83 FR 40514 - Medicare and Medicaid Programs: Application From the Joint Commission (TJC) for Continued Approval of its Psychiatric Hospital Accreditation Program

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 83, Issue 158 (August 15, 2018)

This proposed notice acknowledges the receipt of an application from the Joint Commission (TJC) for continued recognition as a national accrediting organization for psychiatric hospitals that wish to participate in the Medicare or Medicaid programs.

[Federal Register Volume 83, Number 158 (Wednesday, August 15, 2018)]
[Notices]
[Pages 40514-40515]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2018-17519]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3364-PN]


Medicare and Medicaid Programs: 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 with request for comment.

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SUMMARY: This proposed notice acknowledges the receipt of an 
application from the Joint Commission (TJC) for continued 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, no later than 5 p.m. on September 14, 
2018.

ADDRESSES: In commenting, refer to file code CMS-3364-PN. Because of 
staff and resource limitations, we cannot accept comments by facsimile 
(FAX) transmission.
    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 http://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-3364-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-3364-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:  Karena Meushaw (410) 786-6609, Monda 
Shaver (410) 786-3410 or Marie Vasbinder (410)786-8665.

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: http://www.regulations.gov. Follow the search instructions on 
that website to view public 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 a provider agreement with Medicare, 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 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. 
There is an alternative, however, to surveys by State agencies.
    Section 1865(a)(1) of the Act provides that, if a provider entity 
demonstrates through accreditation by a CMS-approved national 
accrediting organization (AO) that all applicable Medicare conditions 
are met or exceeded, 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 CMS 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. An 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 AO are 
set forth at Sec.  488.5. Our regulations at Sec.  488.5(e)(2)(i) 
require an accrediting organization to reapply for continued approval 
of its accreditation program(s) 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, 2019.

II. Provisions of the Proposed Notice

A. 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 an 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 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

[[Page 40515]]

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

B. Evaluation of Deeming Authority Request

    TJC submitted all the necessary materials to enable us to make a 
determination concerning its request for CMS-approval of its 
psychiatric hospital accreditation program. This application was 
determined to be complete on July 30, 2018. 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 TJC will be conducted in accordance with, but 
not necessarily limited to, the following factors:
     The equivalency of TJC's standards for psychiatric 
hospitals as compared with CMS' psychiatric hospital CoPs.
     TJC'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 TJC's processes to those of State agencies, 
including survey frequency, and the ability to investigate and respond 
appropriately to complaints against accredited facilities.
    ++ TJC's processes and procedures for monitoring a psychiatric 
hospital found out of compliance with the TJC's program requirements. 
These monitoring procedures are used only when TJC 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).
    ++ TJC's capacity to report deficiencies to the surveyed facilities 
and respond to the facility's plan of correction in a timely manner.
    ++ TJC'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 TJC's staff and other resources, and its 
financial viability.
    ++ TJC's capacity to adequately fund required surveys.
    ++ TJC's policies with respect to whether surveys are announced or 
unannounced, to assure that surveys are unannounced.
    ++ 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 CMS may require (including corrective action plans).

III. 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. Chapter 35).

IV. 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.
    Upon completion of our evaluation, including evaluation of comments 
received as a result of this notice, we will publish a final notice in 
the Federal Register announcing the result of our evaluation.

V. Regulatory Impact Statement

    This proposed notice does not impose any regulatory impact.
    In accordance with the provisions of Executive Order 12866, this 
regulation was not reviewed by the Office of Management and Budget.

    Dated: August 6, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2018-17519 Filed 8-14-18; 8:45 am]
 BILLING CODE 4120-01-P