[Federal Register Volume 87, Number 189 (Friday, September 30, 2022)]
[Notices]
[Pages 59435-59437]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-21305]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3430-PN]


Medicare and Medicaid Programs: Application From The Joint 
Commission (TJC) for Continued Approval of its Psychiatric Hospital 
Accreditation Program

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

ACTION: Notice with request for comment.

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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 psychiatric 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, by October 31, 2022.

[[Page 59436]]


ADDRESSES: In commenting, refer to file code CMS-3430-PN.
    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-3430-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-3430-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 ONLY 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) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Danielle Adams, (410) 786-8818, Donald 
Howard, (410) 786-6764, or Lillian Williams, (410) 786-8636.

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. CMS will not post on Regulations.gov public 
comments that make threats to individuals or institutions or suggest 
that the individual will take actions to harm the individual. CMS 
continues to encourage individuals not to submit duplicative comments. 
We will post acceptable comments from multiple unique commenters even 
if the content is identical or nearly identical to other comments.

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 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 subpart 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 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. 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 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 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, 2023.

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 
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 psychiatric 
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 psychiatric 
hospitals.

[[Page 59437]]

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 psychiatric hospital accreditation program. This 
application was determined to be complete on July 30, 2022. 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 
psychiatric hospitals as compared with CMS' psychiatric 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 
psychiatric hospital found out of compliance with the Joint 
Commission's program requirements. These monitoring procedures are used 
only when the Joint Commission's identifies noncompliance. If 
noncompliance is identified through validation reviews or complaint 
surveys, the state survey agency monitors corrections as specified at 
Sec.  488.9(c).
    ++ 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 ensure 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.
    In accordance with the provisions of Executive Order 12866, this 
regulation was not reviewed by the Office of Management and Budget.
    The Administrator of the Centers for Medicare & Medicaid Services 
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this 
document on September 8, 2022, authorizes Lynette Wilson, who is the 
Federal Register Liaison, to electronically sign this document for 
purposes of publication in the Federal Register.

    Dated: September 27, 2022.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2022-21305 Filed 9-28-22; 4:15 pm]
BILLING CODE 4120-01-P