[Federal Register Volume 80, Number 12 (Tuesday, January 20, 2015)]
[Notices]
[Pages 2708-2710]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-00699]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3303-FN]
Medicare and Medicaid Programs; Continued Approval of the
Accreditation Commission for Health Care, Inc.; Home Health Agency
Accreditation Program
AGENCY: Centers for Medicare and Medicaid Services, HHS.
ACTION: Final notice.
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SUMMARY: This final notice announces our decision to approve the
Accreditation Commission for Health Care, Inc., (ACHC) for continued
recognition as a national accrediting organization for home health
agencies (HHAs) that wish to participate in the Medicare or Medicaid
programs. An HHA that participates in Medicaid must also meet the
Medicare conditions for participation (CoPs) as required under 42 CFR
488.6(b).
DATES: This final notice is effective February 24, 2015 through
February 24, 2021.
FOR FURTHER INFORMATION CONTACT: Cindy Melanson, (410) 786-0310, or
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 HHA provided certain requirements are
met. Sections 1861(o) and 1891 of the Social Security Act (the Act),
establish distinct criteria for facilities seeking designation as a
HHA. 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 part 488. The regulations at part 484 specify the specific
conditions that a provider must meet to participate in the Medicare
program as an HHA.
Generally, to enter into a Medicare provider agreement, a facility
must first be certified as complying with the conditions set forth in
part 484 and recommended to us for participation by
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a state survey agency. Thereafter, the HHA is subject to periodic
surveys by a state survey agency to determine whether it continues to
meet these conditions. However, there is an alternative to
certification surveys by state agencies. Accreditation by a nationally
recognized Medicare accreditation program approved by us may substitute
for both initial and ongoing state 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 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 and
requires that a national accrediting organization applying for approval
of its Medicare accreditation program must provide us with reasonable
assurance that the accrediting organization requires its 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
Medicare accreditation program every 6 years or sooner as determined by
us. ACHC's current term of approval as a recognized Medicare
accreditation program for HHAs expires February 24, 2015.
II. Application Approval Process
Section 1865(a)(3)(A) of the Act provides a statutory timetable to
ensure that our review of applications for CMS-approval of an
accreditation program is conducted in a timely manner. The Act provides
us with 210 days after the date of receipt of a complete application,
with any documentation necessary to make the determination, to complete
our survey activities and application process. Within 60 days after
receiving a complete application, we must publish a notice in the
Federal Register that identifies the national accrediting body making
the request, describes the request, and provides no less than a 30-day
public comment period. At the end of the 210-day period, we must
publish a notice in the Federal Register approving or denying the
application.
III. Provisions of the Proposed Notice
In the August 22, 2014 Federal Register (79 FR 49777), we published
a proposed notice announcing ACHC's request for continued approval of
its Medicare HHA accreditation program. In that 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
ACHC's Medicare HHA 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 ACHC's: (1) Corporate
policies; (2) financial and human resources available to accomplish the
proposed surveys; (3) procedures for training, monitoring, and
evaluation of its HHA surveyors; (4) ability to investigate and respond
appropriately to complaints against accredited HHAs; and, (5) survey
review and decision-making process for accreditation.
The comparison of ACHC's Medicare accreditation program
standards to our current Medicare HHA CoPs.
A documentation review of ACHC's survey process to:
++ Determine the composition of the survey team, surveyor
qualifications, and ACHC's ability to provide continuing surveyor
training.
++ Compare ACHC'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 HHAs.
++ Evaluate ACHC's procedures for monitoring HHAs it has found to
be out of compliance with ACHC's program requirements. (This pertains
only to monitoring procedures when ACHC identifies non-compliance. If
noncompliance 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 ACHC's ability to report deficiencies to the surveyed HHA
and respond to the HHA's plan of correction in a timely manner.
++ Establish ACHC's ability to provide us with electronic data and
reports necessary for effective validation and assessment of the
organization's survey process.
++ Determine the adequacy of ACHC's staff and other resources.
++ Confirm ACHC's ability to provide adequate funding for
performing required surveys.
++ Confirm ACHC's policies with respect to surveys being
unannounced.
++ Obtain ACHC's agreement to provide us 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 August 22,
2014 proposed notice also solicited public comments regarding whether
ACHC's requirements met or exceeded the Medicare CoPs for HHAs. No
comments were received in response to our proposed notice.
IV. Provisions of the Final Notice
A. Differences Between ACHC's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared ACHC's HHA accreditation requirements and survey
process with the Medicare CoPs of 42 CFR part 484, and the survey and
certification process requirements of parts 488 and 489. Our review and
evaluation of ACHC's HHA application, which were conducted as described
in section III of this final notice, yielded the following areas where,
as of the date of this notice, ACHC has completed revising its
standards and certification processes to meet the requirements at:
Section 1891(c)(2)(A) of the Act, to ensure all renewal
surveys are conducted within 36 months of the last survey end date.
Sec. 484.10(c)(2), to address the patient's right to
participate in the planning of care.
Sec. 484.14(e), to ensure personnel records include
qualifications and current licensure.
Sec. 488.8(a)(2)(v), to ensure data submitted in CMS'
Accrediting Organization System for Storing User Recorded Experiences
(ASSURE) database is complete and accurate.
Sec. 489.3, to ensure situations that rise to the level
of immediate jeopardy (IJ) are cited at the condition level.
B. Term of Approval
Based on our review and observations described in section IV of
this final notice, we have determined that the ACHC accreditation
program requirements meet or exceed our requirements. Therefore, we
approve the ACHC as a national accreditation organization for HHAs that
request participation in the Medicare program, effective February 24,
2015 through February 24, 2021.
V. Collection of Information Requirements
This document does not impose information collection and
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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 (44 U.S.C. 35).
Dated: January 9, 2015.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2015-00699 Filed 1-16-15; 8:45 am]
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