Federal Register / Vol. 88, No. 172 / Thursday, September 7, 2023 / Notices 61595 

Total Annual Hours: 3,320. (For policy 

questions regarding this collection, 

contact Lori Ashby at 410–786–6322.) 

Dated: August 31, 2023. 

William N. Parham, III, 

Director, Paperwork Reduction Staff, Office 

of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2023–19211 Filed 9–6–23; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3437–FN] 

Medicare and Medicaid Programs: 

Application From the Accreditation 

Commission for Health Care, Inc. for 

Continued Approval of its Ambulatory 

Surgical Center (ASC) Accreditation 

Program 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice announces our 

decision to approve the Accreditation 

Commission for Health Care, Inc for 

continued recognition as a national 

accrediting organization for Ambulatory 

Surgical Centers that wish to participate 

in the Medicare or Medicaid programs. 

DATES: The decision announced in this 

notice is applicable on September 22, 

2023 through September 22, 2027. 

FOR FURTHER INFORMATION CONTACT: Joy 

Webb, (410) 786–1667; Erin Imhoff, 

(410) 786–2337. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Ambulatory Surgical Centers (ASCs) 

are distinct entities that operate 

exclusively for the purpose of 

furnishing outpatient surgical services 

to patients. Under the Medicare 

program, eligible beneficiaries may 

receive covered services from an ASC, 

provided that certain requirements are 

met. Section 1832(a)(2)(F)(i) of the 

Social Security Act (the Act) establishes 

distinct criteria for facilities seeking 

designation as an ASC. 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 

416 specify the conditions that an ASC 

must meet to participate in the Medicare 

program, the scope of covered services, 

and the conditions for Medicare 

payment for ASCs. 

Generally, to enter into an agreement, 

an ASC must first be certified by a state 

survey agency (SA) as complying with 

the conditions or requirements set forth 

in part 416 of our Medicare regulations. 

Thereafter, the ASC is subject to regular 

surveys by a SA 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 a Centers for 

Medicare & Medicaid Services (CMS) 

approved national accrediting 

organization (AO) that all applicable 

Medicare conditions are met or 

exceeded, we may deem that provider 

entities as having met the requirements. 

Accreditation by an AO is voluntary and 

is not required for Medicare 

participation. 

If an AO is recognized by the 

Secretary of the Department of Health 

and Human Services 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. The 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 AOs are set forth at 

§ 488.5. The regulations at 

§ 488.5(e)(2)(i) require AOs to reapply 

for continued approval of its 

accreditation program every 6 years or 

sooner as determined by CMS. 

Accreditation Commission for Health 

Care’s (ACHC’s) current term of 

approval for its ASC accreditation 

program expires September 22, 2023. 

II. Application Approval Process 

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

provides a statutory timetable to ensure 

that our review of applications for CMSapproval of an accreditation program is 

conducted in a timely manner. The Act 

provides us 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 

On April 3, 2023, we published a 

proposed notice in the Federal Register 

(88 FR 19645), announcing ACHC’s 

request for continued approval of its 

Medicare ASC accreditation program. In 

the April 3, 2023, proposed notice, we 

detailed our evaluation criteria. Under 

section 1865(a)(2) of the Act and in our 

regulations at § 488.5, we conducted a 

review of ACHC’s Medicare ASC 

accreditation application in accordance 

with the criteria specified by our 

regulations, which include, but are not 

limited to the following: 

• An 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 ASC surveyors; (4) 

ability to investigate and respond 

appropriately to complaints against 

accredited ASCs; and (5) survey review 

and decision-making process for 

accreditation. 

• The comparison of ACHC’s 

Medicare ASC accreditation program 

standards to our current Medicare ASC 

conditions for coverage (CfCs). 

• A documentation review of ACHC’s 

survey process to do the following: 

++ 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 ACHC accredited ASCs. 

++ Evaluate ACHC’s procedures for 

monitoring accredited ASCs 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 SA 

through a validation survey, the SA 

monitors corrections as specified at 

§ 488.9(c)). 

++ Assess ACHC’s ability to report 

deficiencies to the surveyed ASCs and 

respond to the ASC’s plans of correction 

in a timely manner. 

++ Establish ACHC’s ability to 

provide CMS 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. 


ddrumheller on DSK120RN23PROD with NOTICES1
61596 Federal Register / Vol. 88, No. 172 / Thursday, September 7, 2023 / Notices 

++ Confirm ACHC’s policies and 

procedures to avoid conflicts of interest, 

including the appearance of conflicts of 

interest, involving individuals who 

conduct surveys or participate in 

accreditation decisions. 

++ Obtain ACHC’s agreement to 

provide CMS 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. Analysis of and Responses to Public 

Comments on the Proposed Notice 

In accordance with section 

1865(a)(3)(A) of the Act, the April 3, 

2023, proposed notice also solicited 

public comments regarding whether 

ACHC’s requirements met or exceeded 

the Medicare CfCs for ASCs. We 

received two (2) timely pieces of 

correspondence. 

Comment: Two commenters 

expressed support for ACHC and their 

ASC accreditation program and 

encouraged CMS to approve them for 

continued recognition as a national AO 

for ASCs. 

Response: We appreciate the support 

from commenters and agree that ACHC 

should be approved for continued 

recognition as a national AO for ASCs 

that wish to participate in the Medicare 

or Medicaid programs. 

V. 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 ASC 

accreditation requirements and survey 

process with the Medicare CfCs of part 

416, and the survey and certification 

process requirements of parts 488 and 

489. Our review and evaluation of 

ACHC’s ASC accreditation application, 

which were conducted as described in 

section III of this notice, yielded the 

following areas where, as of the date of 

this notice, ACHC has completed 

revising its standards and certification 

processes in order to— 

• Meet the standard’s requirements of 

all the following regulations: 

++ Section 416.44(a), to address that 

an ASC ‘‘must provide a functional and 

sanitary environment for the provision 

of surgical services.’’ 

++ Section 416.44(b)(2), to address the 

requirements regarding Life Safety Code 

(LSC) waivers. 

++ Section 416.45(a), to address the 

regulatory language for granting 

privileges in accordance with 

recommendations from qualified 

medical personnel. 

++ Section 416.54(d)(2), to clarify the 

cycle of testing for the ASC’s emergency 

preparedness plans. 

In addition to the standards review, 

CMS also reviewed ACHC’s comparable 

survey processes, which were 

conducted as described in section III of 

this notice, and yielded the following 

areas where, as of the date of this notice, 

ACHC has completed revising its survey 

processes to demonstrate that it uses 

survey processes that are comparable to 

state survey agency processes by: 

++ Revising the compliant policies 

and processes to align with the State 

Operations Manual, Chapter 5 guidance. 

In particular, ACHC’s Administrative 

Review Offsite Investigation process to 

align with the triage process to track and 

trend for potential focus areas during 

the next onsite survey or complete an 

onsite complaint investigation. 

++ Revising ACHC’s ASC 

Accreditation Process policies to 

include the applicable sections of the 

Health Care Facilities Code (HCFC) 

National Fire Protection Agency (NFPA 

99) in accordance with section 

416.44(c). 

++ Ensuring that all ASC LSC 

surveyors have received comparable, 

adequate training or have sufficient 

experience to make them qualified to 

survey health care facilities to both the 

2012 LSC and 2012 NFPA 99 

requirements. 

++ Ensuring that each deficiency 

citation of the Medicare ASC CfCs is 

documented in such a way that is 

comparable to the state survey agencies 

conducting federal Medicare ASC 

surveys. 

++ Ensuring that all findings of noncompliance, that crosswalk to a 

comparable Medicare CfC, is identified 

in the final survey report. 

++ Providing guidance and 

instruction to surveyors on determining 

the appropriate level of citation for LSC 

deficiencies. 

B. Term of Approval 

Based on our review and observations 

described in section III and section V of 

this notice, we approve ACHC as a 

national accreditation organization for 

ASCs that request participation in the 

Medicare program. The decision 

announced in this notice is effective 

September 22, 2023, through September 

22, 2027 (4 years). In accordance with 

§ 488.5(e)(2)(i) the term of the approval 

will not exceed 6 years. 

While ACHC has taken actions based 

on the findings annotated in section 

V.A, of this notice, (Differences Between 

ACHC’s Standards and Requirements for 

Accreditation and Medicare Conditions 

and Survey Requirements) as authorized 

under § 488.8, we will continue ongoing 

review of ACHC’s ASC survey processes 

to ensure full implementation and 

sustained compliance. In keeping with 

CMS’s initiative to increase AO 

oversight broadly and ensure that our 

requested revisions by ACHC are fully 

implemented, CMS expects more 

frequent review of ACHC’s activities in 

the future. 

VI. 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. 3501 et seq.). 

The Administrator of the Centers for 

Medicare & Medicaid Services (CMS), 

Chiquita Brooks-LaSure, having 

reviewed and approved this document, 

authorizes Evell J. Barco Holland, who 

is the Federal Register Liaison, to 

electronically sign this document for 

purposes of publication in the Federal 

Register. 

Evell J. Barco Holland, 

Federal Register Liaison, Center for Medicare 

& Medicaid Services. 

[FR Doc. 2023–19323 Filed 9–6–23; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Submission for OMB Review; Judicial, 

Court, and Attorney Measures of 

Performance: Feedback and 

Implementation (New Collection) 

AGENCY: Children’s Bureau, 

Administration for Children and 

Families, United States Department of 

Health and Human Services. 

ACTION: Request for public comments. 

SUMMARY: The Children’s Bureau, 

Administration for Children and 

Families (ACF), U.S. Department of 

Health and Human Services (HHS), is 

proposing to collect data for a new 

descriptive study, Judicial, Court, and 

Attorney Measures of Performance 

(JCAMP): Feedback and 

Implementation. This expands on 

earlier work around technical 

assistance, as approved under Office of 

Management and Budget (OMB) #: 

0970–0593. 


ddrumheller on DSK120RN23PROD with NOTICES1