CMS Revises Medicare Conditions of Participation

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The Centers for Medicare & Medicaid Services (CMS) published a final rule on May 12, 2014 which makes numerous modifications to the Medicare Conditions of Participation (COP)  governing hospitals and other Medicare certified suppliers, including but not limited to the following:    
  • In the case of hospitals,
    • CMS will no longer prohibit a multi-hospital system to establish a unified and integrated medical staff.  As an alternative, CMS will reinterpret the current COP to permit either a unique medical staff for each hospital, or a unified and integrated medical staff that is shared by multiple hospitals within a hospital system, but only if the arrangement complies with certain conditions that have been newly adopted by CMS.

    • CMS has deleted the COP that requires a member of the hospital’s medical staff to serve on the hospital’s governing body.  As an alternative, CMS has adopted a new COP that requires the governing body to directly and periodically consult with the individual responsible for the hospital’s organized medical staff or his/her designee.  In the case of a multi-hospital system that uses a single governing body to oversee its multiple hospitals, the COP requires the governing body to similarly consult with the individual responsible for the medical staff of each of the affiliated hospitals.
    • CMS has modified the medical staff COP to include, in accordance with state law, other categories of physicians and non-physician practitioners who are determined to be eligible for appointment by the hospital’s governing body.

    • CMS has modified the COP in order to permit hospitals to credential registered dietitians and other clinically qualified nutrition professionals who are qualified to prescribe diets for hospitalized patients. 
    • CMS has revised the hospital COP for outpatient services to permit practitioners not otherwise on the hospital’s medical staff to order outpatient services for their patients when authorized by the medical staff and permitted by state law. 
    • CMS has modified the nuclear medicine COP such that a pharmacist or physician will no longer required to be present and provide “direct” supervision during the delivery of off-hour nuclear medicine tests. 
    • CMS has reclassified the COP governing swing bed services as an optional service.
  • In the case of critical access hospitals,
    • CMS has deleted the COP that requires the critical access hospital to involve “at least one member who is not a member of the CAH staff” in the development of patient care policies.  CMS determined that this COP is no longer necessary and often represents an unnecessary burden.
    • CMS has revised the COP which requires a physician to be physically present for sufficient periods of time, at least once in every two (2) week period, except in extraordinary circumstances.  Instead, the physician presence will be required, depending on the needs of the facility and its patients.  CMS will similarly revise this COP as it applies to rural health clinics and federally qualified health centers.
  • In the case of ambulatory surgery centers, which are only permitted to perform limited radiological services integral to the performance of certain surgical procedures, CMS will no longer subject the ASC to hospital requirements for radiology services and instead, only apply those requirements specific to the procedures permitted in the ASC setting.
  • In the case of buildings containing long term care facilities, CMS recognizes that some facilities were not able to meet the August 13, 2013 deadline for automatic sprinkler systems.  So to permit continuing access to these facilities, particularly in the event of financial strain, CMS will permit facilities to apply for a deadline extension, not to exceed two (2) years with the possibility of an additional one (1) year extension, but only if certain conditions apply.   
Additionally, please note that these modifications become effective on July 11, 2014, except in the case of the modifications governing long term care facilities and the related automatic sprinkler system requirements, which became effective upon publication, on May 12, 2014.
For additional information, or to obtain a complete summary of all modifications, please consult the Federal Register at or contact Susan Ziel at or Alex Krouse at