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1. [1] 42 CFR 482.12(e), Condition of Participation: governing body, contracted services (eCFR, text as of October 1, 2026)"The hospital must maintain a list of all contracted services, including the scope and nature of the services provided"
2. [2] CMS, State Operations Manual Appendix A (Rev. 248, September 2026)tags A-0083 to A-0085, every contracted service evaluated in the quality program; surveyors obtain the list of contracted services at the entrance conference
3. [3] 42 CFR 482.21, quality assessment and performance improvement (eCFR, October 1, 2026)involves all departments and services, including those furnished under contract
4. [4] 42 CFR 485.635(c)(3) (eCFR, October 1, 2026)a critical access hospital keeps a list of all services furnished under arrangements or agreements
5. [5] 42 CFR 416.41(a) (eCFR, October 1, 2026)an ambulatory surgical center assures that contracted services are provided in a safe and effective manner
6. [6] 45 CFR 164.502(e) (eCFR, October 1, 2026)disclosure to a business associate documented through a written contract
7. [7] US Department of Health and Human Services, Office for Civil Rights, business associates guidance (reviewed July 30, 2026)device-servicing technician as a business associate, janitorial service needing no agreement
8. [8] 42 CFR 1003.200(b)(4) and 1003.210(a)(4) (eCFR, October 1, 2026)civil money penalty of up to $20,000 per item or service for contracting with an excluded party, before inflation adjustment
9. [9] HHS Office of Inspector General, Updated Special Advisory Bulletin on the Effect of Exclusion (May 2013)screening employees and contractors against the LEIE each month
10. [10] 42 CFR 1001.952(j), group purchasing organization safe harbor (eCFR, October 1, 2026)a written agreement with a fee of 3 percent or less of the purchase price or a stated amount, and yearly written disclosure
11. [11] US Government Accountability Office, GAO-15-13 (October 2014)the five largest GPOs mostly awarded 3-year contracts in 2012 and collected about $2.3 billion of vendor administrative fees
12. [12] US Government Accountability Office, GAO-10-738 (August 2010)GPO customers can also buy services such as housekeeping through GPO-negotiated contracts
13. [13] Burns and Yovovich, the Wharton School, for the AHA and AHRMM, Hospital Supply Chain Executives' Perspectives on Group Purchasing: Results from a 2014 National Survey (September 2014)1,210 executives; national GPO mediating 50% or more of purchases, commodity items 86%, purchased services 25%
14. [14] HFMA, sponsored by Kaufman Hall (October 2024)purchased services often bought locally or by individual departments, on vendor paper, with automatic renewal clauses
15. [15] Kaufman Hall, National Hospital Flash Report, July 2026 metrics (September 15, 2026)median operating margin 1.4% year to date including allocations; purchased service expense per calendar day +6% year over year
16. [16] Centers for Medicare & Medicaid Services, FY 2027 IPPS final rule (Federal Register, August 4, 2026, effective October 1, 2026)applicable percentage increase of 2.3 percent
17. [17] US Bureau of Labor Statistics, producer price index for Medicare patients' inpatient care at general medical and surgical hospitals (WPU5121010111)110.8 in January 2020, 132.627 in August 2026 (preliminary)
18. [18] US Bureau of Labor Statistics, producer price index for general medical and surgical hospitals (PCU622110622110)207.3 in January 2020, 254.951 in August 2026 (preliminary)
19. [19] US Bureau of Labor Statistics, producer price indexes for five services, January 2020 to August 2026janitorial services (PCU561720561720), nonresidential building maintenance and repair (PCU2381MR2381MR), security guards and patrol (PCU561612561612), solid waste collection (PCU562111562111) and commercial machinery repair (PCU811310811310)
20. [20] US Bureau of Labor Statistics, consumer price indexes, January 2020 and August 2026all items for all urban consumers (CUUR0000SA0) and food away from home (CUUR0000SEFV)
21. [21] American Hospital Association, Fast Facts on U.S. Hospitals, 2026 (2024 survey data)6,100 hospitals, 5,121 community hospitals, 3,567 in a system, 1,797 rural, 913 state and local government
22. [22] Flex Monitoring Team, critical access hospital list, July 20261,388 critical access hospitals
23. [23] MedPAC, Report to the Congress, March 2026, chapter 116,436 Medicare-certified ambulatory surgical centers in 2024
24. [24] Association of American Medical Colleges, institutional membership400+ academic health systems and teaching hospitals
25. [25] University of Illinois System, Board of Trustees approval thresholds and schedulenon-professional services of $1,000,000 or more in one fiscal year; the Board meets every other month
26. [26] University of California, BFB-BUS-43 (interim, January 26, 2026)competitive bidding of purchases of $100,000 or more a year, medical centers included
27. [27] 2 CFR 200.320, procurement methods under federal awards (eCFR, October 1, 2026)purchases charged to federal grants follow these methods, with formal methods above the simplified acquisition threshold
28. [28] Revised Code of Washington 70.44.140public hospital district purchases above $75,000 by contract after sealed proposals
29. [29] Texas Health and Safety Code section 282.045hospital districts follow the County Purchasing Act
30. [30] Texas Local Government Code sections 262.022 and 262.023 (as amended September 1, 2025)"item" includes any service; competitive procedures above $100,000
31. [31] US District Court for the Northern District of Illinois, In re Stericycle, Inc., Steri-Safe Contract Litigation, No. 13-cv-5795, memorandum opinion and order (October 26, 2017)the $295 million settlement of the small practices' class action over automated price increases in medical-waste contracts, given final approval on March 8, 2018
32. [32] County of San Bernardino Board of Supervisors (November 5, 2019)Arrowhead Regional Medical Center linen RFP released July 12, 2018, four proposals, contract from December 1, 2019
33. [33] Arrowhead Regional Medical Center, linen rental and laundry agreement (2019)$0.520 per clean delivered pound; lost and damaged items at replacement value
34. [34] County of Los Angeles, Department of Health Services laundry agreement (November 15, 2016)$0.414 to $0.85 per clean pound by region; HLAC accreditation required
35. [35] County of San Bernardino Board of Supervisors (June 8, 2021)Arrowhead Regional Medical Center's waste agreements based on its Vizient GPO agreement
36. [36] University Health (Bexar County Hospital District) Board of Managers, December 15, 2020 minutesenvironmental services RFP posted June 10, 2020
37. [37] University Health Board of Managers, January 27, 2026 minutessix proposals on August 18, 2025; award January 27, 2026; a 60 to 90 day transition proposed
38. [38] County of San Mateo Board of Supervisors, file 22-070 (January 25, 2022)San Mateo Medical Center linen agreement extended to an 85-month term
39. [39] County of Monterey Board of Supervisors, file A 24-114 (March 26, 2024)Natividad Medical Center linen agreement extended through June 30, 2025 by amendment No. 9
40. [40] Alameda Health System Board of Trustees, contracts report (November 2019)linen agreement extended two months to complete the RFP
41. [41] Hawaii Office of the Auditor, Report No. 08-08 (April 2008)an elevator maintenance contract renewed automatically in five-year increments since 1986
42. [42] Premier, The Top 5 Areas of Purchased Services Spend (September 22, 2021)about 75 percent of Premier member acute care hospitals self-operate food service