Accreditation Resource Services Newsletter
November 2020

CIHQ-ARS Article

Scope of Service

By: April McLain
I have been a nurse in healthcare for nearly 40 years and have spent much of my career directly or indirectly responsible for regulatory compliance. Many of the standards and regulations promulgated by CMS and accrediting bodies’ standards have been in place for many of those years. I forget at times, that while a regulation or standard has been around nearly as long as I have, there are others just getting started in regulatory compliance, therefore, a brief refresher of an old topic may be helpful. One such topic is scope of services.
What is a scope of services? Simply put, a scope of services is the services provided to patients within the capability of the organization to meet the healthcare needs of the patient. Not every healthcare organization has the capability or capacity to provide all healthcare needs of patients, and having a defined scope of services provides guidance. In the case of a critical access hospital, CMS will specifically review the organization’s scope of services to verify the organization has the facilities and resources to support the services provided.
The standards for the scope of practice are not prescriptive. In broad terms, the organization’s scope of services can be as simple as a list of services provided either directly or contractually by the organization; and a separate list of services not provided by the organization. If services are not provided at the organization, the organization will need to develop agreements with other organizations or providers that provide the service. The scope of services can be contained in a policy and approved by the governing body. While CMS does not specifically require governing body approval, it is implied as the governing body is ultimately responsible for the activities of the organization. Other accrediting organizations may have more specific standards that require evidence that the governing body has approved the organization’s scope of services.
Regardless of how the organization chooses to document their broad scope of services, all services are required to be integrated into the organization. Examples of integration include:
  • Participation in multidisciplinary care-teams and committees, including integration into the organizational-wide QAPI program
  • Compliance with organizational-wide policies that address a single standard of care
  • Following established lines of communication and sharing information between departments
From the broad scope of services, departmental scope of services can be developed. This is where the specific details of the care and services provided to patients are documented. The details of a departmental scope of service should contain the following:
  • A description of the department to include the types of services and facilities provided. If the scope of services varies depending on the location (e.g. different campus, off-site services, etc.) then the variances should be explained along with an explanation of how your organization determined that patients with comparable care needs are assured of receiving a comparable level care
  • The type and ages of the patient population served
  • Hours of operation
  • Staffing plan to include the minimum requirement to provide care and how the staffing will be adjusted to meet patient needs. This should include any State mandated staffing requirements as appropriate
  • Qualification and competency of the staff or reference to source documents such as job descriptions
  • Information on how the department integrates the care and services provided into the overall organization
In lieu of a single broad organizational scope of services policy, many organizations combine the individual departmental scope of services into a single document that is then approved by the governing body. It is left up to the organization to determine how its scope of services will be documented.
CMS Conditions of Participation for Acute Care Hospitals does include specific requirements for written descriptions of the scope of services for certain services as listed below:
  • CMS at 482.27(a)(2) - Laboratory Services requires a written description of the laboratory services provided, including those furnished on routine and stat basis (either directly or under an arrangement with an outside facility).
  • CMS at 482.51(a) - Surgical Services required the scope of surgical services provided by the hospital should be defined in writing and approved by the Medical Staff.
  • CMS at 482.53(a) - Nuclear Medicine requires the scope of nuclear medicine services offered by the hospital be specified in writing, including which types of diagnostic studies and/or therapeutic procedures are provided, where they are provided in the hospital, and the appropriately-trained staff and equipment needed to provide these services. Hospitals may choose to provide nuclear medicine services in one location or at several different locations in the hospital, including, but not limited to, inpatient and outpatient locations of the radiology, cardiology, and oncology departments. The organization of the nuclear medicine service must encompass the full scope and complexity of nuclear services offered throughout the hospital.
  • CMS at 482.57(a) - Respiratory Services requires the scope of diagnostic and/or therapeutic respiratory services offered by the hospital should be defined in writing, and approved by the Medical staff.
A final word on scope of services. There are no specific requirements by CMS as to the frequency of review of the organization’s scope of services. Anyone in healthcare knows that services change, some are added, some are deleted, and some are modified. Making sure your scope of services document keeps up with the changes can be a challenge. Placing your scope of services on a regular review schedule will help keep it current and in good standing with CMS and your accrediting organization.