If our hospital is a critical access hospital and held to the Conditions of Participation for surveys, does transitioning to a 3-year reappointment cycle put the hospital at risk? The State Operations Manual (SOM) would suggest a review be conducted every 24 months. Does this pose a risk to a CMS survey at our hospital?

The current Conditions of Participation recommend reappointment every 24 months. Medicare reimbursement could potentially be a consideration. It is also noteworthy that the Conditions of Participation do not require ongoing provider monitoring and focused provider monitoring throughout the term of medical staff membership. Not performing these monitoring activities routinely puts the hospital at risk for issues going undetected for an extended period.