17070 Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices 

• To meet the requirements at section 

2008D of the SOM, AAAASF revised its 

policies related to the accreditation 

effective date. 

• To meet the requirements at section 

2200F of the SOM, AAAASF revised its 

policies to ensure their surveys are 

complete, accurate, and consistent. 

• To meet the requirements at section 

2700A of the SOM, AAAASF revised its 

policies to ensure all RHC surveys are 

conducted unannounced. 

• To meet the requirements at section 

2704 of the SOM, AAAASF revised its 

RHC Accreditation Facility Handbook to 

include pre-survey preparation 

requirements. 

• To meet the requirements at section 

2728 of the SOM, AAAASF modified its 

policies regarding timeframes for 

sending and receiving a plan of 

correction. 

• To meet the requirements at section 

3010 of the SOM, AAAASF revised its 

policies on immediate jeopardy. 

• To meet the requirements at chapter 

five of the SOM, AAAASF revised its 

policies to ensure all complaints are 

appropriately triaged, investigated and 

resolved. 

• To meet the requirements at Exhibit 

7 of the SOM, AAAASF revised its 

policies to ensure survey deficiencies 

are cited at the appropriate level based 

on the surveyor documentation. 

• To verify AAAASF’s continued 

compliance with the provisions of this 

final notice, CMS will conduct a followup survey observation within 1 year of 

the date of publication of this notice. 

B. Term of Approval 

Based on our review and observations 

described in section III of this final 

notice, we have determined that 

AAAASF’s requirements for RHCs meet 

or exceed our requirements. Therefore, 

we approve AAAASF as a national 

accreditation organization for RHCs that 

request participation in the Medicare 

program, effective March 23, 2012 

through March 23, 2016. 

V. 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 (44 

U.S.C. 35). 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program) 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: March 8, 2012. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

[FR Doc. 2012–6331 Filed 3–22–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3258–PN] 

Medicare and Medicaid Programs; 

Application From Det Norske Veritas 

Healthcare (DNVHC) for Continued 

Approval of Its Hospital Accreditation 

Program 

AGENCY: Centers for Medicare and 

Medicaid Services, HHS. 

ACTION: Proposed notice. 

SUMMARY: This proposed notice with 

comment period acknowledges the 

receipt of an application from Det 

Norske Veritas Healthcare (DNVHC) for 

continued 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 April 23, 2012. 

ADDRESSES: In commenting, please refer 

to file code CMS–3258–PN. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (Fax) 

transmission. 

You may submit comments in one of 

four 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 (one original and two 

copies) to the following address ONLY: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–3258– 

PN, P.O. Box 8016, Baltimore, MD 

21244–8016. 

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 (one 

original and two copies) to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–3258–PN, Mail Stop C4–26–05, 

7500 Security Boulevard, Baltimore, MD 

21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments before the close 

of the comment period to either of 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, please call 

telephone number (410) 786–7195 in 

advance to schedule your arrival with 

one of our staff members. 

Comments 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: 

Barbara Easterling (410) 786–0482, 

Patricia Chmielewski, (410) 786–6899, 

or Cindy Melanson, (410) 786–0310. 

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, 


srobinson on DSK4SPTVN1PROD with NOTICES
Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices 17071 

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 establishes 

distinct criteria for facilities seeking 

designation as a 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 part 488. 

The regulations at part 482 specify the 

conditions that a hospital must meet in 

order to participate in the Medicare 

program, the scope of covered services 

and the conditions for Medicare 

payment for hospitals. 

Generally, in order 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. 

Thereafter, the 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 surveys by 

State agencies. 

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 have met 

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 § 488.4 and § 488.8(d)(3). The 

regulations at § 488.8(d)(3) require 

accrediting organizations to reapply for 

continued approval of its accreditation 

program every 6 years or sooner as 

determined by us. 

DNVHC’s current term of approval for 

their hospital accreditation program 

expires September 26, 2012. 

II. Approval of Deeming Organizations 

Section 1865(a)(2) of the Act and our 

regulations at § 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 us 

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 

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 DNVHC’s 

request for continued approval of its 

hospital accreditation program. This 

notice also solicits public comment on 

whether DNVHC’s requirements meet or 

exceed the Medicare conditions for 

participation for hospitals. 

III. Evaluation of Deeming Authority 

Request 

DNVHC submitted all the necessary 

materials to enable us to make a 

determination concerning its request for 

continued approval of its hospital 

accreditation program. This application 

was determined to be complete on 

January 27, 2012. Section 1865(a)(3)(A) 

of the Social Security Act (the Act), 

requires that within 60 days of receipt 

of an organization’s complete 

application to be a CMS-approved 

accrediting organization, we publish 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. Under section 

1865(a)(2) of the Act and our regulations 

at § 488.8 (Federal review of accrediting 

organizations), our review and 

evaluation of DNVHC will be conducted 

in accordance with, but not necessarily 

limited to, the following factors: 

• The equivalency of DNVHC’s 

standards for a hospital as compared 

with CMS’ hospital conditions of 

participation. 

• DNVHC’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 DNVHC’s 

processes to those of State agencies, 

including survey frequency, and the 

ability to investigate and respond 

appropriately to complaints against 

accredited facilities. 

+ DNVHC’s processes and procedures 

for monitoring a hospital found out of 

compliance with DNVHC’s program 

requirements. These monitoring 

procedures are used only when DNVHC 

identifies noncompliance. If 

noncompliance is identified through 

validation reviews or complaint 

surveys, the State survey agency 

monitors corrections as specified at 

§ 488.7(d). 

+ DNVHC’s capacity to report 

deficiencies to the surveyed facilities 

and respond to the facility’s plan of 

correction in a timely manner. 

+ DNVHC’s capacity to provide us 

with electronic data and reports 

necessary for effective validation and 

assessment of the organization’s survey 

process. 

+ The adequacy of DNVHC’s staff and 

other resources, and its financial 

viability. 

+ DNVHC’s capacity to adequately 

fund required surveys. 

+ DNVHC’s policies with respect to 

whether surveys are announced or 

unannounced, to assure that surveys are 

unannounced. 

+ DNVHC’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). 

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 

(44 U.S.C. 35). 

V. Response to Public 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 


srobinson on DSK4SPTVN1PROD with NOTICES
17072 Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices 

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. 

Authority: Section 1865 of the Social 

Security Act (42 U.S.C. 1395bb) 

(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: March 13, 2012. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

[FR Doc. 2012–6856 Filed 3–22–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–2377–FN] 

Medicare and Medicaid Programs; 

Approval of the Community Health 

Accreditation Program for Continued 

CMS-Approval of its Home Health 

Agency Accreditation Program 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final notice. 

SUMMARY: This notice announces our 

decision to approve the Community 

Health Accreditation Program (CHAP) 

for recognition as a national 

accreditation program for home health 

agencies (HHAs) seeking to participate 

in the Medicare or Medicaid programs. 

DATES: This final notice is effective 

March 31, 2012 through March 31, 2018. 

FOR FURTHER INFORMATION CONTACT: 

Lillian Williams, (410) 786–8636, or 

Patricia Chmielewski, (410) 786–6899. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Under the Medicare program, eligible 

beneficiaries may receive covered 

services in a home health agency (HHA) 

provided certain requirements are met. 

Sections 1861(m) and (o) and 1891 and 

1895 of the Social Security Act (the Act) 

establish distinct criteria for facilities 

seeking designation as an HHA. Under 

this authority, the minimum 

requirements that an HHA must meet to 

participate in Medicare are set forth in 

regulations at 42 CFR part 484, which 

determine the basis and scope of HHA 

covered services, and the conditions for 

Medicare payment for home health care. 

Regulations concerning provider 

agreements are at part 489 and those 

pertaining to activities relating to the 

survey and certification of facilities are 

at part 488. 

Generally, in order to enter into a 

provider agreement with the Medicare 

program, HHAs must first be certified by 

a State survey agency as complying with 

conditions or requirements set forth in 

part 484. Thereafter, the HHA 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 State 

compliance surveys. Accreditation by a 

nationally-recognized accreditation 

program can substitute for ongoing State 

review. 

Section 1865(a)(1) of the Act provides 

that, if a provider entity demonstrates 

through accreditation by an approved 

national accreditation organization that 

all applicable Medicare conditions are 

met or exceeded, we may ‘‘deem’’ those 

provider entities as having met the 

requirements. Accreditation by an 

accreditation organization is voluntary 

and is not required for Medicare 

participation. 

If an accreditation organization is 

recognized by the Secretary as having 

standards for accreditation that meet or 

exceed Medicare requirements, a 

provider entity accredited by the 

national accrediting body’s approved 

program may be deemed to meet the 

Medicare conditions. A national 

accreditation organization applying for 

CMS-approval of its accreditation 

program under part 488, subpart A must 

provide us with reasonable assurance 

that the accreditation organization 

requires the accredited provider entities 

to meet requirements that are at least as 

stringent as the Medicare conditions. 

Our regulations concerning the 

reapproval of accreditation 

organizations are set forth at § 488.4 and 

§ 488.8(d)(3). Section 488.8(d)(3) 

requires accreditation organizations to 

reapply for continued CMS-approval of 

its accreditation program every six 

years, or sooner as determined by us. 

CHAP’s term of approval as a 

recognized accreditation program for 

HHAs expires March 31, 2012. 

II. Deeming Applications Approval 

Process 

Section 1865(a)(3)(A) of the Act 

provides a statutory timetable to ensure 

that our review of deeming applications 

is conducted in a timely manner. The 

Act provides us with 210 calendar days 

after the date of receipt of an application 

to complete our survey activities and 

application review process. Within 60 

days of receiving a completed 

application, we must publish a notice in 

the Federal Register that identifies the 

national accreditation 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 an 

approval or denial of the application. 

III. Proposed Notice 

In the September 23, 2011, Federal 

Register (76 FR 59136), we published a 

proposed notice announcing CHAP’s 

request for continued CMS approval of 

its HHA accreditation program. In the 

proposed notice, we detailed our 

evaluation criteria. Under section 

1865(a)(2) of the Act and our regulations 

at § 488.4 (Application and 

reapplication procedures for 

accreditation organizations), we 

conducted a review of CHAP’s 

application in accordance with the 

criteria specified by our regulations, 

which include, but are not limited to the 

following: 

• An onsite administrative review of 

CHAP’s: (1) Corporate policies; (2) 

financial and human resources available 

to accomplish the proposed surveys; (3) 

procedures for training, monitoring, and 

evaluation of its surveyors; (4) ability to 

investigate and respond appropriately to 

complaints against accredited facilities; 

and, (5) survey review and decisionmaking process for accreditation. 

• A comparison of CHAP’s HHA 

accreditation standards to our current 

Medicare HHA conditions for 

participation. 

• A documentation review of CHAP’s 

survey processes to: 

≈≈ Determine the composition of the 

survey team, surveyor qualifications, 

and the ability of CHAP to provide 

continuing surveyor training. 

≈≈ Compare CHAP’s processes to 

those of State survey agencies, including 

survey frequency, and the ability to 

investigate and respond appropriately to 

complaints against accredited facilities. 

≈≈ Evaluate CHAP’s procedures for 

monitoring providers or suppliers found 

to be out of compliance with CHAP 

program requirements. The monitoring 

procedures are used only when the 

CHAP identifies noncompliance. If 

noncompliance is identified through 

validation reviews, the survey agency 

monitors corrections as specified at 

§ 488.7(d). 


srobinson on DSK4SPTVN1PROD with NOTICES