CMS SOM App. W, Tag C-1008

CAH’s professional healthcare staff, including one or more doctors of

medicine or osteopathy and one or more physician assistants, nurse

practitioners, or clinical nurse specialists, if they are on staff under the

provisions of §485.631(a)(1).

§485.635(a)(4) These policies are reviewed at least biennially by the group of

professional personnel required under paragraph (a)(2) of this section, and

reviewed as necessary by the CAH.

Interpretive Guidelines §485.635(a)(2) & (4)

The CAH’s written policies governing patient care services must be developed with the

advice of members of the CAH’s professional healthcare staff. This advisory group must

include:

• At least one MD or DO; and

• One or more physician assistants, nurse practitioners, or clinical nurse specialists, at

least one of these non-physician practitioners if these professionals are included in the

CAH’s healthcare staff, as permitted at §485.631(a)(1). A CAH with no non-physician practitioners on staff is not required to obtain the services of an outside

non-physician practitioner to serve on the advisory group.

The advisory group not only makes recommendations for new CAH patient care

policies, but is also expected to review the existing patient care policies at least every

2 years and, if it concludes that changes are needed, recommend those changes.

Policies must be reviewed and, as applicable, revised more frequently when required,

for example, in response to a change in Federal or State regulations to which the

CAH is subject.

The CAH must maintain documentation that provides evidence that the advisory

group has conducted its reviews and made recommendations concerning patient care

policies.

Although a CAH’s patient care policies are developed and periodically reviewed with

the advice of members of the CAH’s professional healthcare staff, the final decision

on the content of the written policies is made by the CAH’s governing body or

individual responsible for the CAH, consistent with the requirement at §485.627(a).

If recommendations of the advisory group are rejected, the governing body must

include in the record of its adoption of the final written policies its rationale for

adopting a different policy than that which was recommended.

Survey Procedures §485.635(a)(2) & (4)

• Review any meeting minutes for the group of healthcare professionals that advises

the CAH’s governing body or responsible individual on patient care policies to

determine if the group’s composition meets the regulatory requirements.

• Interview all staff listed as part of the policy development advisory group to

determine if they had the opportunity to express opinions and make recommendations

to the group, for the group’s consideration as a group recommendation.

• Can the CAH provide documentation that the advisory group developed written

recommendations on the CAH’s patient care policies for consideration by the CAH’s

governing body/responsible individual?

• Is there evidence that the group reviewed the CAH’s existing policies at least every

2 years and indicated whether or not it recommended any changes?