CMS SOM App. W, Tag C-1044

under

§485.627(b)(2) of this chapter is also responsible for the following:

(i) Services furnished in the CAH whether or not they are furnished under

arrangements or agreements.

(ii) Ensuring that a contractor of services (including one for shared services and

joint ventures) furnishes services that enable the CAH to comply with all

applicable conditions of participation and standards for the contracted services.

Interpretive Guidelines §485.635(c)(4)

The person principally responsible for the operation of the CAH, in accordance with

§485.627(b)(2), i.e., the CAH’s Chief Executive Officer (CEO), is responsible for the

operation of all patient care services furnished at the CAH. This includes services

provided directly by CAH staff and services provided by the CAH under arrangement or

agreement. It includes not only care provided directly to patients, but also services

related to patient care, such as environmental cleaning, instrument cleaning and

sterilization, laundry, pharmacy services, laboratory services, etc. (This requirement for

the CEO to be responsible does not relieve the CAH’s governing body of its ultimate

responsibility for the CAH’s total operation in those CAHs where there are both a

governing body and a CEO.)

The CEO must take actions to assure that all services furnished by the CAH through a

contractor comply with the applicable requirements of the CAH’s CoPs. When assessing

compliance of a service provided by a contractor with the CoPs, deficiencies cited under

other CoPs warrant a citation of this requirement, because the CEO has failed to assure

that the contractor provides services in a manner that allows the CAH to comply with the

CoPs.

Survey Procedures §485.635(c)(4)(i)

• Ask the CAH’s CEO to demonstrate how he or she provides oversight of all

contracted services related to patient care.

• Ask for specific examples of how the CEO assures that services furnished in the

CAH comply with the CoPs (e.g., policies and procedures, by-laws, etc.) that the

individual responsible for its operations is responsible for all services provided

through arrangements or agreements.