CMS SOM App. A, Tag A-1079

The hospital must --

(1) Assign one or more individuals to be responsible for outpatient services.

(2) Have appropriate professional and nonprofessional personnel available at each

location where outpatient services are offered, based on the scope and complexity of

outpatient services.

Interpretive Guidelines §482.54(b)

The hospital’s outpatient services may be directed by one or more individuals. Hospitals

have the flexibility to determine how best to organize their outpatient services, including

how direction will be provided. As services offered in outpatient departments become

more varied, complex and technologically advanced, hospitals may find it better to have

individuals with more specialized expertise providing direction for a specific type of

outpatient services.

Hospitals should define in writing the qualifications and competencies necessary for their

outpatient services department leader(s). These qualifications should include items such

as education, experience, and specialized training consistent with State law and

acceptable standards of practice.

The hospital should define in writing the qualifications and competencies necessary to

direct each outpatient service for which there is a separate director. Qualifications

include necessary education, experience and specialized training consistent with State

law and acceptable standards of practice.

Adequate types and numbers of qualified licensed healthcare professionals and other

personnel must be available to provide patients with the appropriate level of care for the

outpatient services offered by the hospital. The types and numbers of qualified personnel

required for area of the hospital’s main campus or for each provider-based off-site

location must be based on the scope and complexity of the outpatient services offered and

the number and types of patients treated as outpatients at each.

Survey Procedures 482.54(b)

• Ask the hospital how it has organized its outpatient services and to identify the

individual(s) responsible for providing direction for outpatient services.

• Review the organization’s policies and procedures to determine the person’s

responsibility.

• Review the position description and personnel file of the individual(s) responsible

for a selection of outpatient services to ensure that they are qualified, in

accordance with State law, acceptable standards of practice and hospital policy to

direct the service for which they are responsible.

• Visit several on- and off-campus locations where hospital outpatient services are

provided. Given the scope and complexity of the services being offered, are there

sufficient personnel with the appropriate education, experience, certifications,

current licensure where appropriate, and competencies for assigned

responsibilities?