[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR482.12]



[Page 482-484]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 482_CONDITIONS OF PARTICIPATION FOR HOSPITALS--Table of Contents

 

                        Subpart B_Administration

 

Sec. 482.12  Condition of participation: Governing body.



    The hospital must have an effective governing body legally 

responsible for the conduct of the hospital as an institution. If a 

hospital does not have an organized governing body, the persons legally 

responsible for the conduct of the hospital must carry out the functions 

specified in this part that pertain to the governing body.

    (a) Standard: Medical staff. The governing body must:

    (1) Determine, in accordance with State law, which categories of 

practitioners are eligible candidates for appointment to the medical 

staff;

    (2) Appoint members of the medical staff after considering the 

recommendations of the existing members of the medical staff;

    (3) Assure that the medical staff has bylaws;

    (4) Approve medical staff bylaws and other medical staff rules and 

regulations;

    (5) Ensure that the medical staff is accountable to the governing 

body for the quality of care provided to patients;

    (6) Ensure the criteria for selection are individual character, 

competence, training, experience, and judgment; and

    (7) Ensure that under no circumstances is the accordance of staff 

membership or professional privileges in the hospital dependent solely 

upon



[[Page 483]]



certification, fellowship, or membership in a specialty body or society.

    (b) Standard: Chief executive officer. The governing body must 

appoint a chief executive officer who is responsible for managing the 

hospital.

    (c) Standard: Care of patients. In accordance with hospital policy, 

the governing body must ensure that the following requirements are met:

    (1) Every Medicare patient is under the care of:

    (i) A doctor of medicine or osteopathy (This provision is not to be 

construed to limit the authority of a doctor of medicine or osteopathy 

to delegate tasks to other qualified health care personnel to the extent 

recognized under State law or a State's regulatory mechanism.);

    (ii) A doctor of dental surgery or dental medicine who is legally 

authorized to practice dentistry by the State and who is acting within 

the scope of his or her license;

    (iii) A doctor of podiatric medicine, but only with respect to 

functions which he or she is legally authorized by the State to perform;

    (iv) A doctor of optometry who is legally authorized to practice 

optometry by the State in which he or she practices;

    (v) A chiropractor who is licensed by the State or legally 

authorized to perform the services of a chiropractor, but only with 

respect to treatment by means of manual manipulation of the spine to 

correct a subluxation demonstrated by x-ray to exist; and

    (vi) A clinical psychologist as defined in Sec. 410.71 of this 

chapter, but only with respect to clinical psychologist services as 

defined in Sec. 410.71 of this chapter and only to the extent permitted 

by State law.

    (2) Patients are admitted to the hospital only on the recommendation 

of a licensed practitioner permitted by the State to admit patients to a 

hospital. If a Medicare patient is admitted by a practitioner not 

specified in paragraph (c)(1) of this section, that patient is under the 

care of a doctor of medicine or osteopathy.

    (3) A doctor of medicine or osteopathy is on duty or on call at all 

times.

    (4) A doctor of medicine or osteopathy is responsible for the care 

of each Medicare patient with respect to any medical or psychiatric 

problem that--

    (i) is present on admission or develops during hospitalization; and

    (ii) Is not specifically within the scope of practice of a doctor of 

dental surgery, dental medicine, podiatric medicine, or optometry; a 

chiropractor; or clinical psychologist, as that scope is--

    (A) Defined by the medical staff;

    (B) Permitted by State law; and

    (C) Limited, under paragraph (c)(1)(v) of this section, with respect 

to chiropractors.

    (d) Standard: Institutional plan and budget. The institution must 

have an overall institutional plan that meets the following conditions:

    (1) The plan must include an annual operating budget that is 

prepared according to generally accepted accounting principles.

    (2) The budget must include all anticipated income and expenses. 

This provision does not require that the budget identify item by item 

the components of each anticipated income or expense.

    (3) The plan must provide for capital expenditures for at least a 3-

year period, including the year in which the operating budget specified 

in paragraph (d)(2) of this section is applicable.

    (4) The plan must include and identify in detail the objective of, 

and the anticipated sources of financing for, each anticipated capital 

expenditure in excess of $600,000 (or a lesser amount that is 

established, in accordance with section 1122(g)(1) of the Act, by the 

State in which the hospital is located) that relates to any of the 

following:

    (i) Acquisition of land;

    (ii) Improvement of land, buildings, and equipment; or

    (iii) The replacement, modernization, and expansion of buildings and 

equipment.

    (5) The plan must be submitted for review to the planning agency 

designated in accordance with section 1122(b) of the Act, or if an 

agency is not designated, to the appropriate health planning agency in 

the State. (See part 100 of this title.) A capital expenditure is not 

subject to section 1122 review if 75 percent of the health care 

facility's



[[Page 484]]



patients who are expected to use the service for which the capital 

expenditure is made are individuals enrolled in a health maintenance 

organization (HMO) or competitive medical plan (CMP) that meets the 

requirements of section 1876(b) of the Act, and if the Department 

determines that the capital expenditure is for services and facilities 

that are needed by the HMO or CMP in order to operate efficiently and 

economically and that are not otherwise readily accessible to the HMO or 

CMP because--

    (i) The facilities do not provide common services at the same site;

    (ii) The facilities are not available under a contract of reasonable 

duration;

    (iii) Full and equal medical staff privileges in the facilities are 

not available;

    (iv) Arrangements with these facilities are not administratively 

feasible; or

    (v) The purchase of these services is more costly than if the HMO or 

CMP provided the services directly.

    (6) The plan must be reviewed and updated annually.

    (7) The plan must be prepared--

    (i) Under the direction of the governing body; and

    (ii) By a committee consisting of representatives of the governing 

body, the administrative staff, and the medical staff of the 

institution.

    (e) Standard: Contracted services. The governing body must be 

responsible for services furnished in the hospital whether or not they 

are furnished under contracts. The governing body must ensure that a 

contractor of services (including one for shared services and joint 

ventures) furnishes services that permit the hospital to comply with all 

applicable conditions of participation and standards for the contracted 

services.

    (1) The governing body must ensure that the services performed under 

a contract are provided in a safe and effective manner.

    (2) The hospital must maintain a list of all contracted services, 

including the scope and nature of the services provided.

    (f) Standard: Emergency services. (1) If emergency services are 

provided at the hospital, the hospital must comply with the requirements 

of Sec. 482.55.

    (2) If emergency services are not provided at the hospital, the 

governing body must assure that the medical staff has written policies 

and procedures for appraisal of emergencies, initial treatment, and 

referral when appropriate.

    (3) If emergency services are provided at the hospital but are not 

provided at one or more off-campus departments of the hospital, the 

governing body of the hospital must assure that the medical staff has 

written policies and procedures in effect with respect to the off-campus 

department(s) for appraisal of emergencies and referral when 

appropriate.



[51 FR 22042, June 17, 1986; 51 FR 27847, Aug. 4, 1986, as amended at 53 

FR 6549, Mar. 1, 1988; 53 FR 18987, May 26, 1988; 56 FR 8852, Mar. 1, 

1991; 56 FR 23022, May 20, 1991; 59 FR 46514, Sept. 8, 1994; 63 FR 

20130, Apr. 23, 1998; 63 FR 33874, June 22, 1998; 68 FR 53262, Sept. 9, 

2003]