CMS SOM App. A, Tag A-1690

Standard: Director of inpatient psychiatric services; medical staff.

Inpatient psychiatric services must be under the supervision of a clinical director,

service chief, or equivalent who is qualified to provide the leadership required for

an intensive treatment program…

Interpretive Guidelines §482.62(b)

All psychiatric care provided in the psychiatric hospital must be under the supervision of

a single clinical director, service chief, or equivalent. The individual must be a licensed

MD or DO who is a psychiatrist.

Inpatient psychiatric services provide intensive diagnostic evaluation, emergent

treatment, treatment to stabilize individuals in crisis, and long-term chronic treatment

.

The following functions are examples of psychiatric services under the supervision of the

clinical director, service chief, or equivalent:

• Admission interviews,

• Assessments and evaluations,

• Psychiatric and medical work-ups,

• Treatment team leadership,

• Medication management,

• On-call provision of emergency psychiatric and medical treatment,

• Provision of individual, group and family therapies,

• Provision of clinical supervision to other professionals and paraprofessionals,

• Provision of medical and psychiatric educational workshops and conferences for

all staff, and

• Provision of consultation to staff for clinical and/or administrative matters.

The hospital must demonstrate how their selection for medical director, service chief, or

equivalent is qualified to provide the leadership required for an intensive treatment

program, following nationally recognized standards of practice.

Survey Procedure §482.62(b)

• Verify that a single MD/DO who is a psychiatrist is responsible for supervising

inpatient psychiatric services.

• Review the credentialing file of the clinical director to verify qualifications

and the leadership exhibited for the scope of psychiatric treatment

programs needed by patients.

• Request and review evidence to verify that the clinical director plays an integral

part in supervising the planning, evaluation, and revision of policies, procedures,

and activities that affect the safety, quality, and compliance related to inpatient

psychiatric treatment or services.

• Review medical staff meeting documents, QAPI, and related committee notes to

verify the supervision and leadership activities of the clinical director.