Rural Health Clinic (RHC) Survey Information Request

Upon Surveyor Arrival:

• If applicable, provide a list of Visiting Nurse Service (VNS) visits scheduled during the survey period (if any scheduled, one visit will be observed)
• Provide a list of names, locations, and telephone numbers of key RHC staff and their responsibilities
• Provide a list of patients scheduled for the day of survey
• Provide a list of all office visits for the past six months
• Provide a list of all (if any) patients transferred to another facility for emergency services

Within One Hour of Request:

• Provide a location (conference room; empty office) for the surveyor to review patient records/conduct interviews
• Provide access to a copy machine (if needed)
• Provide a list of all staff including the medical director, active medical staff, support staff, and any staff providing patient care
• Provide a copy of the organizational chart
• Provide any policies or procedures, upon request
• Provide selected RHC personnel records
• Provide documentation of the RHC's program evaluation
• Provide a list of services provided through agreement or arrangements
• Provide a copy of the facility's floor plan