[Federal Register Volume 84, Number 33 (Tuesday, February 19, 2019)]
[Notices]
[Pages 4818-4820]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-02673]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3364-FN]


Application From the Joint Commission (TJC) for Continued 
Approval of Its Psychiatric Hospital Accreditation Program

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

ACTION: Final notice.

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SUMMARY: This final notice announces our decision to approve the Joint 
Commission for continued recognition as a national accrediting 
organization for psychiatric hospitals that wish to participate in the 
Medicare or Medicaid programs.

DATES: The approval announced in this final notice is effective 
February 25, 2019 through February 25, 2023.

FOR FURTHER INFORMATION CONTACT: Mary Ellen Palowitch (410) 786-4496, 
Monda Shaver (410) 786-3410, Tara Lemons (410) 786-3030.

SUPPLEMENTARY INFORMATION: 

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services from 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. 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 subparts A, B, C and 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 an agreement, 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 A, B, C and E 
of our regulations. Thereafter, the psychiatric 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 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 accrediting organization is 
voluntary and is not required for Medicare participation.
    If an accrediting organization is recognized by the Secretary of 
the Department of Health and Human Services 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 accrediting 
organization applying for approval of its accreditation program under 
part 488, subpart A, must provide the Centers for Medicare & Medicaid 
Services (CMS) 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.  488.5. The regulations at Sec.  488.5(e)(2)(i) 
require accrediting organizations to reapply for continued approval of 
its accreditation program every 6 years or sooner as determined by CMS.
    The Joint Commission's current term of approval for their 
psychiatric hospital accreditation program expires February 25, 2019.

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 August 15, 2018, we published a proposed notice in the Federal 
Register (83 FR 40514), announcing the Joint Commission's (TJC's) 
request for continued approval of its Medicare psychiatric hospital 
accreditation

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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 TJC's Medicare psychiatric hospital 
accreditation renewal application in accordance with the criteria 
specified by our regulations, which include, but are not limited to the 
following:
     An onsite administrative review of TJC'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.
     A comparison of TJC's Medicare hospital accreditation 
program standards to our current Medicare hospital Conditions of 
Participation (CoPs) and psychiatric hospital special conditions.
     A documentation review of TJC's psychiatric hospital's 
survey process to:
    ++ Determine the composition of the survey team, surveyor 
qualifications, and TJC's ability to provide continuing surveyor 
training.
    ++ Compare TJC's processes to those CMS require of state survey 
agencies, including periodic resurvey and the ability to investigate 
and respond appropriately to complaints against accredited psychiatric 
hospitals.
    ++ Evaluate TJC's procedures for monitoring psychiatric hospitals 
it has found to be out of compliance with TJC's program requirements. 
(This pertains only to monitoring procedures when TJC 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)).
    ++ Assess TJC's ability to report deficiencies to the surveyed 
hospital and respond to the psychiatric hospital's plan of correction 
in a timely manner.
    ++ Establish TJC'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 TJC's staff and other resources.
    ++ Confirm TJC's ability to provide adequate funding for performing 
required surveys.
    ++ Confirm TJC's policies with respect to surveys being 
unannounced.
    ++ Obtain 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.
    In accordance with section 1865(a)(3)(A) of the Act, the August 15, 
2018 proposed notice also solicited public comments regarding whether 
TJC's requirements met or exceeded the Medicare CoPs for psychiatric 
hospitals. We received no comments in response to our proposed notice.

IV. Provisions of the Final Notice

A. Differences Between TJC's Standards and Requirements for 
Accreditation and Medicare Conditions and Survey Requirements

    We compared TJC's psychiatric hospital accreditation program 
requirements and survey process with the Medicare CoPs at part 482 and 
the survey and certification process requirements of parts 488 and 489. 
Our review and evaluation of TJC'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, TJC 
has revised its standards and certification processes in order to meet 
the requirements at:
     Section 482.12(a)(10), to address that consultation will 
occur directly with the individual assigned the responsibility for the 
organization and conduct of the hospital's medical staff, or his/her 
designee and the timeframe for which direct consultation must occur.
     Section 482.41(b)(3), to provide information related to 
our rule stating that Life Safety Code provisions do not apply in a 
State where CMS finds that a fire and safety code imposed by State law 
adequately protects patients in hospitals.
     Section 482.41(b)(5), to address cooperation with local 
firefighting authorities.
     Section 482.41(b)(7), to address installing alcohol-based 
hand rub dispensers in a manner that adequately protects against 
inappropriate access.
     Section 482.41(e), to address the omission of a standard 
to correspond to references and documents in this CMS requirement.
     Section 482.42(b)(1), to address and clarify that ``make 
certain'' is defined as ``must.''
     Section 482.42(b)(2), to address and clarify that ``make 
certain'' is defined as ``must.''
     Section 482.43(b)(2), to address who may develop or 
supervise the development of the discharge evaluation.
     Section 482.43(c)(1), to address who must develop or 
supervise the development of a discharge plan if the discharge planning 
evaluation indicates a need for a discharge plan.
     Section 482.51(a)(3), to address that a qualified 
registered nurse is immediately available to respond to emergencies.
     Section 482.51(b)(3), to address and include the required 
equipment that must be available to the operating room suites.
     Section Sec.  488.5(a)(4)(i), to ensure that all surveys 
are unannounced.
     Section Sec.  488.5(a)(4)(ii), to ensure that its 
surveyors are provided clear instruction for assessing only the 
applicable CoPs for the psychiatric hospital accreditation program.
     Section 488.5(a)(4)(iv), to ensure that TJC psychiatric 
hospital surveyors document findings of noncompliance with 
accreditation standards at the comparable Medicare CoP; and to ensure 
that all findings of observed noncompliance noted on surveyor 
worksheets are clearly and accurately reflected in the final survey 
deficiency report.
     Section 488.5(a)(4)(v), to ensure that a minimum sample of 
patient records are reviewed for all elements required by the 
regulations.
     Sections 488.5(a)(11)(ii), to ensure that data submitted 
to CMS is timely, complete and accurate.
     Section 488.5(a)(12), to ensure that TJC has a clearly 
defined complaint investigation process that is comparable to CMS; to 
ensure that the process for protecting complainant anonymity does not 
impede the required complaint investigation; to ensure that complaints 
are investigated, based on the submitted allegations, irrespective of 
receiving a ``waiver of anonymity'' from the complainant; to ensure 
that complaints are reviewed and investigated within the comparable 
timelines established by CMS; and to ensure that all complaints that 
would result in condition-level non-compliance, based on allegations 
described therein, are required to be investigated through an onsite 
survey.
     Section 488.5(a)(19)(ii), to ensure that TJC proposed 
survey process and crosswalked standards will not be implemented 
without prior written notice of approval from CMS.
     Section 488.26, to ensure TJC's survey process meets or 
exceeds the Medicare program requirements; and to ensure that surveyors 
assess all required facility locations and services during the survey 
process.
     Section 489.13, to ensure that the granting of 
accreditation and recommendations to CMS for Medicare participation 
occurs only after the

[[Page 4820]]

facility has demonstrated full compliance with all requirements.

B. Term of Approval

    Based on our review and observations described in section III of 
this final notice, we approve TJC as a national accreditation 
organization for psychiatric hospitals that request participation in 
the Medicare program, effective February 25, 2019 through February 25, 
2023.
    To verify TJC's continued compliance with the provisions of this 
final notice, CMS expects to conduct a follow-up corporate on-site 
visit and survey observation within 18 months of the publication date 
of this notice.

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.).

    Dated: February 7, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2019-02673 Filed 2-15-19; 8:45 am]
 BILLING CODE 4120-01-P