In place, and functioning
CMS’s current surveyor guidance sits in the State Operations Manual, Appendix A, under 42 CFR §482.13(c)(2) — Tag A-0144, the patient’s right to receive care in a safe setting. The survey procedures direct surveyors to ask whether appropriate security protections such as alarms and arm-banding systems are in place, and whether they are functioning. Not one question. Two — and the second is the one you have to be able to answer. The same guidance tells surveyors to assess the hospital’s efforts to protect vulnerable patients — newborns, children, the elderly, and patients at risk of self-harm — against nationally recognized standards of practice.
Read the workaround loop through this citation and the whole vertical clicks into place. You own the arm-banding system. But on the night the band was applied late, or the alert fired and no one can retrieve the response record, or the exit lock was on a maintenance bypass — the system was installed and did not function, and you cannot prove otherwise. The integrator’s job is not to sell you the band. It is to make the protection function under real conditions and to produce the record that answers the surveyor’s actual question.
““Are they functioning” is the whole survey in three words. Ownership was never the bar. Demonstrated function is.”
Sources: CMS SOM Appendix A, Tag A-0144, under 42 CFR §482.13(c)(2), as updated by QSO-25-24 (Sept. 5, 2025).
What would change this: Next SOM Appendix A transmittal (QSO series).
Reviewed July 2026 by the Eagle Systems healthcare practice. The systems referenced are how a facility meets the accountability the regulation creates, not a mandate; the accreditation and compliance determinations belong to the organization and its regulators. Current as of Accreditation 360 (eff. Jan 1 2026).