Notice2022-21305
Medicare and Medicaid Programs: Application From The Joint Commission (TJC) for Continued Approval of its Psychiatric Hospital Accreditation Program
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
September 30, 2022
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This proposed notice acknowledges the receipt of an application from The Joint Commission for continued recognition as a national accrediting organization for psychiatric hospitals that wish to participate in the Medicare or Medicaid programs.
Full Text
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<title>Federal Register, Volume 87 Issue 189 (Friday, September 30, 2022)</title>
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[Federal Register Volume 87, Number 189 (Friday, September 30, 2022)]
[Notices]
[Pages 59435-59437]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-21305]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3430-PN]
Medicare and Medicaid Programs: Application From The Joint
Commission (TJC) for Continued Approval of its Psychiatric Hospital
Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice with request for comment.
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SUMMARY: This proposed notice acknowledges the receipt of an
application from The Joint Commission for continued recognition as a
national accrediting organization for psychiatric hospitals that wish
to participate in the Medicare or Medicaid programs.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, by October 31, 2022.
[[Page 59436]]
ADDRESSES: In commenting, refer to file code CMS-3430-PN.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to <a href="http://www.regulations.gov">http://www.regulations.gov</a>. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-3430-PN, P.O. Box 8010,
Baltimore, MD 21244-8010.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-3430-PN, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written ONLY to the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Danielle Adams, (410) 786-8818, Donald
Howard, (410) 786-6764, or Lillian Williams, (410) 786-8636.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: <a href="http://www.regulations.gov">http://www.regulations.gov</a>. Follow the search instructions on that website to
view public comments. CMS will not post on <a href="http://Regulations.gov">Regulations.gov</a> public
comments that make threats to individuals or institutions or suggest
that the individual will take actions to harm the individual. CMS
continues to encourage individuals not to submit duplicative comments.
We will post acceptable comments from multiple unique commenters even
if the content is identical or nearly identical to other comments.
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services from a psychiatric hospital provided certain
requirements are met. Section 1861(f) of the of the Social Security Act
(the Act) establishes distinct criteria for facilities seeking
designation as a psychiatric hospital. Regulations concerning provider
agreements are at 42 CFR part 489 and those pertaining to activities
relating to the survey and certification of facilities are at 42 CFR
part 488. The regulations at 42 CFR part 482 subpart E specify the
minimum conditions that a psychiatric hospital must meet to participate
in the Medicare program, the scope of covered services and the
conditions for Medicare payment for psychiatric hospitals.
Generally, to enter into an agreement, a psychiatric hospital must
first be certified by a State Survey Agency as complying with the
conditions or requirements set forth in part 482 subpart E of our
regulations. Thereafter, the psychiatric hospital is subject to regular
surveys by a State Survey Agency to determine whether it continues to
meet these requirements. Section 1865(a)(1) of the Act provides that,
if a provider entity demonstrates through accreditation by an approved
national accrediting organization that all applicable Medicare
conditions are met or exceeded, we will deem those provider entities as
having met the requirements. Accreditation by an accrediting
organization is voluntary and is not required for Medicare
participation.
If an accrediting organization is recognized by the Secretary of
the Department of Health and Human Services (the Secretary) as having
standards for accreditation that meet or exceed Medicare requirements,
any provider entity accredited by the national accrediting body's
approved program may be deemed to meet the Medicare conditions. A
national accrediting organization applying for approval of its
accreditation program under part 488, subpart A, must provide the
Centers for Medicare & Medicaid Services (CMS) with reasonable
assurance that the accrediting organization requires the accredited
provider entities to meet requirements that are at least as stringent
as the Medicare conditions. Our regulations concerning the approval of
accrediting organizations are set forth at Sec. 488.5. The regulations
at Sec. 488.5(e)(2)(i) require accrediting organizations to reapply
for continued approval of its accreditation program every 6 years or
sooner as determined by CMS.
The Joint Commission's current term of approval for their
psychiatric hospital accreditation program expires February 25, 2023.
II. Approval of Deeming Organizations
Section 1865(a)(2) of the Act and our regulations at Sec. 488.5
require that our findings concerning review and approval of a national
accrediting organization's requirements consider, among other factors,
the applying accrediting organization's requirements for accreditation;
survey procedures; resources for conducting required surveys; capacity
to furnish information for use in enforcement activities; monitoring
procedures for provider entities found not in compliance with the
conditions or requirements; and ability to provide us with the
necessary data for validation.
Section 1865(a)(3)(A) of the Act further requires that we publish,
within 60 days of receipt of an organization's complete application, a
notice identifying the national accrediting body making the request,
describing the nature of the request, and providing at least a 30-day
public comment period. We have 210 days from the receipt of a complete
application to publish notice of approval or denial of the application.
The purpose of this proposed notice is to inform the public of The
Joint Commission's request for continued approval of its psychiatric
hospital accreditation program. This notice also solicits public
comment on whether the Joint Commission's requirements meet or exceed
the Medicare conditions of participation (CoPs) for psychiatric
hospitals.
[[Page 59437]]
III. Evaluation of Deeming Authority Request
The Joint Commission submitted all the necessary materials to
enable us to make a determination concerning its request for continued
approval of its psychiatric hospital accreditation program. This
application was determined to be complete on July 30, 2022. Under
section 1865(a)(2) of the Act and our regulations at Sec. 488.5
(Application and re-application procedures for national accrediting
organizations), our review and evaluation of The Joint Commission will
be conducted in accordance with, but not necessarily limited to, the
following factors:
<bullet> The equivalency of The Joint Commission's standards for
psychiatric hospitals as compared with CMS' psychiatric hospital CoPs.
<bullet> The Joint Commission's survey process to determine the
following:
++ The composition of the survey team, surveyor qualifications, and
the ability of the organization to provide continuing surveyor
training.
++ The comparability of the Joint Commission's processes to those
of state agencies, including survey frequency, and the ability to
investigate and respond appropriately to complaints against accredited
facilities.
++ The Joint Commission's processes and procedures for monitoring a
psychiatric hospital found out of compliance with the Joint
Commission's program requirements. These monitoring procedures are used
only when the Joint Commission's identifies noncompliance. If
noncompliance is identified through validation reviews or complaint
surveys, the state survey agency monitors corrections as specified at
Sec. 488.9(c).
++ The Joint Commission's capacity to report deficiencies to the
surveyed facilities and respond to the facility's plan of correction in
a timely manner.
++ The Joint Commission's capacity to provide CMS with electronic
data and reports necessary for effective validation and assessment of
the organization's survey process.
++ The adequacy of the Joint Commission's staff and other
resources, and its financial viability.
++ The Joint Commission's capacity to adequately fund required
surveys.
++ The Joint Commission's policies with respect to whether surveys
are announced or unannounced, to ensure that surveys are unannounced.
++ The Joint Commission's policies and procedures to avoid
conflicts of interest, including the appearance of conflicts of
interest, involving individuals who conduct surveys or participate in
accreditation decisions.
++ The Joint Commission's agreement to provide CMS with a copy of
the most current accreditation survey together with any other
information related to the survey as we may require (including
corrective action plans).
IV. Collection of Information Requirements
This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq).
V. Response to Public Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
In accordance with the provisions of Executive Order 12866, this
regulation was not reviewed by the Office of Management and Budget.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document on September 8, 2022, authorizes Lynette Wilson, who is the
Federal Register Liaison, to electronically sign this document for
purposes of publication in the Federal Register.
Dated: September 27, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2022-21305 Filed 9-28-22; 4:15 pm]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on September 30, 2022.
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