US · guidance
CMS SOM App. W, Tag C-1006
§485.635(a) Standard: Patient Care Policies
(1) The CAH’s health care services are furnished in accordance with appropriate
written policies that are consistent with applicable State law.
Interpretive Guidelines §485.635(a)(1)
The CAH must have written policies governing the health care services the CAH
furnishes and these policies must be consistent with applicable State law. As discussed in
relation to the requirements at §485.608, CMS does not interpret or enforce local law;
that is the responsibility of State or local government. If surveyors identify practices
related to delivery of health care services that they believe are not consistent with State
law, they should refer the matter to the appropriate State authorities.
The regulation requires the CAH to furnish its health care services in accordance with its
written policies. In other words, the CAH must not only have written policies, but must
actually adhere to them in delivering services.
Survey Procedures §485.635(a)(1)
• Verify that the CAH has written policies covering the health care services that are
furnished in the CAH.
• Observe staff delivering health care services to patients. Is the actual provision of
services consistent with the CAH’s written policies?
History
Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
6d7353d4e580abe9f008b62da0e5d64ebe3fb39f2eaedf054b5f8166a374253b
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