Think the New CMS OB Rules Don't Apply to You? Think Again.

Why Phase I CoPs Affect Every Hospital with an Emergency Department

As we reviewed in our May 7th notice, the Centers for Medicare and Medicaid Services (CMS) introduced new Conditions of Participation (CoPs) for obstetrical (OB) services within the CY 2025 Hospital Outpatient Prospective Payment System (OPPS) Final Rule. The first wave of these critical requirements, Phase I, went into effect on July 1, 2025.

With surveyors now assessing compliance, it is crucial for all Hospitals and Critical Access Hospitals (CAHs) to ensure their policies, procedures, and training are fully aligned with these new standards. Let’s break down the two key components of Phase I.

1. Emergency Services’ Readiness (42 CFR §§482.55 and 485.618)

A common misconception is that these new OB-related CoPs only apply to facilities with dedicated labor and delivery units. However, the Phase I requirements for emergency services readiness are much broader.

These new rules apply to ALL hospitals and CAHs that offer emergency services, regardless of whether they provide specialty OB services.

If your facility has an emergency department, you must meet the following standards:

• Evidence-Based Protocols: You must have established protocols for handling the emergency needs of all patients, and these protocols must align with nationally recognized and evidence-based guidelines.

• Annual Staff Training & Competency: All applicable staff must be trained annually on these emergency protocols. Furthermore, your facility must maintain documentation proving that staff have not only completed the training but can also demonstrate their knowledge and competence on these topics.

• Emergency Provisions (Hospitals Only): Hospitals must ensure they have adequate provisions for treating emergency cases. This includes:

  • Drugs, blood, blood products, and biologicals commonly used in lifesaving procedures.

  • Equipment and supplies necessary for these procedures.

  • A functional call-in system for each patient within every emergency services’ treatment area.

Note: These specific emergency supply requirements do not apply to Critical Access Hospitals (CAHs) and Rural Emergency Hospitals (REHs), as similar requirements are already included in their existing CoPs.

2. Enhanced Transfer Protocols (42 CFR §482.43)

Phase I also strengthens requirements for patient transfers to ensure continuity of care.

These updated transfer protocol requirements are effective for hospitals only, as CAHs already have similar CoPs in place.

Under the new rule, hospitals are required to:

• Develop Written Policies: Maintain comprehensive written policies and procedures for transferring patients to the appropriate level of care. A key clarification in this rule is that this includes intra-hospital transfers, such as moving a patient from the emergency department to an inpatient unit, between different inpatient units in the same hospital, or between units at different hospital campuses.

• Provide Annual Training: Relevant staff must receive training on these transfer policies and procedures on an annual basis.

How WrightCare Consulting Can Help You Achieve Compliance

Meeting these new CMS requirements demands more than just a quick policy update. It requires a thorough review of your current processes, implementation of evidence-based protocols, and a robust system for tracking annual training and competency.

WrightCare Consulting is here to help you navigate these changes with confidence. We have developed a suite of compliance tools and resources specifically designed to address the Phase I CoPs, including example policies and procedures for:

• Emergency Services Readiness

• Scope of Service - Emergency Department

• Emergency Department Staff Orientation

• Education and Training Documentation

• Intra-Hospital and External Transfer Protocols

  
  

For a more comprehensive solution, our Emergency Department Policy and Procedure Manual, Human Resources Manual, and Administrative Manual for Critical Access Hospitals have been updated to reflect these latest regulatory changes.

Don't wait for a survey finding to address these mandatory changes.

Contact WrightCare Consulting today for an assessment of your readiness and to learn how our tools can help you ensure full compliance with the new CMS Obstetrical Services CoPs.