CMS SOM App. A, Tag A-0393

by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all

times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under

§488.54(c)of this chapter.

Interpretive Guidelines §482.23(b)(1)

The hospital must provide nursing services 24 hours a day, 7 days a week. An LPN can provide

nursing services if an RN, who is immediately available for the bedside care of those patients,

supervises that care.

EXCEPTION: Section 488.54(c) sets forth certain conditions under which rural hospitals of

50 beds or fewer may be granted a temporary waiver of the 24-hour registered

nurse requirement by the regional office.

Rural is defined as all areas not delineated as “urbanized” areas by the Census Bureau, in the

most recent census. Temporary is defined as a one year period or less and the waiver cannot be

renewed.

Survey Procedures §482.23(b)(1)

• Review the nurse staffing schedule for a one-week period. If there are concerns

regarding insufficient RN coverage, review the staffing schedules for a second week

period to determine if there is a pattern of insufficient coverage. Document daily RN

coverage for every unit of the hospital. Verify that there is at least one RN for each unit

on each tour of duty, 7 days a week, 24 hours a day. Additional nurses may be required

for vacation or absenteeism coverage.

• EXCEPTION: If the hospital has a temporary waiver of the 24-hour RN requirement

in effect, verify and document the following:

o 50 or fewer inpatient beds;

o The character and seriousness of the deficiencies do not adversely affect the

health and safety of patients

o The hospital meets all the other statutory requirements in §1861(e)(1-8).

o The hospital has made and continues to make a good faith effort to comply with

the 24 hour nursing requirement. Determine the recruitment efforts and methods

used by the hospitals’ administration by requesting copies of advertisements in

newspapers and other publications as well as evidence of contact with nursing

schools and employment agencies. Document that the salary offered by the

hospital is comparable to three other hospitals, located nearest to the facility.

o The hospital’s failure to comply fully with the 24 hour nursing requirement is

attributable to a temporary shortage of qualified nursing personnel in the area in

which the hospital is located.

o A registered nurse is present on the premises to furnish the nursing service during

at least the daytime shift, 7 days a week.

o On all tours of duty not covered by a registered nurse, a licensed practical

(vocational) nurse is in charge.