Notice2025-00448
Medicare and Medicaid Programs: Application From The Joint Commission for Continued Approval of its Hospice 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 13, 2025
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This proposed notice acknowledges the receipt of an application from The Joint Commission for continued recognition as a national accrediting organization for hospices that wish to participate in the Medicare or Medicaid programs.
Full Text
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<title>Federal Register, Volume 90 Issue 7 (Monday, January 13, 2025)</title>
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[Federal Register Volume 90, Number 7 (Monday, January 13, 2025)]
[Notices]
[Pages 2706-2707]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-00448]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3469-PN]
Medicare and Medicaid Programs: Application From The Joint
Commission for Continued Approval of its Hospice Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice with request for comment.
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SUMMARY: This proposed notice acknowledges the receipt of an
application from The Joint Commission for continued recognition as a
national accrediting organization for hospices 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, no later than 5 p.m. on February 12,
2025.
ADDRESSES: In commenting, refer to file code CMS-3469-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="http://www.regulations.gov">http://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-3469-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-3469-PN, Mail Stop C4-26-05, 7500
Security Boulevard, Baltimore, MD 21244-1850.
FOR FURTHER INFORMATION CONTACT: Lillian Williams, (410) 786-8636 or
Melissa Rice, (410) 786-3270.
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="http://www.regulations.gov">http://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 commenter will take actions to harm an 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 in a hospice, provided that certain requirements are
met by the hospice. Section 1861(dd) of the Social Security Act (the
Act) establishes distinct criteria for facilities seeking designation
as a hospice. 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 418 specify the conditions that a hospice must meet in
order to participate in the Medicare program, the scope of covered
services and the conditions for Medicare payment for hospice services.
Generally, to enter into an agreement, a hospice must first be
certified by a state survey agency (SA) as complying with the
conditions or requirements set forth in part 418. Thereafter, the
hospice is subject to regular surveys by a SA to determine whether it
continues to meet these requirements.
However, 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 conditions are met or exceeded, we will
deem those provider entities 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 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 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. Sec. 488.4 and 488.5. The
regulations at Sec. 488.5(e)(2)(i) require AOs to reapply for
continued approval of its accreditation program every 6 years or sooner
as determined by CMS.
The Joint Commission's (TJC's) current term of approval for their
hospice accreditation program expires June 18, 2025.
II. Approval of Deeming Organizations
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 CMS 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 proposed notice is to inform the public of
TJC's request for continued approval of its hospice accreditation
program. This notice also solicits public comment on whether TJC's
requirements meet or exceed the Medicare conditions of participation
(CoPs) for hospices.
III. Evaluation of Deeming Authority Request
TJC submitted all the necessary materials to enable us to make a
determination concerning its request for continued approval of its
hospice accreditation program. This application
[[Page 2707]]
was determined to be complete on November 20, 2024. Under section
1865(a)(2) of the Act and our regulations at Sec. 488.5 (Application
and re-application procedures for national AOs), our review and
evaluation of TJC will be conducted in accordance with, but not
necessarily limited to, the following factors:
<bullet> The equivalency of TJC's standards for hospices as
compared with CMS' hospice CoPs.
<bullet> TJC'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 TJC's processes to those of state agencies,
including survey frequency, and the ability to investigate and respond
appropriately to complaints against accredited facilities.
++ TJC's processes and procedures for monitoring hospices which are
found out of compliance with TJC's program requirements. These
monitoring procedures are used only when TJC identifies noncompliance.
If noncompliance is identified through validation reviews or complaint
surveys, the SA monitors corrections as specified at Sec. 488.9.
++ TJC's capacity to report deficiencies to the surveyed facilities
and respond to the facility's plan of correction in a timely manner.
++ TJC'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 TJC's staff and other resources, and its
financial viability.
++ TJC's capacity to adequately fund required surveys.
++ TJC's policies with respect to whether surveys are announced or
unannounced, to ensure that surveys are unannounced.
++ TJC'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.
++ 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. 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 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. 2025-00448 Filed 1-10-25; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on January 13, 2025.
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