CMS SOM App. A, Tag A-0398

policies and procedures of the hospital. The director of nursing service must provide for

the adequate supervision and evaluation of all nursing personnel which occur within the

responsibility of the nursing service, regardless of the mechanism through which those

personnel are providing services (that is, hospital employee, contract, lease, other

agreement, or volunteer).

Interpretive Guidelines §482.23(b)(6)

The hospital must ensure that there are adequate numbers of clinical nursing personnel to meet

its patients nursing care needs. In order to meet their patient’s needs the hospital may

supplement their hospital employed licensed nurses with volunteer and or contract licensed

nurses.

The hospital and the director of the nursing service are responsible for the clinical activities of all

nursing personnel regardless of whether they are hospital employees, contracted staff, or

volunteers.

All licensed nurses who are working at the hospital must adhere to the policies and procedures of

the hospital. The hospital and the director of the nursing service are responsible for ensuring that

licensed nursing personnel know the hospital’s policies and procedures in order to adhere to

those policies and procedures.

The hospital and the director of the nursing service ensure that nursing care staff person is

adequately supervised and that their clinical activities are evaluated. This supervision and

evaluation of the clinical activities of each non-employee nursing staff person must be conducted

by an appropriately qualified hospital-employed RN.

Survey Procedures §482.23(b)(6)

• Review the method for orienting all licensed nurses to hospital policies and procedures.

The orientation should include at least the following:

o The hospital and the unit;

o Emergency procedures;

o Nursing services policies and procedures; and

o Safety policies and procedures.

• Determine if all nursing personnel are appropriately oriented prior to providing care.

• Confirm with the director of nurses that all nurses performance are evaluated by the

hospital at least once a year. If the performance evaluation is not considered confidential,

review two evaluations.