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US · guidance

CMS SOM App. A, Tag A-0048

[The governing body must:]

activein force · 2026-07-22 – presentas-observed

§482.12(a)(4) Approve medical staff bylaws and other medical staff rules and

regulations;

Interpretive Guidelines §482.12(a)(4)

The governing body decides whether or not to approve medical staff bylaws submitted by the medical

staff. The medical staff bylaws and any revisions must be approved by the governing body before they

are considered effective.

Survey Procedures and §482.12(a)(4)

• Verify that the medical staff operates under current bylaws, rules and policies that have been

approved by the governing body.

• Verify that any revisions or modifications in the medical staff bylaws, rules and policies have

been approved by the medical staff and the governing body, e.g., bylaws are annotated with date

of last review and initialed by person(s) responsible.

History

Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
0880e506c73dfbb91e3c63431c97275c5351c7504bbd81f1b75338c7eac88d49
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