Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.23(b)(6) - All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital.  The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer).

## Interpretive Guidelines §482.23(b)(6)

The hospital must ensure that there are adequate numbers of clinical nursing personnel to meet its patients nursing care needs.  In order to meet their patient's needs the hospital may supplement their hospital employed licensed nurses with volunteer and or contract licensed nurses.

The hospital and the director of the nursing service are responsible for the clinical activities of all nursing personnel regardless of whether they are hospital employees, contracted staff, or volunteers.

All licensed nurses who are working at the hospital must adhere to the policies and procedures of the hospital.  The hospital and the director of the nursing service are responsible for ensuring that licensed nursing personnel know the hospital's policies and procedures in order to adhere to those policies and procedures.

The hospital and the director of the nursing service ensure that nursing care staff person is adequately supervised and that their clinical activities are evaluated.  This supervision and evaluation of the clinical activities of each non-employee nursing staff person must be conducted by an appropriately qualified hospital-employed RN.

## Survey Procedures §482.23(b)(6)

- Review the method for orienting all licensed nurses to hospital policies and procedures.  The orientation should include at least the following:
- o The hospital and the unit;
- o Emergency procedures;
- o Nursing services policies and procedures; and
- o Safety policies and procedures.
- Determine if all nursing personnel are appropriately oriented prior to providing care.
- Confirm with the director of nurses that all nurses performance are evaluated by the hospital at least once a year.  If the performance evaluation is not considered confidential, review two evaluations.

A-0399

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.23(b)(7) - The hospital must have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present.  The policies and procedures must:

- (i)  Establish the criteria such outpatient departments must meet, taking into account the types of services delivered, the general level of acuity of patients served by the department, and the established standards of practice for the services delivered;
- (ii)  Establish alternative staffing plans;
- (iii)  Be approved by the director of nursing;
- (iv)  Be reviewed at least once every 3 years

## Interpretive Guidelines §482.23(b)(7)

Guidance is pending and will be updated in future release.

Structured rule (JSON):
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