[Federal Register Volume 88, Number 98 (Monday, May 22, 2023)]
[Notices]
[Pages 32772-32774]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-10826]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3443-PN]


Medicare and Medicaid Programs; Application by the Center for 
Improvement in Healthcare Quality (CIHQ) for Initial CMS 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 notice acknowledges the receipt of an application from 
the Center for Improvement in Healthcare Quality (CIHQ) for initial 
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 June 21, 2023.

ADDRESSES: In commenting, refer to file code CMS-3443-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-3443-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-3443-PN, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

[[Page 32773]]

    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Donald Howard, (410) 786-6764 or 
Lillian Williams, (410) 786-8638.

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 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 subparts A, B, C and E 
of our CMS 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 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 (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 (AO) applying for approval of its 
accreditation program under part 488, subpart A, must provide Centers 
for Medicare and 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 Center for Improvement in Healthcare Quality (CIHQ) has 
submitted an initial application for CMS-approval of its psychiatric 
hospital accreditation program.

II. Approval of Deeming Organization

    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 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 notice is to inform the public of CIHQ's 
initial request for approval of its psychiatric hospital accreditation 
program. This notice also solicits public comment on whether CIHQ's 
requirements meet or exceed the Medicare conditions of participation 
(CoPs) for psychiatric hospitals.

III. Evaluation of Deeming Authority Request

    CIHQ submitted all the necessary materials to enable us to make a 
determination concerning its request for initial approval of its 
hospital accreditation program. This application was determined to be 
complete on March 23, 2023. Under section 1865(a)(2) of the Act and our 
regulations at Sec.  488.5 (Application and re-application procedures 
for national AO), our review and evaluation of CIHQ will be conducted 
in accordance with, but not necessarily limited to, the following 
factors:
     The equivalency of CIHQ's standards for hospitals as 
compared with CMS' hospital CoPs.
     CIHQ'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 CIHQ's processes to those of state 
agencies, including survey frequency, and the ability to investigate 
and respond appropriately to complaints against accredited facilities.
    ++ CIHQ's processes and procedures for monitoring a hospital found 
out of compliance with the CIHQ's program requirements. These 
monitoring procedures are used only when CIHQ 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).
    ++ CIHQ's capacity to report deficiencies to the surveyed 
facilities and respond to the facility's plan of correction in a timely 
manner.
    ++ CIHQ'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 CIHQ's staff and other resources, and its 
financial viability.
    ++ CIHQ's capacity to adequately fund required surveys.
    ++ CIHQ's policies with respect to whether surveys are announced or 
unannounced, to assure that surveys are unannounced.
    ++ CIHQ'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.

[[Page 32774]]

    ++ CIHQ'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 Barco, who is the Federal Register Liaison, 
to electronically sign this document for purposes of publication in the 
Federal Register.

    Dated: May 17, 2023.
Evell J. Barco Holland,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-10826 Filed 5-19-23; 8:45 am]
BILLING CODE 4120-01-P