CMS Hospital Conditions of Participation (CoP) Survey Readiness

Governing Body & Administration

Overall responsibility for the hospital as a Medicare-participating provider.

• Is there an effective governing body legally responsible for the conduct of the hospital? *
• Has the governing body appointed the members of the medical staff and approved their bylaws? *
• Does the governing body ensure a CEO/administrator is responsible for managing the hospital? *
• Are contracted services provided in a safe and effective manner with governing-body oversight? *
• Has the governing body approved the institutional plan and budget? *

Patient Rights

• Is each patient (or representative) informed of their rights in advance of furnishing or discontinuing care? *
• Does the hospital have a grievance process with time frames for review and written response? *
• Are patients free from restraints/seclusion not clinically necessary and imposed for staff convenience? *
• Is patient confidentiality and privacy protected during care? *

QAPI Program

• Is there an ongoing, data-driven, hospital-wide Quality Assessment and Performance Improvement program? *
• Does the program track adverse patient events and analyze their causes? *
• Has the governing body set priorities and the number/scope of improvement projects annually? *

Nursing Services

• Is there an organized nursing service with a full-time director who is a registered nurse? *
• Are there adequate numbers of licensed nurses to provide care to all patients as needed? *
• Does each patient have an individualized, current nursing care plan? *
• Are drugs and biologicals prepared and administered per orders and accepted standards of practice? *

Medical Record Services

• Are medical records accurately written, promptly completed, properly filed, and accessible? *
• Are records retained for at least 5 years (and are entries authenticated and dated/timed)? *
• Is a history and physical completed and documented no more than 30 days before or 24 hours after admission? *

Infection Prevention, Control & Antibiotic Stewardship

• Is there an active hospital-wide program for surveillance, prevention, and control of infections? *
• Is an infection preventionist(s) appointed by the governing body and qualified through education/training? *
• Is there an antibiotic stewardship program with documented protocols and outcome monitoring? *