80 FR 9466 - Medicare and Medicaid Program; Continued Approval of the Joint Commission's Psychiatric Hospital Accreditation Program
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Federal Register Volume 80, Issue 35 (February 23, 2015)
Centers for Medicare & Medicaid Services
Federal Register Volume 80, Issue 35 (February 23, 2015)
| Page Range | 9466-9468 | |
| FR Document | 2015-03559 |
[Federal Register Volume 80, Number 35 (Monday, February 23, 2015)] [Notices] [Pages 9466-9468] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2015-03559] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3304-FN] Medicare and Medicaid Program; Continued Approval of the Joint Commission's Psychiatric Hospital Accreditation Program AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final notice. ----------------------------------------------------------------------- SUMMARY: This final 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. A psychiatric hospital that participates in Medicaid must also meet the Medicare conditions of participation (CoPs) as required by statute. DATES: Effective Date: This notice is effective February 25, 2015 through February 25, 2019. FOR FURTHER INFORMATION CONTACT: Monda Shaver, (410) 786-3410. Cindy Melanson, (410) 786-0310. Patricia Chmielewski, (410) 786-6899. SUPPLEMENTARY INFORMATION: I. Background A healthcare provider may enter into an agreement with Medicare to participate in the program as a psychiatric hospital provided certain requirements are met. Section 1861(f) of the Social Security Act (the Act) establishes criteria for facilities seeking participation as a psychiatric hospital. Regulations concerning Medicare provider agreements in general are at 42 CFR part 489 and those pertaining to the survey and certification for Medicare participation of providers and certain types of suppliers are at 42 CFR part 488. The regulations at 42 CFR part 482 subpart E, set forth the specific conditions that a provider must meet to participate in the Medicare program as a psychiatric hospital. 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. However, there is an alternative to certification surveys by state agencies. Accreditation by a national Medicare accreditation program approved by the Centers for Medicare & Medicaid Services (CMS) may substitute for both initial and ongoing state agency review. Section 1865(a)(1) of the Act provides that, if the Secretary of the Department of Health and Human Services (the Secretary) finds that accreditation of a provider entity by an approved national accrediting organization meets or exceeds all applicable Medicare conditions, we may treat the provider entity as having met those conditions, that is, we may ``deem'' the provider [[Page 9467]] entity to be in compliance. Accreditation by an accrediting organization is voluntary and is not required for Medicare participation. Part 488 subpart A implements the provisions of section 1865 of the Act and requires that a national accrediting organization applying for approval of its Medicare accreditation program must provide CMS with reasonable assurance that its accredited provider entities 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. 488.4 and Sec. 488.8(d)(3). The regulations at Sec. 488.8(d)(3) require an accrediting organization to reapply for continued approval of its Medicare accreditation program every 6 years or sooner, as determined by CMS. The Joint Commission's current term of approval as a Medicare accreditation program for psychiatric hospitals expires February 25, 2015. II. Application Approval Process Section 1865(a)(3)(A) of the Act 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. III. Provisions of the Proposed Notice On September 23, 2014, we published a proposed notice in the Federal Register (79 FR 56806) entitled ``Continued Approval of the Joint Commission's Psychiatric Hospital Accreditation Program'' announcing the Joint Commission's request for continued approval of its Medicare psychiatric hospital accreditation program. In the proposed notice, we detailed our evaluation criteria. Under section 1865(a)(2) of the Act and in our regulations at Sec. 488.4 and Sec. 488.8, we conducted a review of the Joint Commission's Medicare psychiatric hospital accreditation application in accordance with the criteria specified by our regulations, which include, but are not limited to the following:An onsite administrative review of the Joint Commission'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. A comparison of the Joint Commission's Medicare accreditation program standards to our current Medicare psychiatric hospital conditions of participations (CoPs). A documentation review of the Joint Commission's survey process to-- ++ Determine the composition of the survey team, surveyor qualifications, and the Joint Commission's ability to provide continuing surveyor training. ++ Compare the Joint Commission'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 the Joint Commission's procedures for monitoring psychiatric hospitals it has found to be out of compliance with the Joint Commission's program requirements. (This pertains only to monitoring procedures when the Joint Commission identifies non- compliance. If non-compliance is identified by a State Survey Agency through a validation survey, the State Survey Agency monitors corrections as specified at Sec. 488.7(d).) ++ Assess the Joint Commission's ability to report deficiencies to the surveyed psychiatric hospital and respond to the psychiatric hospital's plan of correction in a timely manner. ++ Establish the Joint Commission'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 the Joint Commission's staff and other resources. ++ Confirm the Joint Commission's ability to provide adequate funding for performing required surveys. ++ Confirm the Joint Commission's policies with respect to surveys being unannounced. ++ Obtain 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. In accordance with section 1865(a)(3)(A) of the Act, the September 23, 2014 proposed notice also solicited public comments regarding whether the Joint Commission's requirements met or exceeded the Medicare CoPs for psychiatric hospitals. We received one comment in response to our proposed notice. The commenter supported our approval of the Joint Commission for continued recognition as a national accrediting organization for psychiatric hospitals that wish to participate in the Medicare or Medicaid programs. IV. Provisions of the Final Notice A. Differences Between the Joint Commission's Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements We compared the Joint Commission's psychiatric hospital accreditation requirements and survey process with the Medicare CoPs in part 482, and the survey and certification process requirements of parts 488 and 489. Our review and evaluation of the Joint Commission's psychiatric hospital accreditation program application, which were conducted as described in section III of this final notice, identified a number of areas in which, as of the date of this notice, the Joint Commission is in the process of, or has completed, revising its standards in order to ensure that its accredited psychiatric hospitals meet the following regulatory requirements: Section 482.61(a)(2), requiring that the medical record include the diagnosis of intercurrent diseases as well as the psychiatric diagnoses. Section 482.61(a)(4), requiring that social service records include a social history and reports of interviews with patients, family members, and others. Section 482.61(a)(5), requiring that a complete neurological examination be recorded at the time of the admission physical examination. Section 482.61(b)(4), requiring that the psychiatric evaluation includes the onset of illness and the circumstances leading to admission. Section 482.61(b)(7), requiring that the psychiatric evaluation include an inventory of the patient's assets. Section 482.61(c)(1), requiring that the individual comprehensive treatment plan be based on the patient's strengths and disabilities. Section 482.61(c)(1)(i), requiring that the treatment plan contain a substantiated diagnosis. Section 482.61(c)(1)(v), requiring that the treatment plan contain adequate documentation to justify the diagnosis, treatment, and rehabilitation activities carried out. Section 482.61(c)(2), requiring that the treatment plan contain documentation of the treatment received by the patient, in a way that assures all active therapeutic efforts are included. Section 482.61(d), requiring that progress notes contain recommendations for revisions in the treatment plan, as indicated, as well as a precise assessment of the patient's [[Page 9468]] progress in accordance with the original or revised treatment plan. Section 482.61(e), requiring that each patient who has been discharged has a documented discharge summary. Section 482.62(c), requiring that, if medical and surgical diagnostic and treatment services are not available within the institution, the institution have an agreement with an outside source of these services to ensure that they are immediately available or a satisfactory agreement must be established for transferring patients to a general hospital that participates in the Medicare program. Section 482.62(g)(1), requiring that therapeutic activities be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. In addition, we determined that the Joint Commission is in the process of, or has completed, revising its accreditation survey processes in order to ensure that they meet the following regulatory requirements: Section 488.4(a)(3), regarding the sample sizes required for medical record reviews and the minimum number of medical records to be reviewed during the survey process. Section 488.8(a)(2)(v), requiring that complaint data submitted to CMS be accurate. Section 488.8(a)(2)(ii), requiring that a process be in place to conduct routine second level survey documentation review to assure that deficiency citations are made at the appropriate level when no ``flags'' have been placed on the survey report through the automated process of the electronic scoring system or the surveyor; that surveyors are adequately equipped and trained to appropriately identify circumstances posing an immediate threat to life and safety; that medical records and credentialing records are sampled appropriately, based on services provided and types of staff employed; and that medical records and credentialing records are reviewed thoroughly, in a uniform and complete manner by surveyors. Section 488.9, requiring the Joint Commission to consistently provide CMS access to observe its entire survey process, including surveyors' use of resources provided outside of the accreditation standards manual (for example, discussions with its Standards Interpretation Group, as outlined in the application). Section 488.26(b), regarding surveyors' abilities to-- --Accurately and completely document instances of non-compliance at the appropriate level of citation [condition versus standard level citations]; --Ensure that all instances of observed non-compliance are documented in the survey report; and, --Ensure that surveyors do not minimize the importance of compliance with regulations. B. Term of Approval Based on our review and observations described in section III of this final notice, we approve the Joint Commission as a national accrediting organization for psychiatric hospitals that request participation in the Medicare program, effective February 25, 2015 through February 25, 2019. To verify the Joint Commission's continued compliance with the provisions of this final notice, CMS will conduct a follow-up corporate on-site visit and survey observation within 18 months of the publication date of this notice. V. 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. Dated: February 13, 2015. Marilyn Tavenner, Administrator, Centers for Medicare & Medicaid Services. [FR Doc. 2015-03559 Filed 2-20-15; 8:45 am] BILLING CODE 4120-01-P
![9466 Federal Register / Vol. 80, No. 35 / Monday, February 23, 2015 / Notices
terminated because it has completed its or viewed at www.DietaryGuidelines.gov ACTION: Final notice.
mission. using the ‘‘Submit Comments’’ and
Meeting Agenda: The meeting agenda ‘‘Read Comments’’ links, respectively. SUMMARY: This final notice announces
will include opportunity for the public HHS and USDA requests that our decision to approve the Joint
to give oral testimony to HHS and commenters provide a brief (250 words Commission for continued recognition
USDA officials on the Advisory Report. or less) summary of the points or issues as a national accrediting organization
Meeting Registration: The meeting in the comment text box. If commenters for psychiatric hospitals that wish to
will be publicly accessible in-person are providing literature or other participate in the Medicare or Medicaid
and by webcast on the Internet. resources, complete citations or programs. A psychiatric hospital that
Registration is required and is expected abstracts and electronic links to full participates in Medicaid must also meet
to open on March 9, 2015. To register, articles or reports are preferred instead the Medicare conditions of participation
please go to www.DietaryGuidelines.gov of attaching these documents to the (CoPs) as required by statute.
and click on the link for meeting comment. All comments must be DATES: Effective Date: This notice is
registration. To register by phone, please received by midnight (E.S.T.) on April effective February 25, 2015 through
call National Capitol Contracting, 8, 2015, after which the time period for February 25, 2019.
Andrea Popp at (703) 243–9696. submitting written comments to the FOR FURTHER INFORMATION CONTACT:
Registration must include name, federal government expires. The ability Monda Shaver, (410) 786–3410.
affiliation, and phone number or email to view public comments will continue Cindy Melanson, (410) 786–0310.
address. to be available. Please allow until April Patricia Chmielewski, (410) 786–6899.
Webcast Public Participation: After 22, 2015, for comment submissions to
registering, individuals participating by SUPPLEMENTARY INFORMATION:
be processed and posted for viewing.
webcast will receive webcast access Meeting Documents: Documents I. Background
information via email. Webcast pertaining to the meeting, including a
registrants can observe the oral A healthcare provider may enter into
meeting agenda and webcast recording
testimony; however, testimony can only an agreement with Medicare to
will be available on
be given in-person. participate in the program as a
www.DietaryGuidelines.gov. Meeting
In-Person Public Participation and psychiatric hospital provided certain
information will continue to be
Building Access: For in-person requirements are met. Section 1861(f) of
accessible online, at the NIH Library
participants, the meetings will be held (see the Addresses section), and upon the Social Security Act (the Act)
in the National Institutes of Health request at the Office of Disease establishes criteria for facilities seeking
(NIH) Clinical Center (Building 10), as Prevention and Health Promotion, participation as a psychiatric hospital.
noted above in the Addresses section. OASH/HHS; 1101 Wootton Parkway, Regulations concerning Medicare
Directions will be posted on Suite LL100 Tower Building; Rockville, provider agreements in general are at 42
www.DietaryGuidelines.gov. For in- MD 20852: Telephone (240) 453–8280; CFR part 489 and those pertaining to the
person participants, check-in at the Fax: (240) 453–8281. survey and certification for Medicare
registration desk onsite at the meeting is participation of providers and certain
Dated: January 13, 2015. types of suppliers are at 42 CFR part
required and will begin at 8:00 a.m.
Don Wright, 488. The regulations at 42 CFR part 482
E.S.T.
Oral Testimony: HHS and USDA Deputy Assistant Secretary for Health, Office subpart E, set forth the specific
of Disease Prevention and Health Promotion, conditions that a provider must meet to
invite requests from the public to
Office of the Assistant Secretary for Health, participate in the Medicare program as
present three minutes of oral testimony U.S. Department of Health and Human
to HHS and USDA officials on the Services. a psychiatric hospital.
Advisory Report at the March 24, 2015 Generally, to enter into an agreement,
Dated: January 13, 2015.
public meeting. a psychiatric hospital must first be
Angela Tagtow,
Registration capacity is limited to 70 certified by a State Survey Agency as
Executive Director, Center for Nutrition Policy complying with the conditions or
individuals confirmed to speak and an and Promotion, U.S. Department of
additional 10 who are not confirmed to Agriculture.
requirements set forth in part 482
speak but are on stand-by (if time subpart E of our regulations. Thereafter,
Dated: January 15, 2015.
remains) to provide oral testimony. the psychiatric hospital is subject to
Chavonda Jacobs-Young,
Capacity will be filled in the order regular surveys by a State Survey
Administrator, Agricultural Research Service, Agency to determine whether it
received. Confirmation by email will
U.S. Department of Agriculture.
include further instructions for continues to meet these requirements.
[FR Doc. 2015–03552 Filed 2–20–15; 8:45 am]
participation. Requests to present oral However, there is an alternative to
BILLING CODE 4150–32P certification surveys by state agencies.
testimony can be made by going to
www.DietaryGuidelines.gov and clicking Accreditation by a national Medicare
on the link for meeting registration and accreditation program approved by the
DEPARTMENT OF HEALTH AND
must include a written outline of the Centers for Medicare & Medicaid
HUMAN SERVICES
intended testimony not exceeding one Services (CMS) may substitute for both
page in length. In addition, the public Centers for Medicare & Medicaid initial and ongoing state agency review.
is encouraged to provide written Services Section 1865(a)(1) of the Act provides
comments (separate from oral that, if the Secretary of the Department
testimony) submitted electronically [CMS–3304–FN] of Health and Human Services (the
Rmajette on DSK2VPTVN1PROD with NOTICES
through the public comments database Secretary) finds that accreditation of a
Medicare and Medicaid Program;
at www.DietaryGuidelines.gov. provider entity by an approved national
Continued Approval of the Joint
Written Public Comments: Written accrediting organization meets or
Commission’s Psychiatric Hospital
comments on the Advisory Report are exceeds all applicable Medicare
Accreditation Program
encouraged from the public and will be conditions, we may treat the provider
accepted through April 8, 2015. Written AGENCY: Centers for Medicare & entity as having met those conditions,
public comments can be submitted and/ Medicaid Services (CMS), HHS. that is, we may ‘‘deem’’ the provider
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![9468 Federal Register / Vol. 80, No. 35 / Monday, February 23, 2015 / Notices
progress in accordance with the original at the appropriate level of citation for inclusion on the Lower Mississippi
or revised treatment plan. [condition versus standard level River Waterway Safety Advisory
• Section 482.61(e), requiring that citations]; Committee Web site must be submitted
each patient who has been discharged —Ensure that all instances of on or before March 2, 2015. Please note
has a documented discharge summary. observed non-compliance are that this meeting may close early if all
• Section 482.62(c), requiring that, if documented in the survey report; and, business is finished.
medical and surgical diagnostic and —Ensure that surveyors do not ADDRESSES: The Committee will meet at
treatment services are not available minimize the importance of compliance the New Orleans Yacht Club, 403 North
within the institution, the institution with regulations. Roadway Street, New Orleans, LA 70124
have an agreement with an outside http://noyc.org/wordpress/.
source of these services to ensure that B. Term of Approval
For information on facilities or
they are immediately available or a Based on our review and observations services for individuals with disabilities
satisfactory agreement must be described in section III of this final or to request special assistance, please
established for transferring patients to a notice, we approve the Joint contact Lieutenant Junior Grade Colin
general hospital that participates in the Commission as a national accrediting Marquis as indicated in the FOR FURTHER
Medicare program. organization for psychiatric hospitals INFORMATION CONTACT paragraph below.
• Section 482.62(g)(1), requiring that that request participation in the To facilitate public participation, we
therapeutic activities be appropriate to Medicare program, effective February are inviting public comment on the
the needs and interests of patients and 25, 2015 through February 25, 2019. issues to be considered by the
be directed toward restoring and To verify the Joint Commission’s committee as listed in the ‘‘Agenda’’
maintaining optimal levels of physical continued compliance with the section below. Written comments must
and psychosocial functioning. provisions of this final notice, CMS will be identified by the Docket No. USCG–
In addition, we determined that the conduct a follow-up corporate on-site 2015–0023 and submitted by one of the
Joint Commission is in the process of, or visit and survey observation within 18 following methods:
has completed, revising its accreditation months of the publication date of this • Federal eRulemaking Portal: http://
survey processes in order to ensure that notice. www.regulations.gov.
they meet the following regulatory Follow the instructions for submitting
requirements: V. Collection of Information
Requirements comments (preferred method to avoid
• Section 488.4(a)(3), regarding the
delays in processing).
sample sizes required for medical record This document does not impose • Fax: 202–493–2251.
reviews and the minimum number of information collection requirements, • Mail: Docket Management Facility
medical records to be reviewed during that is, reporting, recordkeeping or (M–30), U.S. Department of
the survey process. third-party disclosure requirements. Transportation, West Building Ground
• Section 488.8(a)(2)(v), requiring that Consequently, there is no need for Floor, Room W12–140, 1200 New Jersey
complaint data submitted to CMS be review by the Office of Management and Avenue SE., Washington, DC 20590–
accurate. Budget under the authority of the
• Section 488.8(a)(2)(ii), requiring 0001.
Paperwork Reduction Act of 1995. • Hand Delivery: Same as mail
that a process be in place to conduct
routine second level survey Dated: February 13, 2015. address above, between 9 a.m. and 5
documentation review to assure that Marilyn Tavenner, p.m., Monday through Friday, except
deficiency citations are made at the Administrator, Centers for Medicare & Federal Holidays. The telephone
appropriate level when no ‘‘flags’’ have Medicaid Services. number for the Docket Management
been placed on the survey report [FR Doc. 2015–03559 Filed 2–20–15; 8:45 am] Facility is 202–366–9329.
through the automated process of the BILLING CODE 4120–01–P
Instructions: All submissions must
electronic scoring system or the include the words ‘‘Department of
surveyor; that surveyors are adequately Homeland Security’’ and the docket
equipped and trained to appropriately DEPARTMENT OF HOMELAND number for this action. Comments
identify circumstances posing an SECURITY received will be posted without
immediate threat to life and safety; that alteration at http://
medical records and credentialing Coast Guard www.regulations.gov., including any
records are sampled appropriately, personal information provided. You
[Docket No. USCG–2015–0023] may review a Privacy Act notice
based on services provided and types of
staff employed; and that medical regarding our public dockets in the
Lower Mississippi River Waterway
records and credentialing records are January 17, 2008, issue of the Federal
Safety Advisory Committee; Meeting
reviewed thoroughly, in a uniform and Register (73 FR 3316).
complete manner by surveyors. AGENCY:Coast Guard, DHS. Docket: For access to the docket to
• Section 488.9, requiring the Joint Notice of Federal Advisory
ACTION: read documents or comments related to
Commission to consistently provide Committee Meeting. this notice, go to http://
CMS access to observe its entire survey www.regulations.gov, enter the docket
process, including surveyors’ use of SUMMARY: The Lower Mississippi River number in the ‘‘Search’’ field and follow
resources provided outside of the Waterway Safety Advisory Committee the instructions on the Web site.
accreditation standards manual (for will meet to discuss safe transit of FOR FURTHER INFORMATION CONTACT:
Rmajette on DSK2VPTVN1PROD with NOTICES
example, discussions with its Standards vessels and cargoes to and from the Lieutenant Junior Grade Colin Marquis,
Interpretation Group, as outlined in the ports of the Lower Mississippi River. Alternate Designated Federal Officer of
application). This meeting will be open to the public. the Lower Mississippi River Waterway
• Section 488.26(b), regarding DATES: The Committee will meet on Safety Advisory Committee, telephone
surveyors’ abilities to— Wednesday, March 11, 2015, from 9 504–365–2280, or at Colin.L.Marquis@
—Accurately and completely a.m. to 12:00 p.m. Written comments for uscg.mil. If you have any questions on
document instances of non-compliance distribution to committee members and reviewing or submitting material to the
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Document Created: 2015-12-18 13:28:36
Document Modified: 2015-12-18 13:28:36
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Final notice. | |
| Contact | Monda Shaver, (410) 786-3410. | |
| FR Citation | 80 FR 9466 |
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