Notice2025-02918
Medicare and Medicaid Programs; Application From the Accreditation Commission for Health Care Inc. for Continued Approval of Its Home Health Agency Accreditation Program
Primary source
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Published
February 21, 2025
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This notice announces our decision to approve the Accreditation Commission for Health Care Inc. (ACHC) 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
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<title>Federal Register, Volume 90 Issue 34 (Friday, February 21, 2025)</title>
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[Federal Register Volume 90, Number 34 (Friday, February 21, 2025)]
[Notices]
[Pages 10081-10082]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-02918]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3465-FN]
Medicare and Medicaid Programs; Application From the
Accreditation Commission for Health Care Inc. for Continued Approval of
Its Home Health Agency Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), Health and
Human Services (HHS).
ACTION: Notice.
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SUMMARY: This notice announces our decision to approve the
Accreditation Commission for Health Care Inc. (ACHC) 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 February 24,
2025, to February 24, 2031.
FOR FURTHER INFORMATION CONTACT:
Erin Imhoff, (410) 786-2337.
Lillian Williams, (410) 786-8636.
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 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 (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 ACHC'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
On September 17, 2024, we published a proposed notice in the
Federal Register (89 FR 180), announcing ACHC's request for continued
approval of its Medicare HHA 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 ACHC'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 ACHC'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 ACHC's accreditation to our current
Medicare HHA conditions of participation (CoPs).
<bullet> A documentation review of ACHC's survey process to do the
following:
++ Determine the composition of the survey team, surveyor
qualifications, and ACHC's ability to provide continuing surveyor
training.
++ Compare ACHC'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 ACHC's procedures for monitoring HHAs out of compliance
with ACHC's program requirements. The monitoring procedures are used
only when ACHC identifies noncompliance. If noncompliance is identified
through validation reviews, the state survey agency monitors
corrections as specified at Sec. 488.7(d).
++ Assess ACHC's ability to report deficiencies to the surveyed
facilities and respond to the facility's plan of correction in a timely
manner.
++ Establish ACHC'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 ACHC's ability to provide adequate funding for
performing required surveys.
++ Confirm ACHC's policies with respect to whether surveys are
unannounced.
++ Confirm ACHC'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 ACHC'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.
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IV. Analysis of and Responses to Public Comments on the Proposed Notice
In accordance with section 1865(a)(3)(A) of the Act, the September
17, 2024, proposed notice also solicited public comments regarding
whether ACHC's requirements met or exceeded the Medicare CoPs for HHAs.
We received no comments in response to our proposed notice.
V. Provisions of the Final Notice
A. Differences Between ACHC's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared ACHC'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 ACHC's HHA application were
conducted as described in section III. of this notice and have yielded
the one area where, as of the date of this notice, ACHC has completed
revising its standards and certification processes in order to meet the
requirements at Sec. 484.115, to ensure ACHC's standards have a
comparable requirement for adherence to HHA personnel qualifications.
In addition to the standards review, CMS also reviewed ACHC's
comparable survey processes, which were conducted as described in
section III. of this notice, and yielded the one area where, as of the
date of this notice, ACHC has completed revising its survey processes,
in order to demonstrate that it uses survey processes that are
comparable to state survey agency processes by revising ACHC's surveyor
guidance to be comparable with the CMS State Operations Manual,
Appendix Q related to the use Immediate Jeopardy templates.
B. Term of Approval
Based on our review and observations described in section III and
section V of this notice, we approve ACHC as a national AO for HHAs
that request participation in the Medicare program. The decision
announced in this final notice is effective February 24, 2025, through
February 24, 2031 (6 years). In accordance with Sec. 488.5(e)(2)(i),
the term of the approval will not exceed 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 Acting Administrator of the Centers for Medicare & Medicaid
Services (CMS), Stephanie Carlton, 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. 2025-02918 Filed 2-20-25; 8:45 am]
BILLING CODE 4120-01-P
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</html>Indexed from Federal Register on February 21, 2025.
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