CMS SOM App. A, Tag A-1161

of supervision required for personnel to carry out specific procedures must be

designated in writing.

Interpretive Guidelines §482.57(b)(1)

The hospital must have written policies to address, at a minimum:

• Each type of respiratory care service provided by the hospital;

• The qualifications, including job title, licensure consistent with State law,

education, training and experience of personnel authorized to perform each type

of respiratory care service and whether they may perform it without supervision;

and

• The type of personnel qualified to provide the direct supervision.

Survey Procedures §482.57(b)(1)

• Review treatment logs, job descriptions of respiratory care staff, and policies and

procedures to determine the following:

o Duties and responsibilities of staff;

o Qualifications and education required, including licensure, consistent with

State law;

o Specialized training or experience needed to perform specific duties.