CMS SOM App. A, Tag A-1002

Anesthesia services must be consistent with needs and resources. Policies on

anesthesia procedures must include the delineation of preanesthesia and

postanesthesia responsibilities. The policies must ensure that the following are

provided for each patient:

Interpretive Guidelines §482.52(b)

Anesthesia services must be delivered in a manner that is consistent with the needs and

the resources of the hospital. Anesthesia policies at a minimum must address:

• How the hospital’s anesthesia services needs will be met;

• Delivery of anesthesia services consistent with recognized standards for

anesthesia care. A well-designed anesthesia services policy would address issues

such as:

o Patient consent;

o Infection control measures;

o Safety practices in all anesthetizing areas;

o Protocol for supportive life functions, e.g., cardiac and respiratory

emergencies;

o Reporting requirements;

o Documentation requirements;

o Equipment requirements, as well as the monitoring, inspection, testing, and

maintenance of anesthesia equipment in the hospital’s biomedical equipment

program.

o Delineation of pre- and post-anesthesia staff responsibilities

Survey Procedures §482.52(b)

Review the policies developed on anesthesia procedures. Determine whether the

anesthesia service policies for delivery of care address the issues identified in interpretive

guidelines.