[Federal Register Volume 88, Number 38 (Monday, February 27, 2023)]
[Notices]
[Pages 12363-12365]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-03925]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3430-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: Notice.

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SUMMARY: This 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: This notice is effective February 25, 2023 through February 25, 
2029.

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

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, 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 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 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 (AO) 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 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 
may be deemed to meet the Medicare conditions. A national AO applying 
for approval of its accreditation program under part 488, subpart A, 
must provide Centers for Medicare & Medicaid Services (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 AO are 
set forth at Sec.  488.5. The regulations at Sec.  488.5(e)(2)(i) 
require AO 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. 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 
no more than 210 days after the date of receipt of a complete 
application, including any documentation necessary to make the 
determination, for CMS to complete its application review 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

[[Page 12364]]

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

    In the September 30, 2022 Federal Register (87 FR 59435), we 
published a proposed notice announcing The Joint Commission (TJC) 
request for continued approval of its Medicare psychiatric hospital 
accreditation program. In the September 30, 2022 notice, we detailed 
our evaluation criteria. Under the authority of Section 1865(a)(2) of 
the Act and 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.
     The comparison of TJC's Medicare psychiatric hospital 
accreditation program standards to our current Medicare hospitals 
Conditions of Participation (CoPs) and psychiatric hospital special 
conditions.
     A documentation review of TJC's psychiatric hospital 
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 we 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.
    ++ Confirm TJC'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.
    ++ 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.

IV. Analysis of and Responses to Public Comments on the Proposed Notice

    In accordance with section 1865(a)(3)(A) of the Act, the September 
30, 2022 proposed notice also solicited public comments regarding 
whether TJC's requirements met or exceeded the Medicare CoPs for 
psychiatric hospitals. We received one comment in response to the 
proposed notice.
    Comment: A commenter expressed concern about TJC's ability to 
protect disabled patients in facilities that engage in misconduct and 
that do not follow best practices.
    Response: We appreciate this comment and the commenter's concern 
for patient safety. We continue to prioritize patient safety and our 
responsibility for oversight of AOs. As described in Section III of 
this notice, CMS takes various steps when considering to approve or not 
approve a national AO. Each national AO wishing to be recognized by 
Medicare as a national AO must go through a rigorous process to obtain 
CMS approval. We remain steadfast in our commitment to keeping the 
public informed of our evaluation process for national AO seeking CMS 
approval.

V. Provisions of the Notice

A. Differences Between TJC's Standards and Requirements for 
Accreditation and Medicare Conditions of Participation (CoPs) and 
Survey Process Requirements

    We compared TJC's psychiatric hospital accreditation program 
requirements and survey process with the Medicare CoPs at Part 482 
subpart E, 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 notice, yielded the following areas where, as of the date of 
this notice, TJC has completed revising its survey processes in order 
to demonstrate that it uses survey processes that are comparable to 
state survey agency processes by:
     Providing additional training to ensure that TJC 
psychiatric hospital surveyors document findings of noncompliance 
consistent with the regulatory requirement in Section Sec.  488.5 
(a)(4)(iv).
     Providing additional training to surveyors to ensure any 
actions taken by the facility to address the deficiencies include 
specific information in the corrective measures, as provided by Sec.  
488.5 (a)(4)(vii), and are consistent with the plan of correction 
requirements as described in the State Operations Manual (SOM), Chapter 
2, Section 2728B.
     Revising TJC's intake/triage process for all complaint 
requirements to ensure comparability with CMS requirements, Sec.  
488.5(a)(12), and consistent with the SOM, Chapter 5, Section 5075.2.
     Revising TJC's complaint policy regarding offsite 
investigations and maximum timeframes to investigate complaints as 
described in SOM, Chapter 5, Sections 5075.5 and 5075.9.

B. Term of Approval

    Based on our review and observations described in section III. and 
V. of this notice, we approve TJC as a national AO for psychiatric 
hospitals that request participation in the Medicare program. The 
decision announced in this notice is effective February 25, 2023 
through February 25, 2029. In accordance with Sec.  488.5(e)(2)(i), the 
term of the approval will not exceed 6 years.

VI. 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.).
    The Administrator of the Centers for Medicare & Medicaid Services 
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this 
document, authorizes Lynette Wilson, who is the Federal Register 
Liaison, to electronically sign this document for purposes of 
publication in the Federal Register.


[[Page 12365]]


    Dated: February 21, 2023.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-03925 Filed 2-24-23; 8:45 am]
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