Notice2023-21724
Medicare and Medicaid Programs; Application From the Center for Improvement in Healthcare Quality for Initial CMS Approval of Its Psychiatric Hospital
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
October 2, 2023
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) as a national accrediting organization (AO) 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 189 (Monday, October 2, 2023)</title>
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[Federal Register Volume 88, Number 189 (Monday, October 2, 2023)]
[Notices]
[Pages 67755-67757]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-21724]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3443-FN]
Medicare and Medicaid Programs; Application From the Center for
Improvement in Healthcare Quality for Initial CMS Approval of Its
Psychiatric Hospital
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) as a national accrediting
organization (AO) for psychiatric hospitals that wish to participate in
the Medicare or Medicaid programs.
DATES: The decision announced in this notice is applicable on November
1, 2023 through November 1, 2027.
FOR FURTHER INFORMATION CONTACT: 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
[[Page 67756]]
provided certain requirements established by the Secretary of the
Department of Health and Human Services (the Secretary) are met.
Section 1861(f) of the Social Security Act (the Act) establishes
distinct criteria for facilities seeking designation as a psychiatric
hospital under Medicare. Regulations concerning provider agreements and
supplier approval 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 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 a provider agreement with the Medicare
program, 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 A, B, C, and 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 the
Medicare requirements. There is an alternative, however, 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 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 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 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 AOs are set forth at Sec. 488.5. The regulations at Sec.
488.5(e)(2)(i) require the AO to reapply for continued approval of its
accreditation program every 6 years or sooner as determined by CMS.
II. Application Approval Process
Section 1865(a)(2) of the Act and our regulations at Sec. 488.5
require that our findings concerning review and approval of an 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
that were not in compliance with the conditions or requirements; and
their ability to provide us with the necessary data for validation.
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 May 22, 2023 Federal Register (88 FR 32772), we published a
proposed notice announcing CIHQ's request for approval of its Medicare
psychiatric hospital accreditation program. In the proposed notice, we
detailed our evaluation criteria. In accordance with section 1865(a)(2)
of the Act and regulations at Sec. 488.5, we conducted a review of
CIHQ's Medicare psychiatric hospital accreditation 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 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 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 CIHQ's Medicare psychiatric hospital
accreditation program standards to our current Medicare hospitals
Conditions of Participation (CoPs) and psychiatric hospital special
CoPs.
<bullet> A documentation review of CIHQ's psychiatric hospital
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 re-survey and the ability to investigate
and respond appropriately to complaints against accredited psychiatric
hospitals.
++ Evaluate CIHQ's procedures for monitoring psychiatric hospitals
it has found to be out of compliance with CIHQ's program requirements.
(This pertains only to monitoring procedures when CIHQ 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)(1)).
++ Assess CIHQ's ability to report deficiencies to the surveyed
hospital and respond to the psychiatric hospital's plan of correction
in a timely manner.
++ Establish CIHQ'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 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.
++ As authorized under Sec. 488.8(h), CMS reserves the right to
conduct onsite observations of accrediting organization operations at
any time as part of the ongoing review and continuing oversight of an
AO's performance.
In accordance with section 1865(a)(3)(A) of the Act, the May 22,
2023 proposed notice also solicited public comments regarding whether
CIHQ's requirements met or exceeded the Medicare CoPs for psychiatric
[[Page 67757]]
hospitals. No comments were received in response to the proposed
notice.
IV. 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 psychiatric hospital accreditation program
requirements and survey process with the Medicare CoPs at 42 CFR part
482 subpart A, B, C and E, and the survey and certification process
requirements of parts 488 and 489. Our review and evaluation of CIHQ's
psychiatric hospital application, which were conducted as described in
section III of this final notice, yielded the following areas where, as
of the date of this final notice, CIHQ has revised its standards and
certification processes in order to meet the requirements at Sec.
488.26(b). CIHQ revised its requirements to provide additional guidance
and instruction to surveyors on determining the appropriate level of
citation for Life Safety Code deficiencies.
B. Term of Approval
Based on our review and observations described in section III of
this final notice, we have determined that CIHQ's psychiatric hospital
accreditation program requirements meet or exceed our requirements, and
its survey processes are also comparable. Therefore, we approve CIHQ as
a national AO for psychiatric hospitals that request participation in
the Medicare program, effective November 1, 2023 through November 1,
2027.
V. 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 Chyana Woodyard, who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: September 22, 2023.
Chyana Woodyard,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-21724 Filed 9-29-23; 8:45 am]
BILLING CODE P
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