CMS Conditions of Participation

Complete per audit schedule.

  • Industry: Healthcare
  • Frequency: Periodic
  • Estimated Time: 4-6 hours
  • Role: Compliance Officer
  • Total Items: 31
  • Compliance: CMS CoP, 42 CFR

Patient Rights

Patient rights compliance.

  • Patient rights posted?
  • Grievance process in place?

QAPI

Quality assurance compliance.

  • QAPI program active?
  • Quality data being collected?

Pre-Assessment Information

Initial assessment documentation and patient/facility identification

  • Assessor Name / Credentials
  • Assessment Date
  • Department / Unit
  • Assessment Type (Routine/Annual/Complaint)
  • Previous assessment findings reviewed?

Infection Prevention & Control

Verify infection control practices per CDC and Joint Commission standards

  • Hand hygiene compliance observed?
  • Appropriate PPE available and properly used?
  • Isolation precautions properly implemented?
  • Sharps containers available and not overfilled?
  • High-touch surfaces properly disinfected?

Patient Safety & Identification

Verify patient safety protocols and identification procedures

  • Two patient identifiers used before procedures?
  • Fall risk assessment completed?
  • Call light within patient reach?
  • Bed in lowest position with brakes locked?

Medication Safety & Management

Verify medication handling and administration practices

  • Medications stored securely and at proper temperature?
  • Controlled substances properly secured and counted?
  • No expired medications in stock?
  • High-alert medications properly labeled?

Environment of Care & Safety

Verify facility environment meets safety standards

  • Fire exits clear and unobstructed?
  • Emergency equipment functional and accessible?
  • Spill kits available and stocked?
  • Electrical cords and outlets in safe condition?

Documentation & Regulatory Compliance

Complete assessment documentation and ensure regulatory compliance

  • All findings documented with evidence?
  • Corrective actions assigned with timeline?
  • Staff education provided on identified issues?
  • Assessor Signature
  • Additional Observations

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Why Use This CMS Conditions of Participation?

This cms conditions of participation helps healthcare teams maintain compliance and operational excellence. Designed for compliance officer professionals, this checklist covers 31 critical inspection points across 8 sections. Recommended frequency: periodic.

Ensures compliance with CMS CoP, 42 CFR. Regulatory-aligned for audit readiness and inspection documentation.

Frequently Asked Questions

What does the CMS Conditions of Participation cover?

This checklist covers 31 inspection items across 8 sections: Patient Rights, QAPI, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management, Environment of Care & Safety, Documentation & Regulatory Compliance. It is designed for healthcare operations and compliance.

How often should this checklist be completed?

This checklist should be completed periodic. Each completion takes approximately 4-6 hours.

Who should use this CMS Conditions of Participation?

This checklist is designed for Compliance Officer professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.

Can I download this checklist as a PDF?

Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.

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