Notice2023-10826
Medicare and Medicaid Programs; Application by the Center for Improvement in Healthcare Quality (CIHQ) for Initial CMS Approval of Its Psychiatric Hospital Accreditation Program
Primary source
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Published
May 22, 2023
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice acknowledges the receipt of an application from the Center for Improvement in Healthcare Quality (CIHQ) for initial 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 98 (Monday, May 22, 2023)</title>
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[Federal Register Volume 88, Number 98 (Monday, May 22, 2023)]
[Notices]
[Pages 32772-32774]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-10826]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3443-PN]
Medicare and Medicaid Programs; Application by the Center for
Improvement in Healthcare Quality (CIHQ) for Initial CMS 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 notice acknowledges the receipt of an application from
the Center for Improvement in Healthcare Quality (CIHQ) for initial
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 June 21, 2023.
ADDRESSES: In commenting, refer to file code CMS-3443-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="https://www.regulations.gov">https://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-3443-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-3443-PN, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
[[Page 32773]]
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Donald Howard, (410) 786-6764 or
Lillian Williams, (410) 786-8638.
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="https://www.regulations.gov">https://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 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 subparts A, B, C and 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 subparts A, B, C and E
of our CMS 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 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 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 (AO) applying for approval of its
accreditation program under part 488, subpart A, must provide Centers
for Medicare and 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 Center for Improvement in Healthcare Quality (CIHQ) has
submitted an initial application for CMS-approval of its psychiatric
hospital accreditation program.
II. Approval of Deeming Organization
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
AO's requirements consider, among other factors, the applying AO'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 notice is to inform the public of CIHQ's
initial request for approval of its psychiatric hospital accreditation
program. This notice also solicits public comment on whether CIHQ's
requirements meet or exceed the Medicare conditions of participation
(CoPs) for psychiatric hospitals.
III. Evaluation of Deeming Authority Request
CIHQ submitted all the necessary materials to enable us to make a
determination concerning its request for initial approval of its
hospital accreditation program. This application was determined to be
complete on March 23, 2023. Under section 1865(a)(2) of the Act and our
regulations at Sec. 488.5 (Application and re-application procedures
for national AO), our review and evaluation of CIHQ will be conducted
in accordance with, but not necessarily limited to, the following
factors:
<bullet> The equivalency of CIHQ's standards for hospitals as
compared with CMS' hospital CoPs.
<bullet> CIHQ'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 CIHQ's processes to those of state
agencies, including survey frequency, and the ability to investigate
and respond appropriately to complaints against accredited facilities.
++ CIHQ's processes and procedures for monitoring a hospital found
out of compliance with the CIHQ's program requirements. These
monitoring procedures are used only when CIHQ 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).
++ CIHQ's capacity to report deficiencies to the surveyed
facilities and respond to the facility's plan of correction in a timely
manner.
++ CIHQ'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 CIHQ's staff and other resources, and its
financial viability.
++ CIHQ's capacity to adequately fund required surveys.
++ CIHQ's policies with respect to whether surveys are announced or
unannounced, to assure that surveys are unannounced.
++ 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.
[[Page 32774]]
++ 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. 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 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.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Evell Barco, who is the Federal Register Liaison,
to electronically sign this document for purposes of publication in the
Federal Register.
Dated: May 17, 2023.
Evell J. Barco Holland,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-10826 Filed 5-19-23; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on May 22, 2023.
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