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Registered Nurse Immediate Availability to Patient Care Areas

For hospitals that use Joint Commission accreditation for deemed status purposes and for distinct part rehabilitation and psychiatric distinct part units in critical access hospitals, a note has been added to the requirement found at NR.02.03.01 EP 7 regarding the immediate availability of a registered nurse. What patient care areas are included in this ‘Note’?

Any examples are for illustrative purposes only.

While the requirement regarding the provision or supervision of care delivery by a Registered Nurse (RN) is not a new requirement, the ‘note’ clarifies CMS’s expectation regarding the availability of an RN.

For hospitals that use Joint Commission accreditation for deemed status purposes, NR.02.03.01 EP 7 applies to all inpatient units, departments and locations in which the provision of nursing care occurs. This includes outpatient locations as the Conditions of Participation require that the organization’s outpatient services be consistent with the hospital’s inpatient  services. The Emergency Department(ED) would also be included as patients may be boarded in the ED while awaiting admission or transfer.

NR.02.03.01 EP 9 also requires that hospitals that use Joint Commission accreditation for deemed status purposes have policies and procedures that establish which outpatient departments, if any, are not required to have a registered nurse present.

Critical Access Hospitals
NR.02.03.01 EP 7 applies only to critical access hospitals that have either an inpatient rehabilitation or psychiatric distinct part unit (DPU). The requirement does not apply to clinic settings, such as Family Practice, Internal Medicine, etc.

Although the term ‘immediately available’ has not been formally defined, an RN would not be considered ‘immediately available’ if he/she was working on more than one unit, building, floor in a building, etc, at the same time.

Small organizations and those located in rural areas may consider contacting their state’s CMS office regarding a waiver (42 CFR §488.54(c)) option.

Last updated on January 04, 2021
Manual: Critical Access Hospital
Chapter: Nursing NR

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