CMS SOM App. A, Tag A-0023

applicable standards that are required by State or local laws.

Interpretive Guidelines §482.11(c)

All staff that are required by the State to be licensed must possess a current license. The hospital must

assure that these personnel are in compliance with the State’s licensure laws. The laws requiring

licensure vary from state to state. Examples of healthcare professionals that a state may require to be

licensed could include: nurses, MD/DOs, physician assistants, dieticians, x-ray technologists, dentists,

physical therapists, occupational therapists, respiratory therapists and hospital administrators.

All staff must meet all applicable standards required by State or local law for hospital personnel. This

would include at a minimum:

• Certification requirements;

• Minimum qualifications;

• Training/education requirements; and

• Permits (such as food handlers permits).

When telemedicine is used and the practitioner and patient are located in different states, the practitioner

providing the patient care service must be licensed and/or meet the other applicable standards that are

required by State or local laws in both the state where the practitioner is located and the state where the

patient is located.

Survey Procedures §482.11(c)

• Verify for those personnel required to be licensed, certified, and/or permitted by the State, that

the hospital has established, and follows procedures for determining that personnel are properly

licensed, certified, and/or permitted.

• Verify that staff and personnel are licensed, certified, and/or permitted in accordance with State

and local requirements.

• Verify that staff and personnel meet all standards (such as continuing education, basic

qualifications, etc.) required by State and local laws or regulations. Verify that the hospital has a

mechanism established and enforced to ensure compliance.

• Review a sample of personnel files to verify that licensure and/or other required credentials

information is up to date. Verify State licensure compliance of the direct care personnel as well

as administrators and supervisory personnel.