Notice2024-15519
Medicare and Medicaid Programs: Application by DNV Healthcare USA Inc. for Continued CMS Approval of Its Psychiatric 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
July 16, 2024
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice acknowledges the approval of an application from DNV Healthcare USA Inc. for continued CMS approval as a national accrediting organization for its psychiatric hospitals that wish to participate in the Medicare or Medicaid programs.
Full Text
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<title>Federal Register, Volume 89 Issue 136 (Tuesday, July 16, 2024)</title>
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[Federal Register Volume 89, Number 136 (Tuesday, July 16, 2024)]
[Notices]
[Pages 57900-57901]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2024-15519]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3454-FN]
Medicare and Medicaid Programs: Application by DNV Healthcare USA
Inc. for Continued CMS Approval of Its Psychiatric Hospital
Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice acknowledges the approval of an application from
DNV Healthcare USA Inc. for continued CMS approval as a national
accrediting organization for its psychiatric hospitals that wish to
participate in the Medicare or Medicaid programs.
DATES: This notice is applicable on July 30, 2024 through July 30,
2028.
FOR FURTHER INFORMATION CONTACT:
Joann Fitzell (410) 786-4280.
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 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 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 E of CMS 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 CMS 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 CMS 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
CMS 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, CMS 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, CMS must
publish a notice in the Federal Register approving or denying the
application.
III. Provisions of the Proposed Notice
In the February 6, 2024 Federal Register (89 FR 8203), we published
a proposed notice announcing DNV's request for approval of its Medicare
psychiatric 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 DNV's
Medicare psychiatric hospital accreditation application in accordance
with the criteria specified by
[[Page 57901]]
our regulations, which include, but are not limited to the following:
<bullet> An onsite administrative review of DNV'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 DNV'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 DNV's psychiatric hospital
survey process to do the following:
++ Determine the composition of the survey team, surveyor
qualifications, and DNV's ability to provide continuing surveyor
training.
++ Compare DNV'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 DNV's procedures for monitoring psychiatric hospitals
it has found to be out of compliance with DNV's program requirements.
(This pertains only to monitoring procedures when DNV 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 DNV's ability to report deficiencies to the surveyed
hospital and respond to the psychiatric hospital's plan of correction
in a timely manner.
++ Establish DNV'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 DNV's staff and other resources.
++ Confirm DNV's ability to provide adequate funding for performing
required surveys.
++ Confirm DNV's policies with respect to surveys being
unannounced.
++ DNV'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 DNV'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 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 February
6, 2024, proposed notice also solicited public comments regarding
whether DNV's requirements met or exceeded the Medicare CoPs for
psychiatric hospitals. No comments were received in response to our
proposed notice.
IV. Provisions of the Final Notice
A. Differences Between DNV's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared DNV's psychiatric hospital accreditation program
requirements and survey process with the Medicare CoPs at 42 CFR part
482 subpart E, and the survey and certification process requirements of
parts 488 and 489. Our review and evaluation of DNV'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 notice, DNV has completed revising its standards and
certification processes in order to meet the requirements at:
<bullet> Section 482.41(c)(2), to address the requirements
regarding the Health Care Facilities Code waiver allowance.
<bullet> Section 488.5(4)(ii), to address the requirements to
include the requirement for Life Safety Specialist to have training or
experience in the Health Care Facilities Code.
B. Term of Approval
Based on our review and observations described in section III of
this final notice, we have determined that DNV's psychiatric hospital
accreditation program requirements meet or exceed our requirements, and
its survey processes are also comparable. Therefore, we approve DNV as
a national accreditation organization for psychiatric hospitals that
request participation in the Medicare program, effective July 30, 2024
through July 30, 2028.
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 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. 2024-15519 Filed 7-15-24; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on July 16, 2024.
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