Stay Updated with CMS Revised Interpretive Guidelines for Hospitals

January 21, 2014

The Centers for Medicare and Medicaid Services
(CMS) "Interpretive Guidelines for Hospitals" has just been revised.
These are the guidelines used in conducting Medicare/Medicaid surveys to
determine compliance with Medicare/Medicaid hospital conditions of

The revisions reflect
regulatory changes to hospital conditions of participation that became
effective on June 7, 2013. This alert focuses on two of the changes: the
guidelines on the governing body and the guidelines related to on-site doctors
of medicine or osteopathy. One of these changes is relatively new, while the
other may have been overlooked by hospital providers, such as long-term care
hospitals and inpatient rehabilitation facilities, which may not have a doctor
on-site 24/7.

Governing Body

On May 16, 2012, CMS issued a final
rule that revised a number of hospital conditions of participation, including
the regulation pertaining to governing body. The revision allows separately
certified hospitals in a single health care system to establish one governing body.
The interpretive guidelines explain that if a hospital is part of a health care
system comprised of separately certified hospitals, the governing body of the
health care system has three options: 

  1. It may act as the governing body of each separately certified
    hospital, provided doing so is consistent with state law
  2. It may establish several governing bodies, each of
    which is responsible for several separately certified hospitals
  3. It may establish a separate governing body for each
    separately certified hospital

However, if a health care system
chooses to act as the governing body of each separately certified hospital,
each separately certified hospital must independently comply with other
Medicare/Medicaid conditions of participation. Also, each separately certified
hospital may not be operationally integrated.

For example, three separately certified hospitals that are part of a health
care system may have one set of policies and procedures for nursing services,
but they may not have one integrated nursing service with one director of
nursing who manages the nursing staff at all three hospitals. Similarly, three
separately certified hospitals that are part of a health care system may not
have one medical staff; each hospital must have its own.

Finally, the hospital-within-hospital regulations and satellite regulations,
which prohibit common control of co-located hospitals and satellites, remain in
effect. These regulations preclude one governing body where the host hospital
and the co-located hospital or satellite are part of a single health care

On-Site Presence of Doctor of Medicine or

Medicare/Medicaid conditions of participation
do not require that a hospital have a doctor of medicine or osteopathy on-site
24/7. In those circumstances, there is a regulation that requires the hospital
to provide written notice of the doctor’s availability to all inpatients at the
beginning of a planned or unplanned inpatient stay, and to all outpatients for
certain types of planned or unplanned outpatient visits. This regulatory
requirement is reflected in the interpretive guidelines.  

The written notice also must state how the
hospital will meet the medical needs of a patient who develops an emergency
medical condition at a time when there is no doctor of medicine or osteopathy
present. Before admitting a patient or providing outpatient services to a
patient, the hospital must obtain a signed acknowledgement from the patient
stating that he/she understands that a doctor of medicine or a doctor of
osteopathy may not be present at all times. 

For a multi-campus hospital with a separate
satellite, remote, or provider-based location, a separate determination is made
for each location as to whether such notice is required. A hospital that has a
doctor of medicine or osteopathy on-site 24/7 is not required to provide
written notice of the doctor’s availability to patients.

CMS is authorized by
regulation to terminate a provider agreement with a hospital that does not meet
the appropriate Medicare/Medicaid conditions of participation applicable to

If you have questions about Medicare/Medicaid hospital
conditions of participation or the CMS "Interpretive Guidelines for
Hospitals," or need assistance in responding to a Medicare/Medicaid
survey, please contact Rochelle H.
, a partner in Prince Lobel’s Health Care Practice Group and author of this Alert. You can
reach Rochelle at 617 456 8036 or

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