Compliance with the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) is a critical requirement for all freestanding psychiatric hospitals. In addition to maintaining compliance with Joint Commission standards, ongoing compliance with the CMS CoPs is necessary to ensure safe and high quality patient care, as well as Medicare and Medicaid reimbursement.

In order to meet our clients’ needs for consultation and technical assistance related to CMS compliance, we offer the following services:

  • Training on CMS CoPs and Interpretive Guidelines
  • Consultation on integrating CMS and TJC requirements
  • Mock CMS surveys
  • Technical assistance with response to CMS surveys
  • Building ongoing CMS compliance


In 2011, The Joint Commission (TJC) received deemed status with CMS for freestanding psychiatric hospitals. This means that psychiatric hospitals that are TJC accredited are deemed to have met the CMS CoPs for such hospitals. This includes both the A Tags (which apply to all types of hospitals) and the B Tags (which are the Special CoPs for psychiatric hospitals.)

Since that time, it has become increasingly important for psychiatric hospitals to fully understand the CMS CoPs and Interpretive Guidelines. The TJC Hospital standards incorporate the CMS CoPs but the CoPs and Interpretive Guidelines are often more detailed and prescriptive than the accompanying TJC standards. Thus, it’s critical that our psychiatric hospital clients have a full understanding of both sets of standards and how they should be implemented on an operational level.

In addition, the findings in your TJC hospital survey reports are now cross-walked to the CMS CoPs. If a standard is found to be out of compliance with a CoP at the Condition level (as opposed to merely at the Standard level), it can result in your hospital receiving: 1) Contingent Accreditation; 2) a follow-up survey; and 3) a potentially lengthy corrective action process.

Also, surveys conducted by state Health Departments on behalf of CMS can be particularly challenging for psychiatric hospitals. Frequently, this type of survey starts as a Complaint Survey and then leads to a full survey of all of the CMS CoPs including the A Tags (applicable to all hospitals) and the B Tags (for psychiatric hospitals.) In this situation, full compliance with the detailed CMS CoPs becomes even more critical.

Our resident CMS expert is our senior associate, Ms. Collen Sawyer, RN, MS, who is a current CMS surveyor. She specializes in providing consultation to psychiatric hospitals on how to integrate CMS and TJC requirements. She routinely gets rave reviews from our psychiatric hospital clients on helping them navigate the complicated landscape of TJC and CMS compliance.


We can help you maintain compliance with the CMS CoPs.