Section 485.635 - Condition of participation: Provision of services(a)Standard: Patient care policies.(1) The CAH's health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law.(2) The policies are developed with the advice of members of the CAH's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of § 485.631(a)(1) .(3) The policies include the following: (i) A description of the services the CAH furnishes, including those furnished through agreement or arrangement.(ii) Policies and procedures for emergency medical services.(iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH.(iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.(v) Procedures for reporting adverse drug reactions and errors in the administration of drugs.(vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care.(viii) Policies and procedures that address the post-acute care needs of patients receiving CAH services.(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH.(b)Standard: Patient services - (1)General:(i) The CAH provides those diagnostic and therapeutic services and supplies that are commonly furnished in a physician's office or at another entry point into the health care delivery system, such as a low intensity hospital outpatient department or emergency department. These CAH services include medical history, physical examination, specimen collection, assessment of health status, and treatment for a variety of medical conditions.(ii) The CAH furnishes acute care inpatient services.(2)Laboratory services. The CAH provides basic laboratory services essential to the immediate diagnosis and treatment of the patient that meet the standards imposed under section 353 of the Public Health Service Act (42 U.S.C. 263a ). (See the laboratory requirements specified in part 493 of this chapter.) The services provided include the following:(i) Chemical examination of urine by stick or tablet method or both (including urine ketones).(ii) Hemoglobin or hematocrit.(iv) Examination of stool specimens for occult blood.(vi) Primary culturing for transmittal to a certified laboratory.(3)Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards.(4)Emergency procedures. In accordance with requirements of § 485.618 , the CAH provides medical services as a first response to common life-threatening injuries and acute illness.(c)Standard: Services provided through agreements or arrangements.(1) The CAH has agreements or arrangements (as appropriate) with one or more providers or suppliers participating under Medicare to furnish other services to its patients, including- (i) Services of doctors of medicine or osteopathy;(ii) Additional or specialized diagnostic and clinical laboratory services that are not available at the CAH; and(iii) Food and other services to meet inpatients' nutritional needs to the extent these services are not provided directly by the CAH.(2) If the agreements or arrangements are not in writing, the CAH is able to present evidence that patients referred by the CAH are being accepted and treated.(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided.(4) The person principally responsible for the operation of the CAH 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.(5) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH's patients under a written agreement between the CAH and a distant-site telemedicine entity, the distant-site telemedicine entity is not required to be a Medicare-participating provider or supplier.(d)Standard: Nursing services. 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.(2) A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH.(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws.(4) A nursing care plan must be developed and kept current for each inpatient.(e)Standard: Rehabilitation Therapy Services. Physical therapy, occupational therapy, and speech-language pathology services furnished at the CAH, if provided, are provided by staff qualified under State law, and consistent with the requirements for therapy services in § 409.17 of this subpart.58 FR 30671, May 26, 1993; 58 FR 49935, Sept. 24, 1993, as amended at 59 FR 45403, Sept. 1, 1994; 62 FR 46037, Aug. 29, 1997; 72 FR 66408 , Nov. 27, 2007; 73 FR 69941 , Nov. 19, 2008; 75 FR 70844 , Nov. 19, 2010; 76 FR 25564 , May 5, 2011; 77 FR 29076 , May 16, 2012; 78 FR 50970 , Aug. 19, 2013; 79 FR 27156 , May 12, 2014; 81 FR 68871 , Oct. 4, 2016; 82 FR 32260 , July 13, 2017; 84 FR 51827 , 51883, Sept. 30, 2019; 87 FR 72309 , Nov. 23, 2022 81 FR 68871 , 11/28/2016; 82 FR 32260 , 7/13/2017; 84 FR 51827 , 51883, 11/29/2019; 87 FR 72309 , 1/1/2023