CMS SOM App. A, Tag A-0386

The hospital must have a well-organized service with a plan of administrative authority

and delineation of responsibilities for patient care. The director of the nursing service

must be a licensed registered nurse. He or she is responsible for the operation of the

service, including determining the types and numbers of nursing personnel and staff

necessary to provide nursing care for all areas of the hospital.

Interpretive Guidelines §482.23(a)

The hospital may have only one nursing service hospital-wide and the single nursing service

must be under the direction of one RN.

The director of the nursing service must be a currently licensed RN and he/she is responsible for

the operation of the nursing service. The operation of the nursing service would include the

quality of the patient care provided by the nursing service.

The director of the nursing service must determine and provide the types and numbers of nursing

care personnel necessary to provide nursing care to all areas of the hospital.

The organization will include various configurations of the following hospital personnel as

determined necessary by the hospital and the Director of Nursing:

• Assistant/Associate Director(s);

• Supervisors/Coordinators;

• Head Nurses/Nurse Managers;

• Staff Nurses;

• Unit Secretaries/Clerks;

• Nurses Aide/Orderlies.

Survey Procedures §482.23(a)

• Review the organizational chart or plan for nursing services. Determine that the

organizational chart(s) displays lines of authority that delegates responsibility within the

department.

• Read the position description for the director of nursing (DON) to determine that it

delegates to the DON specific duties and responsibilities for operation of the service.

• Verify that the director is currently licensed in accordance with state licensure

requirements.

• Verify that the DON is involved with or approved the development of the nursing service

staffing policies and procedures.

• Verify that the DON approves the nursing service patient care policies and procedures.