CMS Governing Board and Contract Management (ODW6014)-CMS Governing Boards and Contract Management Presentation

CMS Governing Boards and Contract Management Presentation

Pdf Summary

The document summarizes CMS Conditions of Participation (CoPs) requirements and common survey citations related to hospital governing boards and contracted services for both acute hospitals and Critical Access Hospitals (CAHs), using State Operations Manual guidance and survey “tag” references.<br /><br />For governing bodies, CMS requires an effective board (or a designated responsible individual if no board) that is legally accountable for hospital operations and compliance with all CoPs. In health systems, each separately certified hospital must individually adopt policies and maintain clarity in minutes about which facility actions apply to. Boards are frequently cited for weak oversight of credentialing/privileging (allowing practitioners to perform beyond granted privileges), failure to follow/approve hospital policies and medical staff bylaws, inadequate support for services (e.g., emergency surgery resources), and insufficient infection control and QAPI oversight.<br /><br />The board must oversee the medical staff: determine practitioner categories eligible for appointment, appoint practitioners based on medical staff recommendations, ensure bylaws/rules are compliant and board-approved before effective, and ensure the medical staff is accountable for quality of care. Periodic direct consultation with the medical staff leader (e.g., CMO/medical staff president) is required—CMS recommends at least twice yearly—with documented agendas/minutes showing quality-of-care discussion. Patient care standards include ensuring every patient is under a privileged practitioner; Medicare patients admitted by midlevels generally must be under MD/DO care with supporting documentation. Boards must also appoint a CEO and ensure emergency service policies exist (including for off-campus departments); relying on 9-1-1 to provide hospital-required emergency response is not compliant.<br /><br />For contracts, the board remains responsible for safe, effective services whether provided by employees or contractors. Hospitals must keep a complete, centralized list of contracted services, evaluate each through QAPI, set performance metrics, ensure contractor staff are oriented/trained/competent, and use written agreements for telemedicine (including credentialing/privileging and feedback to distant sites). CAH contract requirements similarly stress agreements/arrangements, Medicare-participating providers/suppliers (with telemedicine exceptions), maintaining detailed contract lists, verifying licensure/CLIA as applicable, and ensuring dietary/nutrition needs are met even if services are outsourced.<br /><br />The document concludes with contract management best practices (central contract log, defined ownership/signatory authority, legal/risk review, insurance/indemnification, termination rights) and a case example highlighting potential citations for insufficient oversight and vetting of a contracted hospitalist group.

Keywords

CMS Conditions of Participation (CoPs)

State Operations Manual (SOM) guidance

hospital governing board accountability

Critical Access Hospital (CAH) compliance

medical staff credentialing and privileging oversight

QAPI (Quality Assessment and Performance Improvement) contractor evaluation

infection control board oversight

emergency services policy requirements (including off-campus departments)

telemedicine agreements and credentialing-by-proxy

contracted services centralized contract log and management