Survey protocols and Interpretive Guidelines are established to provide guidance to personnel conducting surveys. They serve to clarify and/or explain the intent of the regulations and allsurveyors are required to use them in assessing compliance with Federal requirements. The purpose of the protocols and guidelines is to direct the surveyor’s attention to certain avenues for investigation in preparation for the survey, in conducting the survey, and in evaluation of the survey findings.
The hospital survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the hospital’s performance or practices.
The Interpretive Guidelines include three parts:
- The first part contains the survey tag number.
- The second part contains the wording of the regulation.
- The third part contains guidance to surveyors, including additional survey procedures and probes.
State Operations Manual: Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases (PDF)
Appendix A of the State Operations Manual, pages 31-35 (PDF)