CMS SOM App. W, Tag C-0988

time to provide medical direction, consultation, and supervision for the services

provided in the CAH, and is available through direct radio or telephone

communication or electronic communication for consultation, assistance with

medical emergencies, or patient referral.

Interpretive Guidelines §485.631(b)(2)

An MD/DO must be present in the CAH for sufficient periods of time to provide overall

medical direction, consultation and supervision of the healthcare services the CAH

furnishes. Being “present” in the CAH means being physically on-site in the CAH. The

regulation does not specify a minimum amount of time an MD/DO must spend on-site

that applies to all CAHs. Instead, CAHs have the flexibility to develop policies

appropriate for their circumstances. With the development of technology such as

telemedicine, a CAH may use a variety of ways and timeframes for MDs/DOs to provide

the necessary medical direction and oversight. For CAHs that offer a range of more

complex services, have more than one MD/DO on staff, and have busy emergency

departments and/or extensive outpatient services, an on-site visit by an MD/DO only

once every week or every two weeks, for example, would be grossly inadequate. On the

other hand, a bi-weekly on-site visit could be unduly burdensome as well as unnecessary

for a small CAH in a remote rural area that offers very limited services and has a low

patient volume.

CAHs are expected to have adequate staffing to provide the services they have chosen to

furnish, including staffing or supervision by MDs/DOs as applicable. CMS expects each

CAH to evaluate its services and adjust its MD/DO on-site schedule accordingly, as an

appropriate MD/DO schedule must reflect the volume and nature of services offered.

Note that §485.618(d) also establishes a maximum timeframe for an MD, DO, PA, NP, or

clinical nurse specialist to be on-call and available to be on-site to provide emergency

care, and that §489.20(r)(2) requires the CAH to maintain an on-call list of MDs/DOs

who are available to be on-site as part of the CAH’s Emergency Medical Treatment and

Labor Act obligations. The CAH must consider all pertinent requirements when

developing its policies for MD/DO presence on site.

In addition to requiring an MD or DO to be on-site for sufficient periods of time,

consistent with the requirement at §485.618(e), the CAH must also ensure an MD/DO is

available through direct radio, telephone or other form of electronic communication, such

as video conferencing, for consultation, assistance in handling patient medical

emergencies and referral of patients to other healthcare facilities. An MD/DO providing

telemedicine services to the CAH may be used to fulfill the requirement for availability

via telecommunications. Further, consistent with the requirements for CAH provision of

emergency services at §485.618(d), unless a, PA, NP, or clinical nurse specialist with

training in emergency care is immediately available via one of these telecommunication

methods and available on site within the timeframe specified at §485.618(d)(1), an MD

or DO must fulfill these requirements.

Survey Procedures §485.631(b)(2)

• Does the CAH have policies and procedures that address the minimum amount of

time and frequency of MD or DO presence on-site at the CAH? Can the CAH

demonstrate how its policy reflects the volume and type of services the CAH

provides such that there is sufficient MD/DO presence on-site to support the

services provided?

• Is there documentation showing that an MD or DO is on-site for the frequency

and duration specified in the CAH’s policies?

• Can the CAH demonstrate that an MD or DO is always available by

telecommunications contact for consultation, assistance and/or patient referral?