[Federal Register Volume 88, Number 72 (Friday, April 14, 2023)]
[Notices]
[Pages 23088-23089]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-07930]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3438-PN]
Medicare and Medicaid Programs: Application From the
Accreditation Commission for Healthcare (ACHC) for Continued CMS-
Approval of Its Hospital Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services, HHS.
ACTION: Notice with comment.
-----------------------------------------------------------------------
SUMMARY: This notice acknowledges the receipt of an application from
the Accreditation Commission for Healthcare 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, by May 15, 2023.
ADDRESSES: In commenting, please refer to file code CMS-3438-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 https://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-3438-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-3438-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: Danielle Adams, (410) 786-8818; 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: https://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 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 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 Accreditation Commission for Healthcare's (ACHC) current term
of approval for their hospital accreditation program expires September
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
AO's
[[Page 23089]]
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 notice is to inform the public of ACHC's
request for continued approval of its hospital accreditation program.
This notice also solicits public comment on whether ACHC's requirements
meet or exceed the Medicare conditions of participation (CoPs) for
hospitals.
III. Evaluation of Deeming Authority Request
ACHC 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 February 27, 2023. 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 ACHC will be conducted in accordance with, but not
necessarily limited to, the following factors:
The equivalency of ACHC's standards for hospitals as
compared with CMS' hospital CoPs.
ACHC'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 ACHC's processes to those of state
agencies, including survey frequency, and the ability to investigate
and respond appropriately to complaints against accredited facilities.
++ ACHC's processes and procedures for monitoring a hospital found
out of compliance with ACHC's program requirements. These monitoring
procedures are used only when ACHC identifies noncompliance. If
noncompliance is identified through validation reviews or complaint
surveys, the SA monitors corrections as specified at Sec. 488.9.
++ ACHC's capacity to report deficiencies to the surveyed
facilities and respond to the facility's plan of correction in a timely
manner.
++ ACHC'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 ACHC's staff and other resources, and its
financial viability.
++ ACHC's capacity to adequately fund required surveys.
++ ACHC's policies with respect to whether surveys are announced or
unannounced, to assure that surveys are unannounced.
++ ACHC'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.
++ ACHC'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 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.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Evell J. Barco Holland, who is the Federal
Register Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: April 11, 2023.
Evell J. Barco Holland,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-07930 Filed 4-13-23; 8:45 am]
BILLING CODE 4120-01-P