[Federal Register Volume 78, Number 36 (Friday, February 22, 2013)]
[Notices]
[Pages 12325-12327]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-04093]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3280-PN]
Medicare and Medicaid Programs; Application From the Center for
Improvement in Healthcare Quality (CIHQ) for CMS-Approval of Its
Hospital Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services, HHS.
ACTION: Proposed notice.
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SUMMARY: This proposed notice with comment period acknowledges the
receipt of an application from the Center for Improvement in Healthcare
Quality (CIHQ) for 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, no later than 5 p.m. on March 25, 2013.
ADDRESSES: In commenting, refer to file code (CMS-3280-PN). Because of
staff and resource limitations, we cannot accept comments by facsimile
(FAX) transmission.
You may submit comments in one of four ways (choose only one of the
ways listed):
1. Electronically. You may submit electronic comments on specific
issues in 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-3280-PN, P.O. Box 8016,
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-3280-PN, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written ONLY to the following addresses.
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert H
Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal Government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Cindy Melanson, (410) 786-0310.
Patricia Chmielewski, (410) 786-6899. Monda Shaver, (410) 786-3410.
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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 Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services in a hospital provided certain requirements are met.
Section 1861(e) of the Social Security Act (the Act), establishes
criteria for facilities seeking designation as a hospital. Regulations
concerning provider agreements are located at 42 CFR part 489 and those
pertaining to activities relating to the survey and certification of
facilities are located at 42 CFR part 488. The regulations at 42 CFR
part 482, specify the conditions that a hospital must meet to
participate in the Medicare programs, the scope of covered services,
and the conditions for Medicare payment for hospitals.
Generally, to enter into an agreement, a hospital must first be
certified by a State survey agency 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 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 will deem those provider entities 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 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 accrediting organization applying for
approval of its accreditation program under part 488, subpart A, must
provide us with reasonable assurance that the accrediting organization
requires the accredited provider entities to 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 accreditation program every 6 years or sooner as determined by
CMS.
II. Approval of Deeming Organizations
Section 1865(a)(2) of the Act and our regulations at Sec. 488.8(a)
require that our findings concerning review and approval of a national
accrediting organization's requirements, consider among other factors,
the applying accrediting organization'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 that identifies the national accrediting body making the
request, describes the nature of the request, and provides at least a
30-day public comment period. We have 210 days from the receipt of a
completed application to publish a notice of approval or denial of the
application.
The purpose of this proposed notice is to inform the public of
CIHQ's request for approval of its hospital accreditation program. This
notice also solicits public comment on whether CIHQ's requirements meet
or exceed Medicare's conditions of participation for hospitals.
III. Evaluation of Deeming Authority Request
CIHQ submitted all the necessary materials to enable us to make a
determination concerning its request for approval of its hospital
accreditation program. This application was determined to be complete
on January 4, 2013. Under section 1865(a)(2) of the Act and our
regulations at Sec. 488.8 (Federal review of accrediting
organizations), 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 a hospital as
compared with CMS' hospital conditions of participation.
CIHQ's survey process to determine the following:
++ CIHQ's composition of the survey team, surveyor qualifications,
and the ability of the organization to provide continuing surveyor
training.
++ CIHQ's processes compared 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 that
is out of compliance with 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. 488.7(d).
++ 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.
++ 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 CMS may require (including corrective action plans).
IV. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995.
V. Response to Public Comments
Because of the large number of public comments we normally receive
on
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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.
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program; No. 93.773 Medicare--Hospital Insurance Program;
and No. 93.774, Medicare--Supplementary Medical Insurance Program)
Dated: February 14, 2013.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2013-04093 Filed 2-21-13; 8:45 am]
BILLING CODE 4120-01-P