CMS SOM App. W, Tag C-0818

Staff of the CAH are licensed, certified, or registered in accordance with applicable

Federal, State, and local laws and regulations.

Interpretive Guidelines §485.608(d)

All staff required by the State to be licensed must possess a current license. The CAH

must ensure that these personnel are in compliance with the State’s licensure laws. The

laws requiring licensure vary from state to state. Examples of healthcare professionals

that a state may require to be licensed could include: nurses, MD/DOs, physician

assistants, dieticians, x-ray technologists, dentists, physical therapists, occupational

therapists, respiratory technicians and facility administrators.

All CAH staff must meet all applicable standards required by State or local law for CAH

personnel. This would include at a minimum:

• Certification requirements;

• Minimum qualifications; and

• Training/education requirements.

Survey Procedures §485.608(d)

• Verify for those personnel required to be licensed by the State, that the CAH has

established, and follows, procedures for determining that personnel providing

patient care services are properly licensed.

• Check a sample of personnel files to verify that licensure information is up to

date. Verify that appropriate categories of staff and personnel are licensed in

accordance with State requirements. Verify state licensure compliance of the

direct care personnel, as well as administrators and supervisory personnel, and

any contracted personnel.

• Verify that there are procedures in place to guarantee licensure of employees

working at the CAH under contract or agreement.

• Review CAH policies regarding certification, licensure, and registration of

personnel. Are the CAH policies compliant with State and local laws? Are the

personnel in compliance with CAH policy?