[Code of Federal Regulations]
[Title 42, Volume 3, Parts 430 to End]
[Revised as of October 1, 1999]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR482.21]

[Page 356-357]
 
PART 482--CONDITIONS OF PARTICIPATION FOR HOSPITALS--Table of Contents
 
                   Subpart C--Basic Hospital Functions
 
Sec. 482.21  Condition of participation: Quality assurance.


    The governing body must ensure that there is an effective, hospital-
wide quality assurance program to evaluate the provision of patient 
care.
    (a) Standard: Clinical plan. The organized, hospital-wide quality 
assurance program must be ongoing and have a written plan of 
implementation.

[[Page 357]]

    (1) All organized services related to patient care, including 
services furnished by a contractor, must be evaluated.
    (2) Nosocomial infections and medication therapy must be evaluated.
    (3) All medical and surgical services performed in the hospital must 
be evaluated as they relate to appropriateness of diagnosis and 
treatment.
    (b) Standard: Medically-related patient care services. The hospital 
must have an ongoing plan, consistent with available community and 
hospital resources, to provide or make available social work, 
psychological, and educational services to meet the medically-related 
needs of its patients.
    (c) Standard: Implementation. The hospital must take and document 
appropriate remedial action to address deficiencies found through the 
quality assurance program. The hospital must document the outcome of the 
remedial action.

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