CMS SOM App. L, Tag Q-0120

The medical staff of the ASC must be accountable to the governing body.

Interpretive Guidelines §416.45

The organization of the medical staff is left to the discretion of the governing body, but

however the staff is organized, the ASC must have an explicit, written policy that

indicates how the medical staff is held accountable by the governing body. The policy

must address all requirements in this condition. Medical staff privileges may be granted

both to physician and non-physician practitioners, consistent with their permitted scope

of practice in the State, as well as their training and clinical experience.

It is possible for an ASC to be owned and operated by one physician, who could be both

the sole member of the governing body and also the sole member of the ASC’s medical

staff. In such cases the physician owner must nevertheless implement a formal process

for complying with all medical staff regulatory requirements.

Survey Procedures §416.45

Ask the ASC’s leadership for its policy detailing how the governing body holds the

medical staff accountable.