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CMS Updates Hospital Interpretive Guidelines Appendix A.

The Centers for Medicare & Medicaid Services (CMS) updated its State Operations Manual (SOM) Hospital Interpretive Guidelines to reflect recent amendments to the Governing Body and Medical Staff Conditions of Participation.  Additionally, CMS made clarifications and technical corrections to the guideline.

Summary of Key Changes to Appendix A:

  • Removal of the requirement under 42 §482.12 that a hospital’s governing body must include at least one member of the medical staff.
  • Additional requirement under 42 §482.12(a)(10) mandating the governing body to consult directly with the employee responsible for the organization and conduct of hospital medical staff.
  • Revision of 42 §482.22(a) to indicate that the medical staff must include MDs or DOs but may also include other categories of physicians listed at 42 §482.12(c)(1) and non-physician practitioners.
  • Addition of 42 §482.22(b)(4) permitting medical staff of a hospital system consisting of multiple, separately-certified hospitals to participate in a unified, integrated medical staff in accordance with state law.
  • Revisions to 42 §§482.22(b)(1)–(3) to address the addition made in 42 §482.22(b)(4) regarding hospitals using a unified, integrated medical staff.

The transmittal updating the SOM is available at:

Centers for Medicare & Medicaid Services.  “Revisions to State Operations Manual (SOM), Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals.”  Transmittal 122.  26 Sept. 2014.