US · guidance
CMS SOM App. A, Tag A-0394
§482.23(b)(2) - The nursing service must have a procedure to ensure that hospital nursing
personnel for whom licensure is required have valid and current licensure.
Interpretive Guidelines §482.23(b)(2)
The hospital’s procedure must ensure that all nursing personnel have valid and current licensure
that complies with State licensure laws. Furthermore, the Condition of Participation (CoP)
Compliance with Federal, State and local laws (42 CFR 482.11) requires the hospital to assure
that personnel meet applicable standards (such as continuing education, certification or training)
required by State or local law.
Survey Procedures §482.23(b)(2)
• Review hospital personnel records or records kept by the nursing service to determine
that RNs, LPNs, and other nursing personnel for whom licensure is required have current
valid licenses.
• Review the nursing service licensure verification policies and procedures. Is licensure
verified for each individual nursing services staff person for whom licensure is required?
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
4dbaf30ec5d5e0950daf3d85c3ca075f79e804c097eee904d4ce638e33dcad04
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