US · guidance
CMS SOM App. J, Tag W322
§483.460(a)(3) The facility must provide or obtain preventive and general care
Guidance §483.460(a)(3)
The facility has procedures in place to ensure that the clients receive general health care
services to assure optimal levels of wellness. General health care services include assessment
and treatment of acute and chronic complaints or situations; teaching relevant heath care
principles to staff and clients; and periodic surveillance of the health status of the clients.
As a result of clinical assessment, referrals are made for specialized assessment and tests.
Facility health care staff follow-up to ensure the assessments are done and the findings
incorporated into the medical care plan and/or the IPP.
The facility must have arrangements in place to provide routine or episodic laboratory, and
radiology services for the clients if not provided in-house or through the clients physician. There
must be a written agreement that specifies the responsibilities of the facility and outside
provider. (See §483.410(a)).
Preventive health care services include screening procedures designed to identify health
concerns and initiate treatment as early as possible. The facility should have a health
prevention program in place and follow the plan to address those screenings that the facility will
perform periodically that are relevant to all clients, and those screenings associated with a
particular gender or age or vulnerability.
Physician refusal to perform a test, such as a pap smear, must be consistent with guidelines for
clients, per the local standard in the community.
If the facility has a physician that refuses to provide preventative healthcare based on the
client’s level of functioning, medical staff at the facility should meet with and consult with this
physician in order to ensure that clients receive the same health services as persons living in the
local community.
Current recommended screenings for men and women can be accessed at the Agency for
Healthcare Research and Quality (AHRQ) and the Centers for Disease Control (CDC).
§483.460(a)(3) as well as annual physical examinations of each client that at a minimum
include the following:
History
Rev. 158, Issued: 09-09-16, Effective: 09-09-16, Implementation: 09-09-16
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
bd0c96c5798b089a3ba74e0c6dfb51949d8fd6ff01b389398e9309dc3730d004
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