What are the 16 Conditions of Participation for Hospitals

CoPs are qualifications developed by CMS that healthcare organizations must meet in order to begin and continue participating in federally funded healthcare programs (Medicare, Medicaid, CHIPS, etc.). These standards involve health and safety guidelines that protect all beneficiaries by improving quality and enforcing patient rights. CoPs apply to all healthcare organizations that participate in federally funded healthcare programs.

Why CoPs Were Established

Conditions of Participation were established because up to a third of all hospitals, especially those located in rural areas, did not seek the voluntary accreditation program offered by the Joint Commission on Accreditation of Hospitals. The Medicare program aimed to maximize healthcare access, but it was clear that existing accreditation programs could not guarantee minimum health and safety compliance. In response, Medicare put forth a set of requirements upon its establishment, which then evolved into the Conditions of Participation.

The Conditions of Participation were designed to protect patient health and safety. They ensure that anyone using a federally funded healthcare program, such as Medicaid, Medicare, or CHIPS, receives quality care from any participating organizations.

Different facilities and services, such as outpatient services, respiratory care, or surgical centers, have their conditions of participation, ensuring that specialized functions adhere to specialized health and safety guidelines.

Why CoPs Compliance Is Important

It is important for hospital facilities to regularly review the CoPs to ensure ongoing compliance with Medicare and Medicaid standards. Facilities that fail to fulfill standards are at risk of exposure to private claims based on allegations of abuse and neglect. In addition, when a hospital fails to comply with the CoPs, any claims submitted to Medicare and Medicaid for reimbursement will be false. Hence, not only can CMS deny payment to the facility, but the hospital will also violate the False Claims Act, resulting in potential sanctions from governmental enforcement agencies, fines, and extensive litigation expenses. Hospitals should be mindful as to whether or not their operations comply with CoPs so as to avoid the costly experience of being forced to defend their operations.

CoP noncompliance can have major consequences. For instance, if conditions of participation are not fulfilled, the provider may be subject to a corrective action plan, financial penalties, and enhanced reporting obligations. Although expulsion from the federal healthcare program is a possibility, it is uncommon and only happens if a provider fails to achieve meaningful compliance during the correction period.

What are the sixteen requirements for hospitals to participate?

Federal, state, and local law compliance: The hospital must abide by all applicable federal laws pertaining to patient safety and health. The state or municipal organization in charge of hospital licensing must have granted the hospital a license or approved it as meeting the licensure requirements.

Governing body. An effective governing body must be legally responsible for the hospital's conduct. Suppose a hospital does not have an organized governing body. In that case, the persons legally responsible for the hospital's conduct must carry out the functions specified in this part that pertain to the governing body.

Patient Rights: Establishes patients' rights, including privacy, safety, grievance processes, and the right to participate in care decisions.

Emergency preparedness is a requirement for participation: The hospital must follow all relevant municipal, state, and federal emergency preparedness regulations. Using an all-hazards approach, the hospital must create and maintain a thorough emergency preparedness program that satisfies the standards of this section.

Services Condition of participation

• If the hospital provides surgical services, they must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered, they must be consistent in quality with inpatient care in accordance with their complexity.
• If the hospital furnishes anesthesia services, they must be provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The service is responsible for all anesthesia administered in the hospital.
• If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice.
• Outpatient services must be appropriately organized and integrated with inpatient services.
• Establishes guidelines for safe and effective medication management, including storage, preparation, and dispensing.
• If the hospital provides rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services must be organized and staffed to ensure the health and safety of patients.
• Sets standards for providing nutritional care and managing food services for patients.
• Requires hospitals to assess patient needs for post-hospital care and ensure smooth transitions to other care settings.
• Mandates hospitals to implement programs to prevent and control infections within the facility.

With the New Year approaching, compliance officers and billing personnel are in an ideal position to assist their organization in complying with the CoPs. The following chart is an example of a compliance checklist an organization should create when addressing revisions in the State Operations Manual Interpretive Guidelines to Hospitals. Hospitals are encouraged to review the Interpretive Guidelines to Hospitals in detail to ensure that all policies and procedures are updated when applicable.