CMS SOM App. W, Tag C-1046

Nursing services must meet the needs of patients.

(1) A registered nurse must provide (or assign to other personnel) the nursing care

of each patient, including patients at a SNF level of care in a swing-bed CAH. The

care must be provided in accordance with the patient’s needs and the specialized

qualifications and competence of the staff available.

Interpretive Guidelines §485.635(d) & (d)(1)

In order to meet the needs of patients, nursing services must be a well-organized service

of the CAH. The CAH designates an individual who is responsible for nursing services,

including development of policies and procedures for nursing services. The designated

individual is generally expected to be a registered nurse. Various titles may be used for

the responsible nurse leader may have (e.g., director of nursing services, nurse executive,

chief nursing officer, or nurse manager). The nurse leader is responsible for the overall

management and evaluation of nursing care in the CAH, including, but not limited to:

• Development and maintenance of nursing policies and procedures;

• Supervision of nursing staff, either directly, or, depending on the size of the CAH,

indirectly through other nursing managers; and

• Ongoing review and analysis of the quality of nursing care.

As required at §485.631(a)(5), the CAH must have a registered nurse, clinical nurse

specialist, or licensed practical nurse on duty whenever the CAH has one or more

inpatients (including patients in a swing bed receiving long term care services).

The CAH must also ensure that, for outpatient nursing services, appropriate nursing staff

are available in accordance with State law and CAH policy.

For both inpatient and outpatient services there must be sufficient numbers of supervisory

and non-supervisory nursing personnel with the appropriate education, experience,

licensure (as applicable), competence and specialized qualifications to respond to the

nursing needs of the patient population of each CAH department or nursing unit. Staffing

schedules must be reviewed and revised as necessary to meet patient care needs and to

make adjustments for nursing staff absenteeism.

The CAH must have a procedure for assigning and coordinating the nursing care for

every CAH patient. A registered nurse must either provide directly, or assign to other

staff, the required nursing care for each CAH patient, including patients receiving swing

bed services. The RN making the assignment must consider the specialized

qualifications and competence of the CAH’s available nursing staff in order to meet

patients’ nursing care needs. Nursing care duties may be assigned to appropriate

personnel, such as a licensed practical nurse, nursing assistant or nurse’s aide, so long as

such assignment is consistent with state law and the individual has the qualifications and

competence to perform the assigned tasks.

The CAH must ensure that all CAH nursing staff are adequately trained and oriented,

aware of CAH nursing policies and procedures, supervised, and that their clinical

activities are evaluated. If temporary outside agency nurses are employed to address

temporary nurse staffing needs, determine how are these nurses oriented and supervised.

(NOTE: Regular nursing services may be provided under arrangement instead of using

CAH employees, but in this case the CAH is responsible for the ongoing training and

supervision of these regular nursing staff.)

Survey Procedures §485.635(d)(1)

• Determine whether an RN has been designated responsible for nursing services at

the CAH.

• Observe the nursing care in progress to determine the adequacy of staffing and to

assess the delivery of care. Sources of information to use in the evaluation of the

nursing services are: staffing schedules, nursing care plans for inpatients,

credentialing and training files (including contracted staff), and QA activities and

reports.

• Interview the registered nurse responsible for nursing services and ask the

following--

o How are the nursing needs of patients determined? Who makes this

determination?

o How are staff assigned to provide nursing care to patients?

o How does the CAH ensure that care provided meets the needs of each patient?

o How are staff trained and oriented? If temporary outside agency nurses are

used, how are they oriented and supervised?

• Review nursing assignments in one or more inpatient units, the emergency

department, and one other outpatient department. Did an RN make the

assignments? Was the complexity of patient care needs and the competence and

specialized qualifications of the nursing staff taken into consideration?

• Review written staffing schedules; do they adhere to the CAH’s policies and

procedures for staffing levels and types of nursing personnel?

• Verify that there is supervision of personnel performance and nursing care for

each nursing unit.

• If there are temporary agency nurses providing services, interview one or more to

determine if they are familiar with the nursing policies and procedures of the unit

or department where they are working.

• Review personnel files to determine that nursing staff have required licenses and

competencies.