cms hospital definition

A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. (Critical Access Hospitals are certified under separate standards. Psychiatric Hospitals are subject to additional regulations beyond basic hospital conditions of participation.) Inpatient Rehabilitation Facilities and Long-Term Care Hospitals are included in the Hospital definition.

accrediting organization(s)

The Joint Commission Logo

part 482 — Condition of Participation for hospitals, Page: 170 (64028)

16. Add §482.15 to subpart B to read as follows:

§482.15 Condition of Participation: Emergency Preparedness

The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the elements below:


(a) The hospital must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. The plan must do the following:

  • (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
  • (2) Include strategies for addressing emergency events identified by the risk assessment.
  • (3) Address patient population, including, but not limited to, persons at-risk; the type of services the hospital has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
  • (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the hospital’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.