[Federal Register Volume 79, Number 19 (Wednesday, January 29, 2014)]
[Notices]
[Pages 4727-4728]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-01639]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3290-PN]


Medicare and Medicaid Programs: Application From the Joint 
Commission for Continued Approval of Its Hospital Accreditation Program

AGENCY: Centers for Medicare and Medicaid Services, HHS.

ACTION: Proposed notice.

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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 hospitals that wish to 
participate in the Medicare or Medicaid programs. Section 1865(b)(3)(A) 
of the Social Security Act (the Act) requires that within 60 days of 
receipt of an organization's complete application, CMS publish a notice 
that identifies the national accrediting body making the request, 
describes the nature of the request, and provides at least a 30-day 
public comment period.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on February 28, 
2014.

ADDRESSES: In commenting, please refer to file code CMS-3290-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to http://www.regulations.gov. Follow the 
``Submit a comment'' instructions.
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address ONLY:
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Attention: CMS-3290-PN, P.O. Box 8016, 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-3290-PN, Mail Stop C4-26-05, 7500 
Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments to the following addresses:
    a. For delivery in Washington, DC--
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, Room 445-G, Hubert H. Humphrey Building, 200 
Independence Avenue SW., Washington, DC 20201
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--
    Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments erroneously mailed to the addresses indicated as 
appropriate for hand or courier delivery may be delayed and received 
after the comment period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Monda Shaver, (410) 786-3410, Cindy 
Melanson, (410) 786-0310, or Patricia Chmielewski, (410) 786-6899.

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 Web site as soon as possible after they have been 
received: http://www.regulations.gov. Follow the search instructions on 
that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services from a hospital provided certain requirements are met. 
Sections 1861(e) of the Social Security Act (the Act), establish 
distinct criteria for facilities seeking designation as a hospital. 
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 
482 specify the minimum conditions that a hospital must meet to 
participate in the Medicare program.
    Generally, to enter into an agreement, a hospital must first be 
certified by a state survey agency as complying with

[[Page 4728]]

the conditions or requirements set forth in part 482 of our 
regulations. Thereafter, the hospital is subject to regular surveys by 
a state survey agency to determine whether it continues to meet these 
requirements. There is an alternative, however, to surveys by state 
agencies.
    Section 1865(a)(1) of the Act provides that, if a provider entity 
demonstrates through accreditation by an approved national accrediting 
organization that all applicable Medicare conditions are met or 
exceeded, we will deem those provider entities as having met the 
requirements. Accreditation by an accrediting organization is voluntary 
and is not required for Medicare participation.
    If an accrediting organization 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 would be deemed to meet the 
Medicare conditions. A national accrediting organization applying for 
approval of its accreditation program under part 488, subpart A, must 
provide us with reasonable assurance that the accrediting organization 
requires the accredited provider entities to meet requirements that are 
at least as stringent as the Medicare conditions. Our regulations 
concerning the approval of accrediting organizations are set forth at 
Sec. Sec.  488.4 and 488.8(d)(3). The regulations at Sec.  488.8(d)(3) 
require accrediting organizations to reapply for continued approval of 
its accreditation program every 6 years or sooner as determined by us.
    The Joint Commission's current term of approval for their hospital 
accreditation program expires July 15, 2014.

II. Approval of Deeming Organizations

    Section 1865(a)(2) of the Act and our regulations at Sec.  488.8(a) 
require that our findings concerning review and approval of a national 
accrediting organization's requirements consider, among other factors, 
the applying accrediting organization'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 us 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 the 
Joint Commission's request for continued approval of its hospital 
accreditation program. This notice also solicits public comment on 
whether the Joint Commission's requirements meet or exceed the Medicare 
conditions of participation (CoPs) for hospitals.

III. Evaluation of Deeming Authority Request

    The Joint Commission submitted all the necessary materials to 
enable us to make a determination concerning its request for continued 
approval of its hospital accreditation program. This application was 
determined to be complete on December 17, 2013. Under section 
1865(a)(2) of the Act and our regulations at Sec.  488.8 (Federal 
review of accrediting organizations), our review and evaluation of the 
Joint Commission will be conducted in accordance with, but not 
necessarily limited to, the following factors:
     The equivalency of the Joint Commission's standards for 
hospitals as compared with CMS' hospital CoPs.
     The Joint Commission'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 the Joint Commission's processes to those 
of state agencies, including survey frequency, and the ability to 
investigate and respond appropriately to complaints against accredited 
facilities.
    ++ The Joint Commission's processes and procedures for monitoring a 
hospital found out of compliance with the Joint Commission's program 
requirements. These monitoring procedures are used only when the Joint 
Commission identifies noncompliance. If noncompliance is identified 
through validation reviews or complaint surveys, the state survey 
agency monitors corrections as specified at Sec.  488.7(d).
    ++ The Joint Commission's capacity to report deficiencies to the 
surveyed facilities and respond to the facility's plan of correction in 
a timely manner.
    ++ The Joint Commission's capacity to provide us with electronic 
data and reports necessary for effective validation and assessment of 
the organization's survey process.
    ++ The adequacy of the Joint Commission's staff and other 
resources, and its financial viability.
    ++ The Joint Commission's capacity to adequately fund required 
surveys.
    ++ The Joint Commission's policies with respect to whether surveys 
are announced or unannounced, to assure that surveys are unannounced.
    ++ The Joint Commission's agreement to provide us 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 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).

V. Response to Public 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.
    Upon completion of our evaluation, including evaluation of comments 
received as a result of this notice, we will publish a final notice in 
the Federal Register announcing the result of our evaluation.

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

    Dated: January 15, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2014-01639 Filed 1-28-14; 8:45 am]
BILLING CODE 4120-01-P