[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: 42CFR482.22]



[Page 488]

 

                         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 C_Basic Hospital Functions

 

Sec. 482.22  Condition of participation: Medical staff.



    The hospital must have an organized medical staff that operates 

under bylaws approved by the governing body and is responsible for the 

quality of medical care provided to patients by the hospital.

    (a) Standard: Composition of the medical staff. The medical staff 

must be composed of doctors of medicine or osteopathy and, in accordance 

with State law, may also be composed of other practitioners appointed by 

the governing body.

    (1) The medical staff must periodically conduct appraisals of its 

members.

    (2) The medical staff must examine credentials of candidates for 

medical staff membership and make recommendations to the governing body 

on the appointment of the candidates.

    (b) Standard: Medical staff organization and accountability. The 

medical staff must be well organized and accountable to the governing 

body for the quality of the medical care provided to patients.

    (1) The medical staff must be organized in a manner approved by the 

governing body.

    (2) If the medical staff has an executive committee, a majority of 

the members of the committee must be doctors of medicine or osteopathy.

    (3) The responsibility for organization and conduct of the medical 

staff must be assigned only to an individual doctor of medicine or 

osteopathy or, when permitted by State law of the State in which the 

hospital is located, a doctor of dental surgery or dental medicine.

    (c) Standard: Medical staff bylaws. The medical staff must adopt and 

enforce bylaws to carry out its responsibilities. The bylaws must:

    (1) Be approved by the governing body.

    (2) Include a statement of the duties and privileges of each 

category of medical staff (e.g., active, courtesy, etc.)

    (3) Describe the organization of the medical staff.

    (4) Describe the qualifications to be met by a candidate in order 

for the medical staff to recommend that the candidate be appointed by 

the governing body.

    (5) Include a requirement that a physical examination and medical 

history be done no more than 7 days before or 48 hours after an 

admission for each patient by a doctor of medicine or osteopathy, or, 

for patients admitted only for oromaxillofacial surgery, by an 

oromaxillofacial surgeon who has been granted such privileges by the 

medical staff in accordance with State law.

    (6) Include criteria for determining the privileges to be granted to 

individual practitioners and a procedure for applying the criteria to 

individuals requesting privileges.

    (d) Standard: Autopsies. The medical staff should attempt to secure 

autopsies in all cases of unusual deaths and of medical-legal and 

educational interest. The mechanism for documenting permission to 

perform an autopsy must be defined. There must be a system for notifying 

the medical staff, and specifically the attending practitioner, when an 

autopsy is being performed.



[51 FR 22042, June 17, 1986, as amended at 59 FR 64152, Dec. 13, 1994]