Why Improving CoPs Compliance Matters

April 1, 2021
April 1, 2021

In 2017, 37% of U.S. healthcare spending, estimated to be $3.5 trillion, or $10,739 per benefi­ciary, could be attributed to Medicare or Medicaid—a larg­er share than the 34% covered by private health insurance (CMS, 2018). It is no wonder that the federal government has established standards that must be met to qualify for inclusion and reimbursement under these public healthcare programs.

The purpose of the article from which this blog post excerpt is taken is to define the Conditions of Participation (CoPs) and to examine new ways healthcare organizations can use assessments and training from HealthStream to ensure staff understand and are adhering to policies that support compliance.

Why CoPs Compliance Matters

Let’s look at a hypothetical case demonstrating what’s at stake in CoPs compliance. A mid-sized, 250-bed hospital in an urban area has just undergone a CMS survey; this organization derives about 70 percent of its annual revenue from Medicare and Medicaid patients. Hospitals are required to be compliant with the Federal requirements set forth in the Medicare Conditions of Participation in order to receive payments from Medicare and Medicaid (42 CFR Part 482). The survey team is made up of at least one RN and others with expertise to determine compliance. Each specific Standard is assigned to one member of the survey team.

Surveys to Determine CoPs Compliance

In addition to reviewing documentation, surveyors observe staff behavior and conduct staff interviews. They also interview patients and caregivers. The surveyor assigned §482.13 Condition of Participation: Patient’s Rights (which should be coordinated by one surveyor with all others assessing for compliance as part of their assignment) reviews the organization’s policy. She discovers that the policy is vague and has no original creation date, nor a review date. Furthermore, in interviewing several patients and caregivers, she finds that they are unable to tell her what the hospital has told them about their rights. Upon further interviewing, she notes that patients are unfamiliar with how to file a grievance.

Deficiency Findings and Corrective Plans

These findings will be included as part of the Exit Conference. The organization is informed it will receive a “statement of deficiencies” (Form CMS 2567) within 10 working days. The document specifies the deficiencies and what the organization is doing to remedy them. In addition, the organization is informed that the results are made public within 90 days. Following receipt of the written report, the organization must submit a corrective plan within 10 days that is approved by the State agency or CMS regional office. Each organization will have a unique plan, which must address its survey findings. Failure to submit an acceptable plan of correction, including reasonable time period, may result in termination of the provider.

This is just one example of how an organization’s failure to comply with the Conditions of Participation can negatively impact an organization’s bottom line and put the source of a majority of its care reimbursement in jeopardy.


CMS, “National Health Expenditures 2017 Highlights,” 2018, Retrieved at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf

This blog post is the first in 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:

  • What Are CoPs
  • Why CoPs Compliance Is Important
  • Connecting the Dots Between the CoPs and Accrediting Standards to Learning
  • How HealthStream Can Help You Meet Cops and Accrediting Standards

Download the article here