Notice2023-17745
Medicare and Medicaid Programs: Application From the Joint Commission for Continued CMS Approval of Its Critical Access 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
August 18, 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 critical access hospitals that wish to participate in the Medicare or Medicaid programs.
Full Text
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<title>Federal Register, Volume 88 Issue 159 (Friday, August 18, 2023)</title>
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[Federal Register Volume 88, Number 159 (Friday, August 18, 2023)]
[Notices]
[Pages 56631-56633]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-17745]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3440-FN]
Medicare and Medicaid Programs: Application From the Joint
Commission for Continued CMS Approval of Its Critical Access Hospital
Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
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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 critical access hospitals that wish to participate in
the Medicare or Medicaid programs.
DATES: The decision announced in this notice is applicable November 21,
2023 to November 21, 2027.
FOR FURTHER INFORMATION CONTACT: Caecilia Blondiaux, (410) 786-2190.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services in a critical access hospital (CAH), provided that the
facility meets certain requirements. Sections 1820(c)(2)(B), 1820(e)
and 1861(mm)(1) of the Social Security Act (the Act) establish distinct
criteria for facilities seeking designation as a CAH. 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. Our regulations at 42 CFR part 485,
subpart F specify the conditions of participation (CoPs) that a CAH
must meet to participate in the Medicare program, the scope of covered
services, and the conditions for Medicare payment for CAHs. The
regulations at 42 CFR 485.647 specify that a CAH's psychiatric or
rehabilitation distinct part unit (DPU), if any, must meet the hospital
requirements specified in subparts A, B, C, and D of part 482 in order
for the CAH DPU to participate in the Medicare program.
Prior to becoming a CAH, to enter into an agreement, a CAH must
first be certified by a state survey agency as a hospital complying
with the conditions of participation at 42 CFR part 482. It then can
convert to a CAH by complying with the conditions or requirements at
part 485, subpart F. Thereafter, the CAH is subject to regular surveys
by a state survey agency to determine whether it continues to meet
these requirements. However, there is an alternative to surveys by
state agencies. Certification by a nationally recognized accreditation
program can substitute for ongoing state review.
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 42 CFR 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 at Sec. Sec.
488.4 and 488.5. The regulations at Sec. 488.5(e)(2)(i) require an AO
to reapply for continued approval of its accreditation program every 6
years or sooner, as determined by CMS. This notice is to announce our
continued approval of TJC's CAH accreditation program for a period of 4
years.
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 March 3, 2023, we published a proposed notice in the Federal
Register (88 FR 13446), announcing TJC's request for continued approval
of its Medicare critical hospital accreditation program. In the
proposed notice, we detailed our evaluation criteria. Under section
1865(a)(2) of the Act and in our regulations at Sec. 488.5, we
conducted a review of TJC's Medicare CAH 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 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
surveyors; (4) ability to investigate and respond appropriately to
complaints against accredited facilities; and (5) survey review and
decision-making process for accreditation.
<bullet> A comparison of TJC's accreditation to our current
Medicare CAH CoPs.
<bullet> A documentation review of TJC's 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 of state survey agencies,
including survey frequency, and the ability to investigate and respond
appropriately to complaints against accredited facilities.
++ Evaluate TJC's procedures for monitoring CAHs out of compliance
with TJC's program requirements. The monitoring procedures are used
only when TJC identifies noncompliance. If noncompliance is identified
through validation reviews, the state survey agency monitors
corrections as specified at Sec. 488.7(d).
++ Assess TJC's ability to report deficiencies to the surveyed
facilities and respond to the facility'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 staff and other resources.
++ Confirm TJC's ability to provide adequate funding for performing
required surveys.
++ Confirm TJC's policies with respect to whether surveys are
unannounced.
++ 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 March 3,
2023 proposed notice also solicited public comments regarding whether
TJC's requirements met or exceeded the Medicare CoPs for CAHs. We
received two comments in response to our proposed notice.
One commenter expressed concerns related to oversight of hospitals
and the healthcare industry as a whole, and in particular, beliefs of
corruption within
[[Page 56633]]
the system and concerns related to the COVID-19 public health emergency
response. Another commenter stated the commenter would like Medicare to
cover acupuncturists in CAHs and other facilities.
While we appreciate the commenters' concerns, these comments are
outside of the scope of this notice. We remain committed to improving
the quality and safety of patients in all healthcare settings and
providing oversight of all AOs.
V. Provisions of the Final Notice
A. Differences Between TJC's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared TJC's CAH requirements and survey process with the
Medicare CoPs and survey process as outlined in the State Operations
Manual (SOM). Our review and evaluation of TJC's CAH application were
conducted as described in section III of this notice and yielded the
following areas where, as of the date of this notice, TJC's has
completed revising its standards and certification processes in order
to:
<bullet> Meet the standard's requirements for all of the following
regulations:
++ Section 485.604(a)(2), to clarify the requirements for education
including a master's or doctoral level degree in a defined clinical
area of nursing from an accredited educational institution.
++ Section 485.616(c)(4)(iv), to specify the requirement of an
internal review of the distant-site physician's or practitioner's
performance of the privileges at the CAH whose patients are receiving
the telemedicine services.
++ Section 485.623(b)(1), to specify that all essential mechanical,
electrical and patient care equipment is maintained in safe operating
condition.
++ Section 485.635(b)(3), to include reference to State law within
the standard for radiology services.
In addition to the standards review, CMS also reviewed TJC's
comparable survey processes, which were conducted as described in
section III of this notice, and 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> Revising TJC's surveyor guide to ensure a comprehensive
review of environmental safety and life safety requirements are
performed.
<bullet> Revising TJC's surveyor guide and survey processes to
ensure compliance with the Medicare-conditions are assessed at each
provider-based location where care is provided per CAH Appendix W of
the SOM.
<bullet> Providing training and education to surveyors related to
the use of open-ended questions during staff interviews to elicit
information, consistent with chapter 2, section 2714 of the SOM.
<bullet> Revising the survey instructions and providing education
to surveyors to conduct patient interviews. In accordance with CAH
Appendix W-Task 3--Information Gathering/Investigation of the SOM,
surveyors must observe the actual provision of care and services to
patients and conduct patient interviews throughout the course of the
survey.
<bullet> Review and assess TJC's surveyor time and resource
allocations of the number of surveyors on site consistent with Sec.
488.5(a)(5), Sec. 488.5(a)(6) and Sec. 488.5(a)(9) to ensure
sufficient time is allotted to conduct all required survey activities.
<bullet> Provide additional training and education to surveyors on
procedures related to investigation of ``immediate jeopardy''
situations in accordance with appendix Q-section VI of the SOM.
<bullet> Review and revise TJC's complaint investigation process,
specifically to ensure the complainant (when not anonymous), receives
an acknowledgement letter and closure letter, as outlined within
chapter 5, sections 5010.2 and 5080.1 of the SOM.
<bullet> Review TJC's elements of performance and survey deficiency
findings to ensure any deficiencies are appropriately correlated or
matched with a Medicare condition, when appropriate, in accordance with
Sec. 488.5(a)(4)(ii).
B. Term of Approval
Based on our review and observations described in section III and
section V of this notice, we approve TJC as a national AO for CAHs that
request participation in the Medicare program. The decision announced
in this final notice is effective November 21, 2023 through November
21, 2027 (4 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 Vanessa Garcia who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Vanessa Garcia,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-17745 Filed 8-17-23; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on August 18, 2023.
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