42 CFR § 482.54 - Condition of participation: Outpatient services.
If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice.
(a) Standard: Organization. Outpatient services must be appropriately organized and integrated with inpatient services.
(b) Standard: Personnel. The hospital must—
(1) Assign one or more individuals to be responsible for outpatient services.
(2) Have appropriate professional and nonprofessional personnel available at each location where outpatient services are offered, based on the scope and complexity of outpatient services.
(c) Standard: Orders for outpatient services. Outpatient services must be ordered by a practitioner who meets the following conditions:
(1) Is responsible for the care of the patient.
(2) Is licensed in the State where he or she provides care to the patient.
(3) Is acting within his or her scope of practice under State law.
(4) Is authorized in accordance with State law and policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. This applies to the following:
(i) All practitioners who are appointed to the hospital's medical staff and who have been granted privileges to order the applicable outpatient services.
(ii) All practitioners not appointed to the medical staff, but who satisfy the above criteria for authorization by the medical staff and the hospital for ordering the applicable outpatient services for their patients.