Revised Hospital Conditions of Participation (CoPs) – Governing
Revised Hospital Regulations Effective July 16, 2012: The Centers for Medicare & Medicaid Services (CMS) has adopted a number
of changes to the hospital CoPs and is in the process of developing interpretive guidelines to assist surveyors in assessing
compliance under the revised regulations. Due to the number and complexity of the revisions, this guidance may not be published
for all of the affected requirements by July 16th, the effective date of the final regulations.
Hospital Governing Body and Medical Staff: In the case of the new requirement for a hospital’s governing body to include a
member of the medical staff under §482.12, CMS is presently reconsidering this policy in light of the numerous comments that
have been received since publication of the final rule. Therefore,
•Surveyors should not attempt to assess compliance with this new requirement or cite deficiencies related to this specific
requirement without receiving instructions from CMS.
•Accrediting organizations with CMS-approved hospital accreditation programs are not expected to revise their standards or
survey processes related to this particular requirement until we have addressed the issue completely.