[Federal Register Volume 85, Number 32 (Tuesday, February 18, 2020)]
[Notices]
[Pages 8874-8875]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-03082]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3391-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.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on March 19, 2020.

ADDRESSES: In commenting, please refer to file code CMS-3391-PN. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    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 http://www.regulations.gov. 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-3391-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-3391-PN, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Caecilia Blondiaux, (410) 786-2190.

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: http://www.regulations.gov. Follow the search instructions on 
that website to view public comments.

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 (SA) as complying with the 
conditions or requirements set forth in part 482 of our regulations. 
Thereafter, the hospital is subject to regular surveys by a SA to 
determine whether it continues to meet these requirements. There is an 
alternative; however, to surveys by SAs.
    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, 488.5 and 
488.5(e)(2)(i). The regulations at

[[Page 8875]]

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 current term of approval for their hospital 
accreditation program expires July 15, 2020.

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 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 18, 2019. Under section 
1865(a)(2) of the Act and our regulations at Sec.  488.5 (Application 
and re-application procedures for national 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 SA monitors 
corrections as specified at Sec.  488.9.
    ++ 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 CMS 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 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.
    ++ 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).

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 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.

    Dated: February 6, 2020.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2020-03082 Filed 2-14-20; 8:45 am]
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