Hospitals have both state and federal regulations to follow. The state regulations they have to follow depend, of course, on the state in which they are located. Federal regulations are those they all must follow. Very often you will find states tend to adopt the federal regulations as their own?with some minor changes. This may or may not be a “good thing”. Some of the Federal regulations are so very vague you could drive a truck through them. This is true for some state regulations too.?Some regulations are very outdated.

One example is in California. The California Code of Regulations. at  70737(a) requires hospitals to report “Any occurrence such as epidemic outbreak, poisoning, fire, major accident, disaster, other catastrophe or unusual occurrence which threatens the welfare, safety or health of patients, personnel or visitors shall be reported as soon as reasonably practical, either by telephone or by telegraph to the local health officer and to the Department.”

Notice the telegraph – when was the last time you sent something to anyone, much less the state, via telegraph? There is no mention of faxes much less e-mail, both forms of communication which are becoming more acceptable. Can you imagine the day that you can text message a complaint into the state even as you see a situation happening?

You will find this same allowance about telegraphs for other types of health facilities at 71535(a); 72541, 73539, 75053, 75339, 76513(g), 76551(a), 76913(g), 76923(a)…. And I could go on and on, but I think you get the idea.

So the regulations (whether state or federal) don’t always keep up with the changing times and needs of the healthcare consumer.

Let’s talk a bit about those Federal regulations that all hospitals in the United States must follow. Well, let me take that back a bit, there are some exceptions. Not all hospitals have to follow the Federal regulations. So you are asking, which ones don’t?

Those hospitals that don’t receive Medicare or Medicaid payments don’t need to follow the Federal regulations. As you can imagine, most hospitals accept Medicare and Medicaid. That is often the lifeblood of the hospitals. Most insurance companies follow right along with Medicare and Medicaid, so the Federal requirements do apply in most cases. For those hospitals that are totally private pay – they would not have to follow the Federal regulations, but they would still have to follow their state’s licensing regulations.

Ahh, again, another piece in the puzzle….Did you know, Ohio is the only state that doesn’t license its hospitals. But, I digress…..

The Federal Regulations for hospitals are located in the Code of Federal Regulations, Title 22, Part 482.

Hospitals that do want to receive Medicare and Medicaid monies are required to be in compliance with the Medicare Conditions of Participation (COPs). In order to determine if the Hospital is in fact in compliance with the conditions of participation a survey is conducted. The surveys are unannounced and are conducted following protocols and guidelines set forth by CMS (The Centers for Medicare and Medicaid Services).

The survey protocols and Interpretive Guidelines (IGs) clarify and/or explain the intent of the regulations and all surveyors (some states may call them evaluators or investigators) are required to use them in assessing compliance with Federal requirements. They are there to help direct the surveyor’s attention to certain avenues for investigation while preparing for the survey, ?while conducting the survey, and while evaluating the findings of the survey.

The hospital survey is conducted to determine whether the facility is in compliance with the regulations. Deficiencies are based on a violation of the regulations, which, in turn, is to be based on observations of the hospital’s performance or practices.

We will discuss more about Interpretive Guidelines at another time. Suffice it to say for now there are interpretive guidelines for all the facility types. Some are more helpful than others, and CMS is revising many of them.

The COPs for hospitals are organized into the following general categories:

  • Compliance with Federal, State, and Local Laws
  • Governing Body
  • Patient’s Rights
  • Quality Assessment and Performance Improvement
  • Medical Staff
  • Nursing Services
  • Medical Record Services
  • Pharmaceutical Services
  • Radiologic Services
  • Laboratory Services
  • Food and Dietetic Services
  • Utilization Review
  • Physical Environment
  • Infection Control
  • Discharge Planning
  • Organ, Tissue, and Eye Procurement
  • Surgical Services
  • Anesthesia Services
  • Nuclear Medicine Services
  • Outpatient Services
  • Emergency Services
  • Rehabilitation Services
  • Respiratory Services

So there you have it, the COPs for the hospital. There is so much more to this, things that will help you be a better informed consumer – so come on back and keep learning. Be safe, know what you need to know!


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One Response to “The Hospital COPs – Used By A Hospital Surveyor”

  1. T Hammonds Says:

    Thanks a ton for blogging “Nursing Home and Hospital Surveyor » The Hospital COPs – Used By A Hospital Surveyor”. How interesting that in a way the people who do this job could be considered “COPs” themselves, or “nursing home police”. Understanding how COP has several meanings in your world of investigation in hospitals and other health facilities helps us to understand the intricate aspects of the job. I hope every hospital strives to follow the Conditions of Participation closely.

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