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.
Prior to 1986, CoPs were primarily focused on “structure over process measures… such as staff qualifications, written policies and procedures, and committee structure, which were usually specified at the standard level” (McGeary, 1990).
For example, a typical provision was a medical staff meetings standard calling for regular efforts to review, analyze, and evaluate clinical work, using an adequate evaluation method. Explanatory evidence for surveyors included attendance records for meetings involving reviews of clinical practice at least monthly. Conditions were revised in 1986 as part of the Reagan Era’s push for deregulation. Changes involved “eliminating prescriptive requirements specifying credentials or committees, departments, and other organizational arrangements. They were replaced with more general statements of desired performance or outcome in order to increase administrative flexibility” (McGeary, 1990). At the same time, more emphasis was placed on such measures as “infection control and surgical and anesthesia services. In addition, quality assurance was made a separate condition” (McGeary, 1990).
CoPs were established to align state licensure requirements and declare minimal health and safety requirements across healthcare organizations throughout the country.
As many as a third of hospitals, especially those in rural areas, did not participate in the voluntary accreditation program of the Joint Commission on Accreditation of Hospitals. Even though a goal of Medicare was to maximize healthcare access, it was evident that existing accreditation programs would not guarantee minimum health and safety conditions in all hospitals (McGeary, 1990). Therefore, the establishment of Medicare included requirements about “the maintenance of clinical records, medical staff bylaws, a 24-hour nursing service supervised by a registered nurse, utilization review planning, institutional planning and capital.
Non-compliance with CoPs can be serious. For example, “If conditions of participation are not met, various sanctions may be imposed upon the provider, including a corrective action plan, monetary sanctions, and increased reporting requirements. While a provider may eventually be excluded from the federal healthcare program, exclusion is relatively rare and only occurs if the provider fails to become substantially compliant during the corrective period” (Lauer et al, 2011).
Lauer, K., Ohta, J., and Hargreaves, A., “Violations of Payment/Participation Conditions as Predicates for False Claims,” Health Law Litigation, Spring/Summer 2011, Vol. 9 No. 2, Retrieved at https://www.lw.com/thoughtLeadership/violations-of-payment-participation-conditions-as-predicates-for-false-claims
McGeary, M., Medicare Conditions Of Participation And Accreditation For Hospitals in Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods; 1990, Retrieved at https://www.ncbi.nlm.nih.gov/books/NBK235473/
This blog post continues a series excerpting the HealthStream article, Using Assessments and Training to Improve Conditions of Participation, by Debbie Newsholme, Senior Director of Content Development and Compliance Solutions, HealthStream. This article also includes:
To learn more about improving CoPs compliance in healthcare, download the article.
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