59134 Federal Register / Vol. 76, No. 185 / Friday, September 23, 2011 / Notices 

Assessment of Healthcare Providers and 

Systems (HCAHPS); Use: The HCAHPS 

(Hospital Consumer Assessment of 

Healthcare Providers and Systems) 

survey is the first national, 

standardized, publicly reported survey 

of patients’ perspectives of hospital 

care. HCAHPS (pronounced ‘‘H-caps’’), 

also known as the CAHPS® Hospital 

Survey, is a survey instrument and data 

collection methodology for measuring 

patients’ perceptions of their hospital 

experience. While many hospitals have 

collected information on patient 

satisfaction for their own internal use, 

until HCAHPS there was no national 

standard for collecting and publicly 

reporting information about patient 

experience of care that allowed valid 

comparisons to be made across hospitals 

locally, regionally and nationally. 

Three broad goals have shaped 

HCAHPS. First, the survey is designed 

to produce data about patients’ 

perspectives of care that allow objective 

and meaningful comparisons of 

hospitals on topics that are important to 

consumers. Second, public reporting of 

the survey results creates new 

incentives for hospitals to improve 

quality of care. Third, public reporting 

serves to enhance accountability in 

health care by increasing transparency 

of the quality of hospital care provided 

in return for the public investment. 

With these goals in mind, the Centers 

for Medicare & Medicaid Services (CMS) 

has taken substantial steps to assure that 

the survey is credible, useful, and 

practical. Hospitals implement HCAHPS 

under the auspices of the Hospital 

Quality Alliance (HQA), a private/ 

public partnership that includes major 

hospital and medical associations, 

consumer groups, measurement and 

accrediting bodies, government, and 

other groups that share an interest in 

improving hospital quality. Both the 

HQA and the National Quality Forum 

have endorsed HCAHPS. 

The enactment of the Deficit 

Reduction Act of 2005 created an 

additional incentive for acute care 

hospitals to participate in HCAHPS. 

Since July 2007, hospitals subject to the 

Inpatient Prospective Payment System 

(IPPS) annual payment update 

provisions (‘‘subsection (d) hospitals’’) 

must collect and submit HCAHPS data 

in order to receive their full IPPS annual 

payment update. IPPS hospitals that fail 

to publicly report the required quality 

measures, which include the HCAHPS 

survey, may receive an annual payment 

update that is reduced by 2.0 percentage 

points. Non-IPPS hospitals, such as 

Critical Access Hospitals, may 

voluntarily participate in HCAHPS. 

The Patient Protection and Affordable 

Care Act of 2010 (Pub. L. 111–148) 

includes HCAHPS among the measures 

to be used to calculate value-based 

incentive payments in the Hospital 

Value-Based Purchasing program, 

beginning with discharges in October 

2012. 

Currently the HCAHPS survey asks 

discharged patients 27 questions about 

their recent hospital stay. The survey 

contains 18 core questions about critical 

aspects of patients’ hospital experiences 

(communication with nurses and 

doctors, the responsiveness of hospital 

staff, the cleanliness and quietness of 

the hospital environment, pain 

management, communication about 

medicines, discharge information, 

overall rating of hospital, and would 

they recommend the hospital). The 

survey also includes four items to direct 

patients to relevant questions, three 

items to adjust for the mix of patients 

across hospitals, and two items that 

support Congressionally-mandated 

reports. 

This revision is being submitted in 

order to add five new items to the 

survey: Three items that comprise a 

Care Transitions composite; one item 

that asks whether the patient was 

admitted through the emergency room; 

and one item that asks about the 

patient’s overall mental health. This 

marks the first addition of items to the 

HCAHPS Survey since its national 

implementation in 2006. Form Number: 

CMS–10102 (OCN: 0938–0981); 

Frequency: Occasionally; Affected 

Public: Individuals or Households, 

Private Sector—Business or other forprofits and not-for-profit institutions. 

Number of Respondents: 2,713,812; 

Total Annual Responses: 2,713,812; 

Total Annual Hours: 365,136. (For 

policy questions regarding this 

collection contact William Lehrman at 

410–786–1037. For all other issues call 

410–786–1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 

Reports Clearance Office on (410) 786– 

1326. 

In commenting on the proposed 

information collections please reference 

the document identifier or OMB control 

number. To be assured consideration, 

comments and recommendations must 

be submitted in one of the following 

ways by November 22, 2011: 

1. Electronically. You may submit 

your comments electronically to http:// 

www.regulations.gov. Follow the 

instructions for ‘‘Comment or 

Submission’’ or ‘‘More Search Options’’ 

to find the information collection 

document(s) accepting comments. 

2. By regular mail. You may mail 

written comments to the following 

address: CMS, Office of Strategic 

Operations and Regulatory Affairs, 

Division of Regulations Development, 

Attention: Document Identifier/OMB 

Control Number, Room C4–26–05, 7500 

Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Dated: September 20, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–24522 Filed 9–22–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–2375–FN] 

Medicare and Medicaid Programs; 

Approval of the Joint Commission’s 

Continued Deeming Authority for 

Critical Access Hospitals 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final notice. 

SUMMARY: This notice announces our 

decision to approve the Joint 

Commission for continued recognition 

as a national accreditation program for 

critical access hospitals (CAHs) seeking 

to participate in the Medicare or 

Medicaid programs. 

DATES: Effective Date: This final notice 

is effective November 21, 2011 through 

November 21, 2017. 

FOR FURTHER INFORMATION CONTACT: 

L. Tyler Whitaker, (410) 786–5236. 

Patricia Chmielewski, (410) 786–6899. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Under the Medicare program, eligible 

beneficiaries may receive covered 

services in a critical access hospital 

(CAH) provided certain requirements 

are met. Sections 1820(c)(2)(B) and 

1861(mm) of the Social Security Act 

(the Act) establish distinct criteria for 

facilities seeking designation as a CAH. 

The minimum requirements that a CAH 

must meet to participate in Medicare are 

set forth in regulations at 42 CFR part 


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Federal Register / Vol. 76, No. 185 / Friday, September 23, 2011 / Notices 59135 

485, subpart F. Conditions for Medicare 

payment for CAHs are set forth at 

§ 413.70. Applicable regulations 

concerning provider agreements are 

located in 42 CFR part 489 and those 

pertaining to facility survey and 

certification are located in 42 CFR part 

488, subparts A and B. 

For a CAH to enter into a provider 

agreement with the Medicare program, a 

CAH must first be certified by a State 

survey agency as complying with the 

conditions or requirements set forth in 

section 1820 of the Act, and 42 CFR part 

485 of the regulations. Subsequently, 

the CAH is subject to ongoing review by 

a State survey agency to determine 

whether it continues to meet the 

Medicare requirements. However, there 

is an alternative to State compliance 

surveys. Certification by a nationally 

recognized accreditation program can 

substitute for ongoing State review. 

Section 1865(a)(1) of the Act 

stipulates that, if a provider entity 

demonstrates through accreditation by 

an approved national accreditation 

organization (AO) that all applicable 

Medicare conditions are met or 

exceeded, we may ‘‘deem’’ those 

provider entities as having met the 

requirements. Accreditation by an AO is 

voluntary and is not required for 

Medicare participation. A national AO 

applying for deeming authority under 

42 CFR part 488, subpart A must 

provide us 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 

reapproval of AO’s are set forth at 

§ 488.4 and § 488.8(d)(3). The 

regulations at § 488.8(d)(3) require AO’s 

to reapply for continued approval of 

deeming authority every 6 years, or 

sooner as we determine. The Joint 

Commission’s term of approval as a 

recognized accreditation program for 

CAHs expires November 21, 2011. 

We received a complete application 

from the Joint Commission for 

continued recognition as a national 

accrediting organization for CAHs on 

April 1, 2011. In accordance with the 

requirements at § 488.4 and 

§ 488.8(d)(3), we published a proposed 

notice on May 13, 2011 (76 FR 30107). 

This final notice is required to be 

published no later than November 21, 

2011. 

II. Deeming Application Approval 

Process 

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

provides a statutory timetable to ensure 

that our review of applications for 

deeming authority is conducted in a 

timely manner. The statute provides us 

210 calendar days after the date of 

receipt of a complete application, with 

any documentation necessary to make a 

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 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 

a notice in the Federal Register 

approving or denying the application. 

III. Provisions of the Proposed Notice 

and Response to Comments 

In the May 13, 2011 Federal Register 

(76 FR 28040), we published a proposed 

notice announcing the Joint 

Commission’s request for continued 

approval as a deeming organization for 

critical access hospitals. In the proposed 

notice, we detailed our evaluation 

criteria. Under section 1865(a)(2) of the 

Act and in our regulations at § 488.4 we 

conducted a review of the Joint 

Commission’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 

the Joint Commission’s: 

++ Corporate policies. 

++ Financial and human resources 

available to accomplish the proposed 

surveys. 

++ Procedures for training, 

monitoring, and evaluation of its 

surveyors. 

++ Ability to investigate and respond 

appropriately to complaints against 

accredited facilities. 

++ Survey review and decisionmaking process for accreditation. 

• A comparison of the Joint 

Commission’s CAH accreditation 

standards to our current Medicare CAH 

conditions of participation (CoPs). 

• A documentation review of the 

Joint Commission’s survey processes 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 of State survey 

agencies, including survey frequency, 

and the ability to investigate and 

respond appropriately to complaints 

against accredited facilities. 

++ Evaluate the Joint Commission’s 

procedures for monitoring CAHs found 

to be out of compliance with the Joint 

Commission’s program requirements. 

The monitoring procedures are used 

only when the Joint Commission 

identifies noncompliance. If 

noncompliance is identified through 

validation reviews, the State survey 

agency monitors corrections as specified 

at § 488.7(d). 

++ Assess the Joint Commission’s 

ability to report deficiencies to the 

surveyed facilities and respond to the 

facility’s plan of correction in a timely 

manner. 

++ Establish the Joint Commission’s 

ability to provide us with electronic 

data and reports necessary for effective 

validation and assessment of the Joint 

Commission’s survey process. 

++ Determine the adequacy of staff 

and other resources. 

++ Review the Joint Commission’s 

ability to provide adequate funding for 

performing required surveys. 

++ Confirm the Joint Commission’s 

policies with respect to whether surveys 

are announced or unannounced. 

++ Obtain the Joint Commission’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 May 13, 

2011 proposed notice also solicited 

public comments regarding whether the 

Joint Commission’s requirements meet 

or exceed the Medicare CoPs for CAHs. 

We received one comment in response 

to our proposed notice. 

The commenter expressed strong 

support for the Joint Commission’s 

application for CAH deeming authority. 

The commenter stated that the Joint 

Commission’s standards are clearly 

written and closely align with the 

Medicare CoPs, and that the Joint 

Commission’s accreditation program 

provides CAHs with a viable alternative 

to other healthcare AOs. 

IV. Provisions of the Final Notice 

A. Differences Between the Joint 

Commission’s Standards and 

Requirements for Accreditation and 

Medicare’s Conditions and Survey 

Requirements 

We compared the Joint Commission’s 

CAH accreditation requirements and 

survey process with the Medicare CoPs 

and survey process as outlined in the 

State Operations Manual (SOM). Our 

review and evaluation of the Joint 

Commission’s deeming application, 

which were conducted as described in 

section III of this final notice, yielded 

the following: 

• To meet the requirements at 

§ 485.618(c)(2), the Joint Commission 

revised its crosswalk to include the 

requirement that an organization’s 


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59136 Federal Register / Vol. 76, No. 185 / Friday, September 23, 2011 / Notices 

medical staff and the person directly 

responsible for operation of the facility 

approve contractual agreements. 

• To meet the requirements at 

§ 485.623(b)(2), the Joint Commission 

revised its crosswalk and survey process 

to address the proper routine storage 

and prompt disposal of trash. 

• To meet the requirements at 

§ 485.631(c)(2), the Joint Commission 

revised its crosswalk to address the 

requirement that physician assistants, 

nurse practitioners, or clinical nurse 

specialists provide services in 

accordance with the CAH’s policies. 

• To meet the requirements at 

§ 485.635(a)(3)(iii), the Joint 

Commission revised its standards to 

include guidelines for the maintenance 

of health care records, and procedures 

for the periodic review and evaluation 

of the services furnished by the CAH. 

• To meet the requirements at 

§ 485.635(f) through (f)(2), the Joint 

Commission revised its crosswalk to 

include the patient visitation right 

standards and related survey process 

revisions. 

• To meet the requirements at 

§ 485.638(a)(2), the Joint Commission 

revised its crosswalk to address the 

requirement that medical records are 

readily accessible. 

• To meet the requirements at 

§ 485.639(b)(1), the Joint Commission 

revised its standards to include the 

requirement that a qualified practitioner 

must examine the patient immediately 

before surgery to evaluate the risk of the 

procedure to be performed. 

• To meet the requirements at 

§ 485.639(b)(2), the Joint Commission 

revised its standards to include the 

requirement that a qualified practitioner 

examine each patient before surgery to 

evaluate the risk of anesthesia. 

• To meet the requirements at 

§ 485.639(b)(3), the Joint Commission 

revised its standards to address the 

requirement that a qualified practitioner 

must evaluate each patient for proper 

anesthesia recovery before discharge 

from the CAH. 

• To meet the requirements at 

§ 485.643(f), the Joint Commission 

revised its glossary to ensure that the 

definition of organ includes ‘‘intestines 

(or multivisceral organs).’’ 

• To meet the requirements at 

§ 485.645(d)(1), the Joint Commission 

revised its crosswalk to include 

standards which address the residents’ 

right to send and receive mail that is not 

opened. 

• To meet the requirements at 

§ 412.27(d)(6)(i), the Joint Commission 

revised its crosswalk to include the 

requirement that programs be directed 

toward restoring and maintaining 

optimal levels of physical and 

psychosocial functioning. 

• To meet the requirements at 

§ 412.29(c), the Joint Commission 

revised it crosswalk to include 

standards to ensure patients receive 

social services, psychological services 

(including neuropsychological services), 

orthotic and prosthetic services, as 

needed. 

• To meet the requirements at 

§ 482.13(h) through (h)(4), the Joint 

Commission revised its crosswalk to 

include the patient visitation right 

standards and related survey process 

revisions. 

• To meet the requirements at 

§ 482.30(d)(3), the Joint Commission 

revised its standards to ensure that 

written notification regarding the 

admission to or continued stay in the 

hospital when it is not medically 

necessary, is given no later than 2 days 

after this determination has been made. 

• To meet the requirements at 

§ 482.41(b)(1)(i), the Joint Commission 

revised its standards to require quarterly 

testing of tamper and water flow 

devices. 

• To meet the requirements at 

§ 482.41(b)(8), the Joint Commission 

revised its standards to ensure the CAH 

maintains written evidence of regular 

inspections and approval by State or 

local fire control agencies for the entire 

CAH. 

• To meet the requirements at 

§ 482.51, the Joint Commission revised 

its standards to ensure that if the 

hospital provides surgical services, the 

services are well organized and 

provided in accordance with acceptable 

standards of practice and if outpatient 

surgical services are offered the services 

must be consistent in quality with 

inpatient care in accordance with the 

complexity of services offered. 

• To meet the requirements at 

§ 488.4(a)(7), the Joint Commission 

revised its survey process to include 

policies and procedures with respect to 

the withholding or removal of 

accreditation status or requirements, 

and other actions taken by the Joint 

Commission in response to 

noncompliance with standards and 

requirements. 

• To meet the requirements at section 

2728 of the State Operations Manual 

(SOM), the Joint Commission modified 

its policies regarding timeframes for 

sending and receiving a plan of 

correction (PoC). 

• To meet the requirements at 

§ 488.12, the Joint Commission modified 

its policies and procedures to ensure its 

survey files are complete. 

B. Term of Approval 

Based on the review and observations 

described in section III of this final 

notice, we have determined that the 

Joint Commission’s requirements for 

CAHs meet or exceed our requirements. 

Therefore, we approve the Joint 

Commission as a national accreditation 

organization for CAHs that request 

participation in the Medicare program, 

effective November 21, 2011 through 

November 21, 2017. 

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). 

Authority: Section 1865 of the Social 

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

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: August 31, 2011. 

Donald M. Berwick, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2011–24496 Filed 9–22–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–2377–PN] 

Medicare and Medicaid Programs; 

Application by Community Health 

Accreditation Program for Continued 

Deeming Authority for Home Health 

Agencies 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed notice. 

SUMMARY: This proposed notice with 

comment period acknowledges the 

receipt of a deeming application from 

the Community Health Accreditation 

Program (CHAP) for continued 

recognition as a national accrediting 

organization for home health agencies 

(HHAs) that wish to participate in the 

Medicare or Medicaid programs. 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, we publish a notice that 


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