Notice2023-03925
Application From the Joint Commission (TJC) for Continued Approval of its Psychiatric Hospital Accreditation Program
Primary source
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Published
February 27, 2023
Effective
February 25, 2023
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice announces our decision to approve 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 88 Issue 38 (Monday, February 27, 2023)</title>
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[Federal Register Volume 88, Number 38 (Monday, February 27, 2023)]
[Notices]
[Pages 12363-12365]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-03925]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3430-FN]
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.
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SUMMARY: This notice announces our decision to approve 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: This notice is effective February 25, 2023 through February 25,
2029.
FOR FURTHER INFORMATION CONTACT: Danielle Adams (410) 786-8818, Donald
Howard (410) 786-6764 or Lillian Williams (410) 786-8636.
SUPPLEMENTARY INFORMATION:
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 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 a provider 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 (AO) that all applicable Medicare conditions are met or
exceeded, we may treat the provider entity as having met those
conditions; that is, we may ``deem'' the provider entity as having met
the 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
may be deemed to meet the Medicare conditions. A national AO applying
for approval of its accreditation program under part 488, subpart A,
must provide Centers for Medicare & Medicaid Services (CMS) with
reasonable assurance that the AO requires the accredited provider
entities to meet requirements that are at least as stringent as the
Medicare conditions. Our regulations concerning the approval of AO are
set forth at Sec. 488.5. The regulations at Sec. 488.5(e)(2)(i)
require AO 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. 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
no more than 210 days after the date of receipt of a complete
application, including any documentation necessary to make the
determination, for CMS to complete its application review 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
[[Page 12364]]
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
In the September 30, 2022 Federal Register (87 FR 59435), we
published a proposed notice announcing The Joint Commission (TJC)
request for continued approval of its Medicare psychiatric hospital
accreditation program. In the September 30, 2022 notice, we detailed
our evaluation criteria. Under the authority of Section 1865(a)(2) of
the Act and our regulations at Sec. 488.5, we conducted a review of
TJC's Medicare psychiatric hospital accreditation renewal application
in accordance with the criteria specified by our regulations, which
include, but are not limited to, the following:
<bullet> An onsite administrative review of TJC's: (1) Corporate
policies; (2) financial and human resources available to accomplish the
proposed surveys; (3) procedures for training, monitoring, and
evaluation of its psychiatric hospital surveyors; (4) ability to
investigate and respond appropriately to complaints against accredited
psychiatric hospitals; and (5) survey review and decision-making
process for accreditation.
<bullet> The comparison of TJC's Medicare psychiatric hospital
accreditation program standards to our current Medicare hospitals
Conditions of Participation (CoPs) and psychiatric hospital special
conditions.
<bullet> A documentation review of TJC's psychiatric hospital
survey process to:
++ Determine the composition of the survey team, surveyor
qualifications, and TJC's ability to provide continuing surveyor
training.
++ Compare TJC's processes to those we require of state survey
agencies, including periodic resurvey and the ability to investigate
and respond appropriately to complaints against accredited psychiatric
hospitals.
++ Evaluate TJC's procedures for monitoring psychiatric hospitals
it has found to be out of compliance with TJC's program requirements.
(This pertains only to monitoring procedures when TJC identifies non-
compliance. If noncompliance is identified by a state survey agency
through a validation survey, the state survey agency monitors
corrections as specified at Sec. 488.9(c)).
++ Assess TJC's ability to report deficiencies to the surveyed
hospital and respond to the psychiatric hospital's plan of correction
in a timely manner.
++ Establish TJC's ability to provide CMS with electronic data and
reports necessary for effective validation and assessment of the
organization's survey process.
++ Determine the adequacy of TJC's staff and other resources.
++ Confirm TJC's ability to provide adequate funding for performing
required surveys.
++ Confirm TJC's policies with respect to surveys being
unannounced.
++ Confirm TJC'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 TJC'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 September
30, 2022 proposed notice also solicited public comments regarding
whether TJC's requirements met or exceeded the Medicare CoPs for
psychiatric hospitals. We received one comment in response to the
proposed notice.
Comment: A commenter expressed concern about TJC's ability to
protect disabled patients in facilities that engage in misconduct and
that do not follow best practices.
Response: We appreciate this comment and the commenter's concern
for patient safety. We continue to prioritize patient safety and our
responsibility for oversight of AOs. As described in Section III of
this notice, CMS takes various steps when considering to approve or not
approve a national AO. Each national AO wishing to be recognized by
Medicare as a national AO must go through a rigorous process to obtain
CMS approval. We remain steadfast in our commitment to keeping the
public informed of our evaluation process for national AO seeking CMS
approval.
V. Provisions of the Notice
A. Differences Between TJC's Standards and Requirements for
Accreditation and Medicare Conditions of Participation (CoPs) and
Survey Process Requirements
We compared TJC's psychiatric hospital accreditation program
requirements and survey process with the Medicare CoPs at Part 482
subpart E, and the survey and certification process requirements of
Parts 488 and 489. Our review and evaluation of TJC's psychiatric
hospital application, which were conducted as described in section III
of this notice, yielded the following areas where, as of the date of
this notice, TJC has completed revising its survey processes in order
to demonstrate that it uses survey processes that are comparable to
state survey agency processes by:
<bullet> Providing additional training to ensure that TJC
psychiatric hospital surveyors document findings of noncompliance
consistent with the regulatory requirement in Section Sec. 488.5
(a)(4)(iv).
<bullet> Providing additional training to surveyors to ensure any
actions taken by the facility to address the deficiencies include
specific information in the corrective measures, as provided by Sec.
488.5 (a)(4)(vii), and are consistent with the plan of correction
requirements as described in the State Operations Manual (SOM), Chapter
2, Section 2728B.
<bullet> Revising TJC's intake/triage process for all complaint
requirements to ensure comparability with CMS requirements, Sec.
488.5(a)(12), and consistent with the SOM, Chapter 5, Section 5075.2.
<bullet> Revising TJC's complaint policy regarding offsite
investigations and maximum timeframes to investigate complaints as
described in SOM, Chapter 5, Sections 5075.5 and 5075.9.
B. Term of Approval
Based on our review and observations described in section III. and
V. of this notice, we approve TJC as a national AO for psychiatric
hospitals that request participation in the Medicare program. The
decision announced in this notice is effective February 25, 2023
through February 25, 2029. In accordance with Sec. 488.5(e)(2)(i), the
term of the approval will not exceed 6 years.
VI. 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.).
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.
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Dated: February 21, 2023.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-03925 Filed 2-24-23; 8:45 am]
BILLING CODE P
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