CMS SOM App. A, Tag A-0049

§482.12(a)(5) Ensure that the medical staff is accountable to the governing body for

the quality of care provided to patients;

Interpretive Guidelines §482.12(a)(5)

The governing body must ensure that the medical staff as a group is accountable to the governing body

for the quality of care provided to patients. The governing body is responsible for the conduct of the

hospital and this conduct includes the quality of care provided to patients.

All hospital patients must be under the care of a practitioner who meets the criteria of 42 CFR

482.12(c)(1)and who has been granted medical staff privileges, or under the care of a practitioner who is

directly under the supervision of a member of the medical staff. All patient care is provided by or in

accordance with the orders of a practitioner who has been granted privileges in accordance with the

criteria established by the governing body, and who is working within the scope of those granted

privileges.

Survey Procedures §482.12(a)(5)

• Verify that the governing body is periodically apprised of the medical staff evaluation of patient

care services provided hospital wide, at every patient care location of the hospital.

• Verify that any individual providing patient care services is a member of the medical staff or is

accountable to a member of the medical staff qualified to evaluate the quality of services

provided, and in turn, is responsible to the governing body for the quality of services provided.