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)

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.

[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]


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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.

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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