical (required)

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.

Yes No N/A

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 critical (required)

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) critical (required)

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)? critical (required)

Confirm that documented hours reflect clinical availability for patient care, not administrative-only time, per 42 CFR 491.8(a) intent.

Yes No N/A

Provider Schedule or Time Records Attached critical (required)

Confirm that supporting documentation (e.g., schedules, sign-in logs, EHR time records) is attached or on file to substantiate hours claimed.

Yes No N/A

Photo evidence (optional)

50 Percent Coverage Calculation and Compliance Determination

Calculated NP/PA/CNM Coverage Percentage critical (required)

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? critical (required)

Based on the calculated percentage above, confirm whether the clinic is in compliance with 42 CFR 491.8(a) for this review period.

Yes No N/A

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.

Yes No N/A

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).

Yes No N/A

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.

Yes No N/A

Photo evidence (optional)

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.

Yes No N/A

Administrator and Medical Director Sign-Off

Clinic Administrator Attestation: Information is accurate and complete critical (required)

The clinic administrator confirms that all hours, provider names, and compliance determinations documented in this log are accurate to the best of their knowledge.

Yes No N/A

Clinic Administrator Signature critical (required)

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.

Yes No N/A

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.

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