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CMS Proposes Hospital Conditions of Participation

June 17, 2016—The Centers for Medicare and Medicaid Services (CMS) June 13 proposed updated Conditions of Participation (COP) for both hospitals and critical access hospitals. Providers must abide by these conditions to participate in the Medicare and Medicaid programs.

The new COPs focus on implementation of antibiotics and infection control programs, changing the terminology of “licensed independent practitioner,” increased documentation, and updating discrimination policies, among other issues. 

Under the proposed COPs, hospitals are required to have both an antibiotic stewardship program and a hospital-wide infection prevention and control program to help reduce antibiotic overuse and healthcare associated infections. CMS also plans to transition from the title of “licensed independent practitioner” to simply “licensed practitioner,” to allow physician assistants to be used to their full ability under state scope of practice laws. CMS and stakeholders had concerns that using “licensed independent practitioner” could increase workforce shortages.

Under the new proposal, hospitals are also required to have a policy prohibiting discrimination on the basis of religion, race, color, sex, gender orientation, age, disability, or national origin. CMS notes that such a policy would address “discriminatory behavior by healthcare providers that may create real or perceived barriers to care.” Additionally, patient medical records would need to include details justifying any admission and readmission, along with document discharge and transfer summaries.

Comments on the proposed COP are due by Aug. 15. The AAMC plans to submit a response on the regulation.


Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806