Complying with governing body CoPs

According to CMS, all hospitals must have a governing body (§482.12) . To ensure your hospital is compliant with CMS' regulations, here are some tips: 

• Review hospital board/governing body bylaws and/or responsibility matrix to ensure aspects critical to their role are outlined (e.g., responsibility for medical staff bylaws and credentialing, QAPI, Emergency Medical Treatment and Active Labor Act of 1986 [EMTALA], grievance process, and contracted services).
• Review governing body meeting minutes for documentation on approval/denial of medical staff recommendations and actions. There must be written documentation that identifies the individual or individuals that are legally responsible for the conduct of the hospital operations.
• Review medical staff bylaws/P&Ps and whether the medical staff accepted changes or revisions at large with final approval by the governing body.
• Review credentials files to verify the information is up to date and complete and that criteria for selection apply to the discipline and meet minimum components defined by CMS and the accreditor. Ensure that privileges comply with the scope of practice laws and are in accordance with medical staff bylaws, rules, and regulations.
• Review contract for telemedicine privileges if using distant-site information.
• Review medical staff bylaws if using distant-site information for telemedicine providers.
• If working in a multihospital system and staff from other entities within the system are floating in:
  • Evaluate whether staff working are wearing the correct name badge for the entity being floated to.
  • Ensure resources shared are properly allocated (i.e., review schedules and verify that their hours are appropriately charged).
  • Evaluate whether floating staff members are oriented to the hospital and departments served.
  • Evaluate if facility-specific job descriptions exist and, if so, that floating staff members have signed the job descriptions for those facilities.
  • Ensure floating staff members are appropriately evaluated.

Source: CMS Compliance Crosswalk

Editor's note: This crosswalk is included with your Accreditation and Quality Compliance Center Platinum membership. To access it, click here.