US · guidance
CMS SOM App. W, Tag C-0330
§485.641 Condition of Participation: Periodic Evaluation and Quality Assurance
Review
Interpretive Guidelines §485.641
While conducting the survey, a surveyor may identify a patient care practice or other
CAH practice with which the surveyor is unfamiliar. Health care and CAH practice are
continually changing due to new laws, regulations and standards of practice. In order for
the surveyor to determine compliance with the CAH CoP, the surveyor should interview
appropriate CAH staff to gather additional information, such as:
• Tell me about this practice.
• Is the practice a requirement or standard of practice?
• What is your source for this requirement, activity or standard of practice?
• Show me your source material for this practice.
If the CAH produces a law, regulation, or standard of practice from a nationally
recognized organization, evaluate whether the CAH’S policies and procedures reflect the
law, regulation, or standard of practice. Then, evaluate whether the CAH’S actual
practice reflects their policies and procedures, as well as the law, regulation or standard
of practice.
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
650290f066a5f4372d4f670905f6532694b93a5962166dcfecebf5aaddce700a
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