CMS SOM App. A, Tag A-1691

must be adequate to provide essential psychiatric services.

Interpretive Guidelines §482.62(b)

The hospital must ensure that it has adequate numbers of full-time, part-time, or

consulting MD/DOs with the appropriate qualifications to provide essential psychiatric

services to each patient at all times.

Factors to consider the adequacy of physician coverage includes, but is not limited to, the

following list:

• Average daily census;

• Types of psychiatric and behavioral health conditions specific to the patient

population;

• Ages of the hospital’s patient population (pediatric vs adult psychiatric

services);

• Whether the hospital’s patients are violent or non-violent;

• Whether the hospital’s MD/DOs have the proper qualifications to address the

modalities of care provided by the hospital;

• The ability of the hospital to ensure physician coverage on evening, nights

and weekends;

• The ability of the hospital to employ physicians with the appropriate

qualifications to participate in treatment planning; and

• Availability of physicians to consult with multi-disciplinary staff regarding

treatment issues.

Survey Procedures §482.62(b)

• Review a sample of medical records and interview staff to verify patients are

under the supervision of a psychiatrist.

• Based on census and services provided by the hospital, is there evidence of

adequate qualified MD/DO staff to provide essential psychiatric services?

• Interview RNs, SWs, and other disciplines about physician/psychiatrist presence,

accessibility and availability to participate in the provision of patient care.

• Review patient records for evidence of ongoing consultation and evaluation by

physician staff.