CMS Governing Board and Contract Management (ODW5015)-2025 Governing Board and Contract Mgt Presentation

2025 Governing Board and Contract Mgt Presentation

Pdf Summary

The provided document discusses compliance with CMS Conditions of Participation for hospitals, focusing on the governing body's responsibilities and contractual obligations. Led by Laura A. Dixon, Esq., the document outlines key information for hospital governing boards to fulfill regulatory requirements and avoid citations.

Key Highlights:
1. <strong>Governing Body Duties</strong>: The governing body, responsible for hospital operations, must ensure an effective governing system is in place, appoint qualified medical staff, and maintain compliance with all Conditions of Participation (CoPs).

2. <strong>Contracted Services</strong>: Hospitals must manage services provided by contractors to ensure they meet hospital standards and CoPs. This includes maintaining a list of all contracts and ensuring services under contract are evaluated for quality and compliance.

3. <strong>Medical Staff and Bylaws</strong>: The board must approve medical staff bylaws, ensure the medical staff is accountable for patient care quality, and ensure the onboarding of practitioners follows set rules and qualifications.

4. <strong>Quality and Compliance Oversight</strong>: The governing body needs to function effectively, holding ultimate responsibility for hospital compliance. This includes oversight of the hospital's Quality Assessment and Performance Improvement (QAPI) programs.

5. <strong>Survey Procedures</strong>: CMS surveyors verify contractual compliance by reviewing documentation, confirming written criteria for staff appointment, and assessing quality services under contract. 

6. <strong>Deficiencies</strong>: Common deficiencies cited include inadequate monitoring of contracted services, lack of comprehensive contractual documentation, and failure to ensure appropriate staff licensing and competency.

This document serves as a guide for hospitals and critical access hospitals to adhere to CMS mandates, emphasizing the importance of stringent oversight by governing bodies to ensure patient safety and regulatory compliance.

Keywords

CMS Conditions of Participation

hospital compliance

governing body responsibilities

contractual obligations

medical staff bylaws

quality oversight

QAPI programs

survey procedures

deficiencies

patient safety