The hospital provides services that meet patient needs.

(1)

The hospital provides services directly or through referral, consultation, contractual arrangements, or other agreements that meet the needs of the population(s) served, are organized appropriate to the scope and complexity of services offered, and are in accordance with accepted standards of practice. Services may include but are not limited to the following: - Outpatient - Emergency - Medical records - Diagnostic and therapeutic radiology - Nuclear medicine - Surgical - Anesthesia - Laboratory - Respiratory - Dietetic - Obstetrical Note: If obstetrical services are provided, they are in accordance with nationally recognized acceptable standards of practice for the health care (including physical and behavioral health) of pregnant, birthing, and postpartum patients. If outpatient obstetrical services are offered, the services are consistent in quality with inpatient care in accordance with the complexity of services offered. As applicable, the services must be integrated with other departments of the hospital.

(2)

The hospital has an organized nursing service, with a plan of administrative authority and delineation of responsibility for patient care, that provides 24-hour nursing services. Note: For hospitals that use Joint Commission accreditation for deemed-status purposes: Rural hospitals with a 24-hour nursing waiver granted under 42 CFR 488.54(c) are not required to have 24-hour nursing services.

(5)

If the hospital provides outpatient services, the services are integrated with inpatient services.

(7)

If the hospital provides emergency services, the services are organized under the direction of a qualified member of the medical staff and are integrated with other departments of the hospital.

(8)

For hospitals that use Joint Commission accreditation for deemed status purposes: If emergency services are provided at the hospital, the hospital complies with the requirements of 42 CFR 482.55.

(9)

For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital provides nuclear medicine services, and nuclear medicine staff perform laboratory tests, the services meet the applicable requirements for laboratory services specified in 42 CFR 482.27.

(10)

If the hospital provides outpatient surgical services, the services are consistent with the quality of inpatient surgical care.

(11)

The surgical services are consistent with the resources available.

(12)

The hospital has laboratory services available, either directly or through a contractual agreement with a Clinical Laboratory Improvement Amendments (CLIA)–certified laboratory that meets the requirements of 42 CFR 493.

(13)

Emergency laboratory services are available 24 hours a day, 7 days a week.

(14)

The hospital maintains a written description of the scope of laboratory services provided that is available to the medical staff.

(15)

For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital provides respiratory care services, and respiratory care staff perform blood gasses or other clinical laboratory tests, the applicable requirements for laboratory services specified in 42 CFR 482.27 are met.

(20)

In accordance with the complexity and scope of services offered, the hospital has adequate provisions and protocols to meet the emergency needs of patients.

(21)

In accordance with the complexity and scope of services offered, the hospital protocols are consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate postdelivery care.

(22)

In accordance with the complexity and scope of services offered, the hospital has provisions that include equipment, supplies, and medication used in treating emergency cases. Such provisions are kept at the hospital and readily available for treating emergency cases to meet the needs of patients. The available provisions include the following: - Drugs, blood and blood products, and biologicals commonly used in lifesaving procedures - Equipment and supplies commonly used in life-saving procedures - A call-in system for each patient in each emergency services treatment area

(23)

If obstetrical services are provided, obstetrical services are consistent with the needs and resources of the hospital. Policies governing obstetrical care are designed to assure the achievement and maintenance of high standards of medical practice and patient care and safety.

(24)

If obstetrical services are provided, the hospital has adequate provisions and protocols, consistent with nationally recognized and evidence-based guidelines, for obstetrical emergencies, complications, immediate post-delivery care, and other patient health and safety events as identified as part of the quality assessment and performance improvement (QAPI) program. Provisions include equipment, supplies, and medication used in treating emergency cases. Such provisions are kept in the hospital and are readily available for treating emergency cases. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: See 42 CFR 482.21 for QAPI program requirements. For 482.21, refer to https://www.ecfr.gov/current/title-42/ section-482.21. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The equipment addressed at this EP is in addition to the equipment required at 42 CFR 482.59(b)(1). For 482.59(b)(1), refer to https://www.ecfr.gov/current/title-42/part-482/section-482.59#p-482.59(b)(1).