CMS SOM App. H, Tag V762

The governing body— (1) Is

responsible for all medical staff appointments and credentialing in accordance with State

law, including attending physicians, physician assistants, nurse practitioners and clinical

nurse specialists; and

Interpretive Guidance § 494.180(c)(1):

Privileges for physicians and non-physician practitioners (i.e., advanced practice registered

nurses and physician’s assistants) are granted by the facility’s governing body based on the

individual practitioner’s qualifications and performance. The facility must define the

requirements for practice at the facility in accordance with any applicable State laws. The

medical staff credential files must include evidence the individual meets those requirements,

including current licensure in the applicable State. Refer to V681 for issues related to

professional licensing.

If the State has more stringent licensure requirements for ESRD facilities regarding medical staff

appointments, and those requirements are not met, those findings may be cited at this tag.