[Federal Register Volume 76, Number 38 (Friday, February 25, 2011)]
[Notices]
[Pages 10598-10600]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-4294]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2326-FN]


Medicare and Medicaid Programs; Approval of the Joint Commission 
for Deeming Authority for Psychiatric Hospitals

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final notice.

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SUMMARY: This notice announces our decision to approve the Joint 
Commission for recognition as a national accreditation program for 
psychiatric hospitals seeking to participate in the Medicare or 
Medicaid programs. This initial 4-year approval is effective February 
25, 2011, through February 25, 2015.

DATES: Effective Date: This final notice is effective February 25, 
2011.

FOR FURTHER INFORMATION CONTACT: L. Tyler Whitaker, (410) 786-5236; 
Patricia Chmielewski, (410) 786-6899.

SUPPLEMENTARY INFORMATION:

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services in a psychiatric hospital provided certain 
requirements are met. Section 1861(f) of the Social Security Act (the 
Act) establishes distinct criteria for facilities seeking designation 
as a psychiatric hospital. The regulations at 42 CFR part 482, subpart 
E specify, among other things, the conditions that a psychiatric 
hospital must meet to participate in the Medicare program. Regulations 
concerning provider agreements are located at 42 CFR part 489 and those 
pertaining to survey and certification of facilities are at 42 CFR part 
488.
    Generally, in order to enter into a provider agreement, a 
psychiatric hospital must first be certified by a State survey agency 
as complying with the conditions or requirements set forth in section 
1861(f) of the Act, and 42 CFR part 482, including the special 
provisions applying to psychiatric hospitals in subpart E of our 
regulations. Thereafter, the psychiatric hospital is subject to ongoing 
review by a State survey agency to determine whether it continues to 
meet the Medicare requirements. However, there is an alternative to 
State compliance surveys. Accreditation 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 
accreditation organization (AO) that all applicable Medicare conditions 
are met or exceeded, we may ``deem'' that provider entity as having met 
the requirements. Accreditation by an AO is

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voluntary and is not required for Medicare participation. A national AO 
applying for deeming authority 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 conditions.

II. Deeming Application Approval Process

    Section 1865(a)(3)(A) of the Act provides a statutory timetable to 
ensure that our review of applications for deeming authority is 
conducted in a timely manner. The statute provides 210 calendar days 
after the date of receipt of a complete application, with any 
documentation necessary to make a 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 accreditation 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 and Response to Comments

    In the October 22, 2010 Federal Register (75 FR 65360), we 
published a proposed notice announcing the Joint Commission's request 
for approval as a deeming organization for psychiatric hospitals. In 
that notice, we detailed our evaluation criteria. Under section 
1865(a)(2) of the Act and Sec.  488.4 (Application and reapplication 
procedures for accreditation organizations), we conducted a review of 
the Joint Commission's application in accordance with the criteria 
specified by our regulations, which include, but are not limited to, 
the following:
     An onsite administrative review of the Joint Commission'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.
     A comparison of the Joint Commission's psychiatric 
hospital accreditation standards to our current Medicare psychiatric 
hospital conditions of participation (CoPs).
     A documentation review of the Joint Commission's survey 
processes to:
    + Determine the composition of the survey team, surveyor 
qualifications, and the Joint Commission's ability to provide 
continuing surveyor training.
    + Compare the Joint Commission'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 the Joint Commission's procedures for monitoring 
psychiatric hospitals determined to be out of compliance with the Joint 
Commission's program requirements. The monitoring procedures are used 
only when the Joint Commission identifies noncompliance. If 
noncompliance is identified through validation reviews, the State 
survey agency monitors corrections as specified at Sec.  488.7(d).
    + Assess the Joint Commission's ability to report deficiencies to 
the surveyed facilities and respond to the facility's plan of 
correction in a timely manner.
    + Establish the Joint Commission's ability to provide us with 
electronic data and reports necessary for effective validation and 
assessment of the Joint Commission's survey process.
    + Determine the adequacy of staff and other resources.
    + Review the Joint Commission's ability to provide adequate funding 
for performing required surveys.
    + Confirm the Joint Commission's policies with respect to whether 
surveys are announced or unannounced.
    + Obtain the Joint Commission'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.
    In accordance with section 1865(a)(3)(A) of the Act, the October 
22, 2010 proposed notice also solicited public comments regarding 
whether the Joint Commission's requirements met or exceeded the 
Medicare CoPs for psychiatric hospitals. We received 4 comments in 
response to our proposed notice.
    All of the commenters expressed strong support for the Joint 
Commission's application for psychiatric hospital deeming authority. 
The commenters stated that the Joint Commission's standards are clearly 
written and closely align with the Medicare CoPs, and that the Joint 
Commission's accreditation program provides psychiatric hospitals with 
a viable alternative to other healthcare accreditation organizations.

IV. Provisions of the Final Notice

A. Differences Between the Joint Commission's Standards and 
Requirements for Accreditation and Medicare's Conditions and Survey 
Requirements

    We compared the Joint Commission's psychiatric hospital 
accreditation requirements and survey process with the Medicare CoPs 
and survey process as outlined in the State Operations Manual (SOM). 
Our review and evaluation of the Joint Commission's deeming 
application, which were conducted as described in section III. of this 
final notice, yielded the following:
     To meet the requirements at Appendix AA of the SOM, the 
Joint Commission revised its policies to ensure surveyors draw a 
representative number of patients from each distinct program area for 
observation and interview based on the size of that program.
     To meet the requirements at Sec.  482.13(e), the Joint 
Commission revised its crosswalk to address the requirement that all 
patients have the right to be free from physical or mental and corporal 
punishment.
     To meet the requirements at Sec.  482.24(b)(2), the Joint 
Commission revised its standards to address the requirement that the 
medical record system must allow for timely retrieval of patient 
information by diagnosis and procedure.
     To meet the requirements at Sec.  482.26(b)(1), the Joint 
Commission revised its crosswalk to ensure the hospital maintains 
proper safety precautions against radiation hazards.
     To meet the requirements at Sec.  482.41(a), the Joint 
Commission modified its standards to prevent hospitals from conducting 
back-to-back emergency preparedness response drills.
     To meet the requirements at Sec.  482.41(a)(1), the Joint 
Commission revised its standards to include all of the essential 
electrical system specific requirements, per National Fire Protection 
Association (NFPA) 99:1999: 12-3.3 and corresponding Chapter 3 
requirements.
     To meet the requirements at Sec.  482.41(b)(1)(i), the 
Joint Commission revised its standards to address the availability of 
the fire safety plan, and ensure that all required fire safety elements 
are addressed. In addition, the Joint Commission revised its standards 
to require quarterly testing of tamper and water flow devices, and 
ensure no gaps exist around penetrations.
     To meet the requirements at Sec.  482.41(b)(9)(i) through 
(iii) and Sec.  482.41(b)(9)(v), the Joint Commission

[[Page 10600]]

revised its Web site to ensure it includes all of the alcohol-based 
hand rub dispenser requirements.
     To meet the requirements at Sec.  482.45(b)(3), the Joint 
Commission revised its standards to address the hospital's 
responsibility to provide organ transplant data directly to the 
Department of Health and Human Services when requested by the 
Secretary.
     To meet the requirements at Sec.  482.56, the Joint 
Commission revised its crosswalk to ensure that if the hospital 
provides rehabilitation, physical therapy, occupational therapy, 
audiology, or speech pathology services, the services are organized and 
staffed to ensure the health and safety of patients.
     To meet the requirements at Sec.  482.61(a)(3), the Joint 
Commission revised its standards to ensure psychiatric hospitals 
clearly document the reason for admission as stated by the patient and/
or others significantly involved in the patient's care.
     To meet the requirements at Sec.  482.61(a)(5), the Joint 
Commission revised its standards to address the requirement that, when 
indicated, a complete neurological examination be recorded at the time 
of the admission physical examination.
     To meet the requirements at Sec.  482.61(c)(1)(ii), the 
Joint Commission revised its standards to include both short-term and 
long-range patient goals.
     To meet the requirements at Sec.  482.61(c)(1)(iv), the 
Joint Commission revised its standards to ensure the patient's 
treatment plan includes the responsibilities of each member of the 
treatment team.
     To meet the requirements at Sec.  482.62, the Joint 
Commission revised its crosswalk to address the psychiatric hospital's 
responsibility to formulate written, individualized, comprehensive 
treatment plans, provide active treatment measures, and engage in 
discharge planning.
     To meet the requirements at Sec.  482.62(f), the Joint 
Commission revised its standard to ensure that the hospital has a 
director of social services who monitors and evaluates the quality and 
appropriateness of social services furnished.
     The Joint Commission revised its psychiatric hospital 
survey procedures to ensure all applicable hospital CoPs at 42 CFR part 
482 are adequately evaluated for compliance.

B. Term of Approval

    Based on the review and observations described in section III. of 
this final notice, we have determined that the Joint Commission's 
requirements for psychiatric hospitals meet or exceed our requirements. 
Therefore, we approve the Joint Commission as a national accreditation 
organization for psychiatric hospitals that request participation in 
the Medicare program effective February 25, 2011 through February 25, 
2015.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

VI. Regulatory Impact Statement

    In accordance with the provisions of Executive Order 12866, this 
regulation was not reviewed by the Office of Management and Budget.

    Authority:  Section 1865 of the Social Security Act (42 U.S.C. 
1395bb).

(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: February 18, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2011-4294 Filed 2-24-11; 8:45 am]
BILLING CODE 4120-01-P