CMS SOM App. A, Tag A-0046

§482.12(a)(2) Appoint members of the medical staff after considering the

recommendations of the existing members of the medical staff;

Interpretive Guidelines §482.12(a)(2)

The governing body determines whether to grant, deny, continue, revise, discontinue, limit, or revoke

specified privileges, including medical staff membership, for a specific practitioner after considering the

recommendation of the medical staff. In all instances, the governing body’s determination must be

consistent with established hospital medical staff criteria, as well as with State and Federal law and

regulations. Only the hospital’s governing body has the authority to grant a practitioner privileges to

provide care in the hospital.

Survey Procedures §482.12(a)(2)

• Review records of medical staff appointments to determine that the governing body is involved

in appointments of medical staff members.

• Confirm that there is evidence that the governing body considered recommendations of the

medical staff before making medical staff appointments.