CMS SOM App. W, Tag C-0894

(1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of

medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse

specialist with training or experience in emergency care on call and immediately

available by telephone or radio contact, and available on site within the following

timeframes:

(i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area

other than an area described in paragraph (d)(1)(ii) of this section; or

(ii) Within 60 minutes, on a 24-hour a day basis, if all of the following

requirements are met:

(A) The CAH is located in an area designated as a frontier area (that is, an

area with fewer than six residents per square mile based on the latest

population data published by the Bureau of the Census) or in an area that

meets criteria for a remote location adopted by the State in its rural health

care plan, and approved by CMS, under section 1820(b) of the Act.

(B) The State has determined under criteria in its rural health care plan,

that allowing an emergency response time longer than 30 minutes is the only

feasible method of providing emergency care to residents of the area served

by the CAH.

(C) The State maintains documentation showing that the response time of up

to 60 minutes at a particular CAH it designates is justified because other

available alternatives would increase the time needed to stabilize a patient in

an emergency.

(2) A registered nurse with training and experience in emergency care can be

utilized to conduct specific medical screening examinations only if—

(i) The registered nurse is on site and immediately available at the CAH when a

patient requests medical care; and

(ii) The nature of the patient's request for medical care is within the scope of

practice of a registered nurse and consistent with applicable State laws and the

CAH's bylaws or rules and regulations.

(3) A registered nurse satisfies the personnel requirement specified in paragraph

(d)(1) of this section for a temporary period if--

(i) The CAH has no greater than 10 beds;

(ii) The CAH is located in an area designated as a frontier area or remote

location as described in paragraph (d)(1)(ii)(A) of this section;

(iii) The State in which the CAH is located submits a letter to CMS signed by the

Governor, following consultation on the issue of using RNs on a temporary

basis as part of their State rural health care plan with the State Boards of

Medicine and Nursing, and in accordance with State law, requesting that a

registered nurse with training and experience in emergency care be included

in the list of personnel specified in paragraph (d)(1) of this section. The letter

from the Governor must attest that he or she has consulted with State Boards

of Medicine and Nursing about issues related to access to and the quality of

emergency services in the States. The letter from the Governor must also

describe the circumstances and duration of the temporary request to include

the registered nurses on the list of personnel specified in paragraph (d)(1) of

this section;

(iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this

section, a CAH must submit documentation to the State survey agency

demonstrating that it has been unable, due to the shortage of such personnel

in the area, to provide adequate coverage as specified in this paragraph (d).

(4) The request, as specified in paragraph (d)(3)(iii) of this section, and the

withdrawal of the request, may be submitted to us at any time, and are effective

upon submission.

Interpretive Guidance § 485.618(d)

When State laws are more stringent and require more stringent staffing or expanded

operational hours, the CAH must staff its emergency department in accordance with state

laws. For example, if State law requires the CAH emergency department be open and be

staffed with a MD/DO 24/7 then the CAH must comply.

Survey Procedures §485.618(d)

• Review on-call schedules to determine how the CAH ensures that a qualified staff

member is on call 24 hours a day and available on site at the CAH within 30

minutes, or 60 minutes in certain frontier areas.

• Interview staff to determine how the CAH staff knows who is on call.

• What documentation demonstrates that a MD/DO, nurse practitioner, physician

assistant, clinical nurse specialist or registered nurse (as allowed under (d)(3))

with emergency training or experience has been on call and available on site at the

CAH within 30 or 60 minutes, as appropriate?