Notice2022-27465
Medicare and Medicaid Programs: Application From the Center for Improvement in Healthcare Quality for Continued Approval of Its 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
December 19, 2022
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice announces our decision to approve the Center for Improvement in Healthcare Quality (CIHQ) for continued recognition as a national accrediting organization for hospitals that wish to participate in the Medicare or Medicaid programs.
Full Text
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<title>Federal Register, Volume 87 Issue 242 (Monday, December 19, 2022)</title>
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[Federal Register Volume 87, Number 242 (Monday, December 19, 2022)]
[Notices]
[Pages 77615-77617]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-27465]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3429-FN]
Medicare and Medicaid Programs: Application From the Center for
Improvement in Healthcare Quality for Continued Approval of Its
Hospital Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice announces our decision to approve the Center for
Improvement in Healthcare Quality (CIHQ) for continued recognition as a
national accrediting organization for hospitals that wish to
participate in the Medicare or Medicaid programs.
DATES: The decision announced in this notice is applicable January 1,
2023 through January 1, 2028.
FOR FURTHER INFORMATION CONTACT:
Erin Imhoff, (410) 786-2337.
Caecilia Blondiaux, (410) 786-2190.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services from a hospital, provided certain requirements are
met. Section 1861(e) of the Social Security Act (the Act) establishes
statutory authority for the Secretary of the Department of Health and
Human Services (Secretary) to set distinct criteria for facilities
seeking designation as a 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 specify the minimum
conditions of participation that a hospital must meet to participate in
the Medicare program.
Generally, to enter into an agreement, a hospital must first be
certified by a state survey agency (SA) as complying with the
conditions or requirements set forth in part 482 of our regulations.
Thereafter, the hospital is subject to regular surveys by a SA 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 a Centers for Medicare & Medicaid
Services (CMS) approved national accrediting organization (AO) that all
applicable Medicare requirements are met or exceeded, we will deem
those provider entities as having met such requirements. Accreditation
by an AO is voluntary and is not required for Medicare participation.
If an AO 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
would be deemed to meet the Medicare requirements. A national AO
applying for approval of its accreditation program under part 488,
subpart A, must provide CMS with reasonable assurance that the AO
requires the accredited provider entities to meet requirements that are
at least as stringent as the Medicare requirements. Our regulations
concerning the approval of AOs are set forth at Sec. Sec. 488.4, 488.5
and 488.5(e)(2)(i). The regulations at Sec. 488.5(e)(2)(i) require AOs
to reapply for continued approval of its accreditation program every 6
years or sooner, as determined by CMS.
[[Page 77616]]
Center for Improvement in Healthcare Quality (CIHQ)'s current term
of approval for their hospital accreditation program expires July 26,
2023. As discussed in the proposed notice (87 FR 43525), CIHQ submitted
its application for renewal earlier than expected and therefore CMS
will adjust their future term of approval accordingly.
II. Application Approval Process
Section 1865(a)(3)(A) of the Act provides a statutory timetable to
ensure that our review of applications for CMS approval of an
accreditation program is conducted in a timely manner. The Act provides
us 210 days after the date of receipt of a complete application, with
any documentation necessary to make the determination to complete our
survey activities and application process. Within 60 days after
receiving a complete application, we must publish a notice in the
Federal Register that identifies the national accrediting body making
the request, describes the request, and provides no less than a 30-day
public comment period. At the end of the 210-day period, we must
publish a notice in the Federal Register approving or denying the
application.
III. Provisions of the Proposed Notice
On July 21, 2022, we published a proposed notice in the Federal
Register (87 FR 43525), announcing CIHQ's request for continued
approval of its Medicare hospital accreditation program. In that
proposed notice, we detailed our evaluation criteria. Under section
1865(a)(2) of the Act and in our regulations at Sec. Sec. 488.5 and
488.8(h), we conducted a review of CIHQ's Medicare hospital
accreditation application in accordance with the criteria specified by
our regulations, which include, but are not limited to the following:
<bullet> An administrative review of CIHQ's: (1) corporate
policies; (2) financial and human resources available to accomplish the
proposed surveys; (3) procedures for training, monitoring, and
evaluation of its CIHQ facility surveyors; (4) ability to investigate
and respond appropriately to complaints against accredited CIHQ
facilities; and (5) survey review and decision-making process for
accreditation.
<bullet> A review of CIHQ's survey processes to confirm that a
provider or supplier, under CIHQ's hospital deeming accreditation
program, meets or exceeds the Medicare program requirements.
<bullet> A documentation review of CIHQ's survey process to do the
following:
++ Determine the composition of the survey team, surveyor
qualifications, and CIHQ's ability to provide continuing surveyor
training.
++ Compare CIHQ's processes to those we require of state survey
agencies, including periodic resurvey and the ability to investigate
and respond appropriately to complaints against CIHQ accredited
hospitals.
++ Evaluate CIHQ's procedures for monitoring accredited hospitals
it has found to be out of compliance with its program requirements.
++ Assess CIHQ's ability to report deficiencies to the surveyed
hospitals and respond to the hospitals plan of correction in a timely
manner.
++ Determine the adequacy of CIHQ's staff and other resources.
++ Confirm CIHQ's ability to provide adequate funding for
performing required surveys.
++ Confirm CIHQ's policies with respect to surveys being
unannounced.
++ Confirm CIHQ'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.
++ Obtain CIHQ'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. Analysis of and Responses to Public Comments on the Proposed Notice
In accordance with section 1865(a)(3)(A) of the Act, the July 21,
2022 proposed notice also solicited public comments regarding whether
CIHQ's requirements met or exceeded the Medicare conditions of
participation for hospitals. We received approximately 19 timely public
comments from hospitals and individuals, and another that was out of
scope of the proposed rule.
Comment: Most commenters expressed support for CIHQ and their
hospital accreditation program and encouraged CMS to approve them for
continued recognition as a national AO for hospitals.
Response: We appreciate the support from those hospitals who have
experience with CIHQ's Medicare hospital accreditation program and
agree that CIHQ should be approved for continued recognition as a
national AO for hospitals that wish to participate in the Medicare or
Medicaid programs.
Comment: A commenter expressed concern about hospital accreditation
programs overall and the responsibility of CMS to oversee the process.
The comment was not specific to CIHQ.
Response: We appreciate this comment and the concern for patient
safety and quality of care. We continue to prioritize patient safety
and our responsibility for oversight of AOs. As described in section
III. Provisions of the Proposed Notice of this notice, CMS takes
various steps when considering whether to approve or not approve a
national AO. Each AO wishing to be recognized by Medicare as a national
AO must go through a rigorous process for CMS approval. We remain
steadfast in our commitment to keeping the public informed of our
evaluation process for AOs seeking approval from CMS.
Comment: A commenter expressed concern for paying out of pocket for
chronic diseases.
Response: We thank the commenter for expressing concern, but this
comment is outside the scope of the notice.
Final Decision: After consideration of the public comments
received, we are finalizing our decision to approve CIHQ's application
for continued recognition as a national AO for hospitals that wish to
participate in the Medicare or Medicaid programs.
V. Provisions of the Final Notice
A. Differences Between CIHQ's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared CIHQ's hospital accreditation requirements and survey
process with the Medicare conditions of participation of part 482, and
the survey and certification process requirements of parts 488 and 489.
Our review and evaluation of CIHQ's renewal application, which were
conducted as described in section III. of this final notice, yielded
the following areas where, as of the date of this notice, CIHQ has
completed revising its standards and certification processes in order
to--
<bullet> Meet the requirements of all of the following Medicare
regulations:
++ Section 482.41(a)(1), to include the appropriate Life Safety
Code (LSC) references that address hospitals classified as new
occupancies.
++ Section 482.41(b)(1)(i), to include the appropriate National
Fire Protection Agency (NFPA) 101 requirements for hospitals classified
as Business Occupancies.
++ Section 482.41(d)(4), to include compliance with the 2008
American Society of Heating, Refrigerating and Air-Conditioning
Engineers (ASHRAE) Standard 170--Ventilation of Health Care Facilities,
in accordance with 2012
[[Page 77617]]
NFPA requirements and to ensure sterile supply and medical equipment
manufacturer instructions for use (IFUs) are considered before
hospitals reduce relative humidity levels.
++ Section 488.5(a)(3), to correct formatting and technical errors
in the crosswalk as requested by CMS.
In addition to the standards review, CMS reviewed CIHQ's comparable
survey processes, which was conducted as described in section III. of
this notice, and also reviewed corporate policies, which yielded the
following areas where, as of the date of this notice, CIHQ has
completed revising its survey processes to demonstrate that it uses
survey processes that are comparable to state survey agency processes
by:
++ Revising Facility & Life Safety worksheets for surveyors to
explain that the worksheet does not include all 2012 LSC & Health Care
Facilities Code requirements in accordance with survey comparability at
Sec. 488.5(a)(4)(ii).
++ Providing additional training to surveyors related to the number
of medical records that should be reviewed during the survey of larger
hospitals in accordance with survey comparability at Sec.
488.5(a)(4)(ii).
++ Improving the level of detail in survey documentation in
accordance with survey comparability at Sec. 488.5(a)(4)(ii).
++ Providing CMS with the job description required for CIHQ's LSC
Consultants in accordance with the description of education and
experience requirements surveyors must meet at Sec. 488.5(a)(7).
++ Revising complaint procedures to ensure the survey investigation
process is clearly documented in accordance with the organizations
complaint procedures at Sec. 488.5(a)(12).
B. Term of Approval
Based on our review and observations described in section III. and
section V. of this notice, we approve CIHQ as a national accreditation
organization for hospitals that request participation in the Medicare
program. The decision announced in this notice is effective January 1,
2023 through January 1, 2028 (5 years). Due to the timing of the start
of the fiscal year and associated travel restrictions, CMS was unable
to conduct a hospital survey observation of CIHQ surveyors in
accordance with 42 CFR 488.8(h), which is one component of the
comparability evaluation. Therefore, we are providing CIHQ with a
reduced term of approval. In accordance with 42 CFR 488.5(e)(2)(i), CMS
may not give a term of the approval that exceeds 6 years.
Based on our discussions with CIHQ and the information provided in
its application, we are confident that CIHQ will continue to ensure
that its deemed hospitals will continue to meet or exceed Medicare
standards. Additionally, CIHQ has applied for critical access hospital
deeming authority and as part of that application we will complete a
survey observation. Critical access hospitals have similar CoPs and
survey process to hospitals and therefore we are confident in a 5-year
approval term for this application.
VI. Collection of Information and Regulatory Impact Statement
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.).
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Lynette Wilson, who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: December 14, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2022-27465 Filed 12-16-22; 8:45 am]
BILLING CODE 4120-01-P
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