Medicare Conditions of Participation
Hospitals

3.) Hospitals

        a.) Basic Hospital Functions

Hospitals participating in Medicare must meet certain regulatory requirements.67 The Secretary of the Department of Health and Human Services has the authority to impose additional requirements if they are necessary to protect patients’ health and safety.68

Hospitals must comply with the following conditions of participation for Medicare:

• Hospitals must comply with applicable federal, state and local laws related to patient safety and licensing requirements.69
• A hospital must have a governing body legally responsible for the conduct of the hospital as an institution.70
• A hospital must protect and promote each patient’s rights, including patients’ visitation rights.71
• The hospital must inform each patient or the patient’s representative of the patient’s rights prior to furnishing or discontinuing patient care. The hospital must establish a process for prompt resolution of patient grievances and inform each patient how to file a grievance.
• A hospital must develop a hospital-wide quality assessment and performance improvement program to improve health outcomes, identify and reduce medical errors, and measure quality indicators including adverse patient events.72
• A hospital must maintain a medical record for every patient.73
• A hospital must have a utilization review plan that provides for review of services furnished by the institution and its medical staff to patients entitled to benefits under the Medicare and Medicaid programs.74
• A hospital must have a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.75
• A hospital must have written protocols on organ procurement and transplantation.76

        b.) Optional Hospital Services

A hospital must provide the following services that meet the needs of patients and comply with acceptable standards of practice:

• Inpatient and outpatient surgical services77
• Anesthesia services78
• Nuclear medicine services79
• Outpatient services80
• Emergency services81
• Rehabilitation services82
• Respiratory care services83

        c.) Requirements for Specialty Hospitals

                i.) Psychiatric hospitals

Psychiatric hospitals must be primarily engaged in providing psychiatric services, meet the conditions of participation for hospitals, maintain clinical records on all patients and meet staffing requirements.84 A patient’s medical record must contain a psychiatric evaluation, a treatment plan, and the patient’s progress.85 A psychiatric hospital must have adequate numbers of qualified professional and support staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning.86

                ii.) Long-term care services

A hospital that has a Medicare provider agreement must meet several eligibility requirements in order to be granted CMS’ approval to provide post-hospital extended care services and be reimbursed as a swing-bed hospital.87 The facility must substantially comply with skilled nursing facility requirements.

                iii.) Transplant centers

A transplant center that has a Medicare provider agreement must meet the following conditions of participation in order to gain CMS’ approval to provide transplant services:88

• A transplant center must be located in a transplant hospital that is a member of the Organ Procurement and Transplantation Network (OPTN).89
• A transplant center must notify CMS of any significant changes related to the center’s transplant program or changes that could affect its compliance with the conditions of participation. 90
• A transplant center must seek Medicare approval to provide transplantation services to pediatric patients.91
• Transplant centers must meet all data submission, clinical experience and outcome requirements to be granted initial approval and re-approval by CMS.92
• A transplant center must use written patient selection criteria in determining a patient’s suitability for placement on the waiting list or a patient’s suitability for transplantation.93
• Transplant centers must have written protocols for validation of donor-recipient blood type and other vital data for the decease organ recovery, organ receipt, and living donor organ transplantation processes.94
• Transplant centers must have written patient management policies for the transplant and discharge phases of transplantation.95
• Transplant centers must develop a written, comprehensive, data-driven quality assessment and performance improvement (QAPI) program designed to monitor and evaluate performance of all transplantation services including services provided under contract or arrangement.96
• A transplant center must ensure that the hospital in which it operates has a written agreement for the receipt of organs with an organ procurement organization (OPO).97
• A transplant center must meet hospital’s responsibilities to ensure patients’ rights and protect and promote each transplant patient and living donor’s rights.98
• Kidney transplant centers must directly furnish transplantation and other medical and surgical specialty services required for the care of end-stage renal disease patients. A kidney transplant center must have written policies and procedures for ongoing communications with dialysis patients’ local dialysis facilities.99