Notice2023-28831
Medicare and Medicaid Programs; Application from the Community Health Accreditation Program (CHAP) for Continued Approval of Its Home Health Agency 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
January 2, 2024
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice announces our decision to approve the Community Health Accreditation Program (CHAP) for continued recognition as a national accrediting organization for home health agencies (HHAs) that wish to participate in the Medicare or Medicaid programs.
Full Text
<html>
<head>
<title>Federal Register, Volume 89 Issue 1 (Tuesday, January 2, 2024)</title>
</head>
<body><pre>
[Federal Register Volume 89, Number 1 (Tuesday, January 2, 2024)]
[Notices]
[Pages 80-82]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-28831]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3446-FN]
Medicare and Medicaid Programs; Application from the Community
Health Accreditation Program (CHAP) for Continued Approval of Its Home
Health Agency Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), Health and
Human Services (HHS).
[[Page 81]]
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice announces our decision to approve the Community
Health Accreditation Program (CHAP) for continued recognition as a
national accrediting organization for home health agencies (HHAs) that
wish to participate in the Medicare or Medicaid programs.
DATES: The decision announced in this notice is applicable March 31,
2024, to March 31, 2030.
FOR FURTHER INFORMATION CONTACT: Caecilia Andrews, (410) 786-2190.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services from a home health agency (HHA), provided certain
requirements are met. Sections 1861(m) and (o), 1891 and 1895 of the
Social Security Act (the Act) establish distinct criteria for an entity
seeking designation as an HHA. Regulations concerning provider
agreements are at 42 Code of Federal Regulations (CFR) part 489 and
those pertaining to activities relating to the survey and certification
of facilities and other entities are at 42 CFR part 488. The
regulations at 42 CFR parts 409 and 484 specify the conditions that an
HHA must meet to participate in the Medicare program, the scope of
covered services and the conditions for Medicare payment for home
health care.
Generally, to enter into a provider agreement with the Medicare
program, an HHA must first be certified by a state survey agency as
complying with the conditions or requirements set forth in 42 CFR part
484 of our regulations. Thereafter, the HHA 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.
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 (HHS) (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 CHAP's HHA accreditation program for a period of
6 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
In the August 8, 2023 Federal Register (88 FR 53489), we published
a proposed notice announcing CHAP's request for continued approval of
its Medicare HHA accreditation program. In the August 2023 proposed
notice (88 FR 53489), 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 CHAP's Medicare HHA 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 CHAP's--
++ Corporate policies;
++ Financial and human resources available to accomplish the
proposed surveys;
++ Procedures for training, monitoring, and evaluation of its
surveyors;
++ Ability to investigate and respond appropriately to complaints
against accredited facilities; and
++ Survey review and decision-making process for accreditation.
<bullet> A comparison of CHAP's accreditation to our current
Medicare HHA conditions of participation (CoPs).
<bullet> A documentation review of CHAP's survey process to do the
following:
++ Determine the composition of the survey team, surveyor
qualifications, and CHAP's ability to provide continuing surveyor
training.
++ Compare CHAP'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 CHAP's procedures for monitoring HHAs out of compliance
with CHAP's program requirements. The monitoring procedures are used
only when CHAP identifies noncompliance. If noncompliance is identified
through validation reviews, the state survey agency monitors
corrections as specified at Sec. 488.7(d).
++ Assess CHAP's ability to report deficiencies to the surveyed
facilities and respond to the facility's plan of correction in a timely
manner.
++ Establish CHAP'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 CHAP's ability to provide adequate funding for
performing required surveys.
++ Confirm CHAP's policies with respect to whether surveys are
unannounced.
++ Obtain CHAP'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.
++ Review CHAP'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.
IV. Analysis of and Responses to Public Comments on the Proposed Notice
In accordance with section 1865(a)(3)(A) of the Act, the August 8,
2023 proposed notice also solicited public comments regarding whether
CHAP's requirements met or exceeded the Medicare CoPs for HHAs. We
received no comments in response to our proposed notice.
[[Page 82]]
V. Provisions of the Final Notice
A. Differences Between CHAP's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared CHAP's HHA requirements and survey process with the
Medicare CoPs and survey process as outlined in the State Operations
Manual (SOM). Our review and evaluation of CHAP's HHA application were
conducted as described in section III. of this notice and have yielded
the following areas where, as of the date of this notice, CHAP has
completed revising its standards and certification processes to meet
the standard's requirements of all the following regulations:
<bullet> Section 484.50(c)(8), to clarify under Patient Right's
that the HHA must also comply with the requirements of 42 CFR 405.1200
through 405.1204 when providing the patient with written notice, in
advance of a specific service being furnished.
<bullet> Section 484.75(c)(2), to specify that when rehabilitative
therapy services are provided under the supervision of an occupational
therapist or physical therapist, the qualified professional meets the
requirements of Sec. 484.115(f) or (h), respectively.
<bullet> Section 484.75(c)(3), to specify that when medical social
services are provided under the supervision of a social worker, the
requirements of Sec. 484.115(m) are met.
<bullet> Section 484.100(a), to appropriately cross-reference the
Medicare conditions of Sec. Sec. 420.201, 420.202, and 420.206 or
corresponding comparable CHAP standards.
<bullet> Section 484.102(d)(2)(iii), to include the requirement for
HHAs to analyze the HHA's response to and maintain documentation of all
drills, tabletop exercises, and emergency events, and revise the HHA's
emergency plan, as needed.
<bullet> Section 484.105(g), to appropriately cross-reference the
Medicare conditions of Sec. Sec. 485.713, 485.715, 485.719, 485.723,
and 485.727 or corresponding comparable CHAP standards.
In addition to the standards review, CMS also reviewed CHAP'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, CHAP has completed revising its survey
processes, in order to demonstrate that it uses survey processes that
are comparable to state survey agency processes by removing references
to ``blackout dates,'' by allowing facilities to select dates which
suggested the facility would be unavailable for surveys, as CMS expects
all Medicare-participating facilities to be survey ready at all times.
B. Term of Approval
Based on our review and observations described in sections III. and
V. of this notice, we approve CHAP as a national AO for HHAs that
request participation in the Medicare program. The decision announced
in this final notice is effective March 31, 2024, through March 31,
2030 (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 Chyana Woodyard, who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Chyana Woodyard,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-28831 Filed 12-29-23; 8:45 am]
BILLING CODE 4120-01-P
</pre></body>
</html>Indexed from Federal Register on January 2, 2024.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.