CMS SOM App. A, Tag A-0083

The governing body must be responsible for services furnished in the hospital whether or not they

are furnished under contracts. The governing body must ensure that a contractor of services

(including one for shared services and joint ventures) furnishes services that permit the hospital to

comply with all applicable conditions of participation and standards for the contracted services.

Interpretive Guidelines §482.12(e)

The governing body has the responsibility for assuring that hospital services are provided in compliance

with the Medicare Conditions of participation and according to acceptable standards of practice,

irrespective of whether the services are provided directly by hospital employees or indirectly by

contract. The governing body must take actions through the hospital’s QAPI program to: assess the

services furnished directly by hospital staff and those services provided under contract, identify quality

and performance problems, implement appropriate corrective or improvement activities, and to ensure

the monitoring and sustainability of those corrective or improvement activities. See §482.21 QAPI.

Survey Procedures §482.12(e)

Ascertain that all contractor services provided in the hospital are in compliance with the Conditions of

Participation for hospitals.