View Proposed Rule Will Streamline Hospital Conditions of Participation (PDF)

What you need to know

The Centers for Medicare and Medicaid Services has proposed changes to hospital Conditions of Participation which, if implemented, would significantly impact hospitals.

What you need to do

Hospitals should review the proposed changes and submit their comments to CMS by December 23, and should prepare to adjust their policies to reflect these changes once the rule is finalized.

In January, President Obama released Executive Order 13563 instructing federal agencies to eliminate regulations that are obsolete or unduly burdensome to healthcare providers.  In response, the Centers for Medicare and Medicaid Services published a proposed rule to streamline the hospital Conditions of Participation.  CMS’ proposed changes to the hospital COPs include:

Hospital Governance and Management

  • Hospitals in a multi-hospital system may be governed by a single governing body.  Currently, each hospital facility within a multi-hospital system is required to have a separate governing body.
  • Hospitals would be permitted to assign more than one individual to be ultimately responsible for outpatient services.
  • A hospital’s governing body may grant practice privileges to practitioners without requiring them to be members of the hospital’s medical staff if permitted by state law. 
  • The current requirement that non-physicians receive special training in administering blood transfusions and intravenous medications would be eliminated.

Patient Care and Services

  • Critical access hospitals would be permitted to utilize contracts or other arrangements to furnish diagnostic, therapeutic, laboratory and radiology services and emergency procedures.  Currently, critical access hospitals must furnish these services directly rather than via contracts with affiliates or other entities.
  • Hospitals using an interdisciplinary care plan to provide patient care will no longer be required to maintain a separate, additional care plan for nursing services, and may instead integrate nursing services into the overall care plan.
  • A broader range of practitioners may now prepare, administer, document and sign for drugs and biologics if permitted by state law and hospital policy.  Hospitals may also use pre-printed and electronic standing orders and protocols to prepare and administer drugs and biologics under certain circumstances.

Reporting Requirements

  • The current requirement for hospitals to maintain a separate infection control log would be eliminated in favor of a more flexible approach to developing systems for identifying, reporting, investigating and controlling infections.
  • Hospitals will be given more time to report patient deaths after use of physical restraints.


Many of these changes will provide welcome respite from duplicative systems or complicated processes.  Hospitals wishing to comment on these changes should submit their comments to CMS by December 23.