CMS SOM App. A, Tag A-1081

§482.54 Condition of Participation: Outpatient Services

If the hospital provides outpatient services, the services must meet the needs of the

patients in accordance with acceptable standards of practice.

Interpretive Guidelines §482.54

This is an optional hospital service; however, if a hospital provides any degree of

outpatient care to its patients, the hospital must comply with the requirements of this

Condition of Participation (CoP).

The Medicare Hospital CoP apply to both inpatient and outpatient services of the

hospital. The hospital must be in compliance with the CoP in 42 CFR §482 in all on-campus and off-campus outpatient service locations.

All outpatient services provided by the hospital, both on campus and at any provider-based clinics, must meet the needs of the patients, in accordance with acceptable

standards of practice. The hospital must ensure that services, equipment, staff, and

facilities are adequate to provide the outpatient services offered at each location in

accordance with acceptable standards of practice.

Acceptable standards of practice include standards that are set forth in Federal or State

laws, regulations or guidelines, as well as standards and recommendations promoted by

nationally recognized professional organizations (e.g., the American Medical

Association, American College of Radiology, American College of Surgeons, etc.).

If the hospital offers outpatient surgical services, the Surgical Services CoP (§482.5)

requires that the offered services must be consistent in quality with inpatient care in

accordance with the services offered.

The hospital’s outpatient services must be integrated into its hospital-wide QAPI

program.

Survey Procedures §482.54

• Verify that equipment, staff and facilities are adequate to provide the

outpatient services offered at each location are in accordance with acceptable

standards of practice.

• Verify that outpatient services at all locations are in compliance with the

hospital CoP.

• Determine locations and type(s) of outpatient services provided.

• Verify that the hospital’s outpatient services are integrated into its hospital-wide QAPI program.