What Are Conditions of Participation (CoPs)?

What Are CoPs?

The CMS Conditions of Participation (CoPs) are essential qualifications developed by the Centers for Medicare & Medicaid Services that healthcare organizations must meet to begin and continue participating in federally funded healthcare programs, including Medicare, Medicaid, and CHIPS. These Medicare Conditions of Participation establish key health and safety guidelines designed to protect beneficiaries by enhancing quality and enforcing patient rights. All healthcare organizations participating in federally funded programs are subject to these Conditions of Participation.

Prior to 1986, the focus of the CMS Conditions of Participation was primarily on structure rather than process measures. This included aspects such as staffing qualifications and the implementation of written policies and procedures. Specific standards dictated the organisational structures required, often mandating the regular review and analysis of clinical work at medical staff meetings, with evidence necessary for surveyors to demonstrate compliance with these Conditions of Participation.

In 1986, significant changes were made to the Medicare Conditions of Participation as part of the Reagan Era's push for deregulation. These revisions eliminated many prescriptive requirements, including those related to credentials and committees, and replaced them with more general performance outcomes to boost administrative flexibility. Significant emphasis was also shifted towards measures like infection control, surgical, and anesthesia services. Furthermore, quality assurance practices were separated, drawing more attention to how healthcare organizations could better adhere to the Conditions of Participation.

Why CoPs Were Established

The primary aim of the CMS Conditions of Participation was to align state licensure requirements with minimal health and safety standards across healthcare organizations nationwide. It became apparent that voluntary accreditation programs, such as those offered by the Joint Commission on Accreditation of Hospitals, were not sufficiently covering hospitals, particularly in rural areas. Even with Medicare's objective to enhance healthcare access, it was recognized that compliance with existing accreditation programs would not guarantee that all hospitals met the necessary health and safety conditions. Therefore, the establishment of Medicare included explicit requirements concerning the maintenance of clinical records and medical staff bylaws, among others—a commitment to ensuring compliance with the Conditions of Participation.

Why CoPs Compliance Is Important

Compliance with the CMS Conditions of Participation is crucial for healthcare providers, as failure to meet these Medicare Conditions of Participation can result in severe consequences. If healthcare organizations do not comply with the Conditions of Participation, they may face various sanctions, including the enforcement of a corrective action plan, monetary penalties, and increased reporting demands. Although exclusion from federal healthcare programs is rare, it may occur if a provider fails to achieve substantial compliance during the corrective period.

References

Lauer, K., Ohta, J., and Hargreaves, A., “Violations of Payment/Participation Conditions as Predicates for False Claims,” Health Law Litigation, Spring/Summer 2011, Vol. 9 No. 2, Retrieved at https://www.lw.com/thoughtLeadership/violations-of-payment-participation-conditions-as-predicates-for-false-claims

McGeary, M., Medicare Conditions Of Participation And Accreditation For Hospitals in Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods; 1990, Retrieved at https://www.ncbi.nlm.nih.gov/books/NBK235473/