[Federal Register Volume 88, Number 189 (Monday, October 2, 2023)]
[Notices]
[Pages 67755-67757]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-21724]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3443-FN]


Medicare and Medicaid Programs; Application From the Center for 
Improvement in Healthcare Quality for Initial CMS Approval of Its 
Psychiatric Hospital

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces our decision to approve the Center for 
Improvement in Healthcare Quality (CIHQ) as a national accrediting 
organization (AO) for psychiatric hospitals that wish to participate in 
the Medicare or Medicaid programs.

DATES: The decision announced in this notice is applicable on November 
1, 2023 through November 1, 2027.

FOR FURTHER INFORMATION CONTACT: Donald Howard, (410) 786-6764 or 
Lillian Williams, (410) 786-8636.

SUPPLEMENTARY INFORMATION: 

I. Background

    Under the Medicare program, eligible beneficiaries may receive 
covered services from a psychiatric hospital

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provided certain requirements established by the Secretary of the 
Department of Health and Human Services (the Secretary) are met. 
Section 1861(f) of the Social Security Act (the Act) establishes 
distinct criteria for facilities seeking designation as a psychiatric 
hospital under Medicare. Regulations concerning provider agreements and 
supplier approval 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 482 subpart A, B, C, 
and E, specify the minimum conditions that a psychiatric hospital must 
meet to participate in the Medicare program, the scope of covered 
services, and the conditions for Medicare payment for psychiatric 
hospitals.
    Generally, to enter into a provider agreement with the Medicare 
program, a psychiatric hospital must first be certified by a State 
Survey Agency as complying with the conditions or requirements set 
forth in part 482 subpart A, B, C, and E of our regulations. 
Thereafter, the psychiatric hospital is subject to regular surveys by a 
State Survey Agency to determine whether it continues to meet the 
Medicare requirements. There is an alternative, however, to surveys by 
State agencies. Certification 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 accrediting 
organization (AO) that all applicable Medicare conditions are met or 
exceeded, we may treat the provider entity as having met those 
conditions, that is, we may ``deem'' the provider entity 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 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. A national 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 Sec.  488.5. The regulations at Sec.  
488.5(e)(2)(i) require the AO to reapply for continued approval of its 
accreditation program every 6 years or sooner as determined by CMS.

II. Application Approval Process

    Section 1865(a)(2) of the Act and our regulations at Sec.  488.5 
require that our findings concerning review and approval of an AO's 
requirements consider, among other factors, the applying AO'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 
that were not in compliance with the conditions or requirements; and 
their ability to provide us with the necessary data for validation.
    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 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 May 22, 2023 Federal Register (88 FR 32772), we published a 
proposed notice announcing CIHQ's request for approval of its Medicare 
psychiatric hospital accreditation program. In the proposed notice, we 
detailed our evaluation criteria. In accordance with section 1865(a)(2) 
of the Act and regulations at Sec.  488.5, we conducted a review of 
CIHQ's Medicare psychiatric hospital accreditation application in 
accordance with the criteria specified by our regulations, which 
include, but are not limited to the following:
    <bullet> An onsite administrative review of CIHQ's: (1) Corporate 
policies; (2) financial and human resources available to accomplish the 
proposed surveys; (3) procedures for training, monitoring, and 
evaluation of its psychiatric hospital surveyors; (4) ability to 
investigate and respond appropriately to complaints against accredited 
psychiatric hospitals; and (5) survey review and decision-making 
process for accreditation.
    <bullet> The comparison of CIHQ's Medicare psychiatric hospital 
accreditation program standards to our current Medicare hospitals 
Conditions of Participation (CoPs) and psychiatric hospital special 
CoPs.
    <bullet> A documentation review of CIHQ's psychiatric hospital 
survey process to do the following:
    ++ Determine the composition of the survey team, surveyor 
qualifications, and CIHQ 's ability to provide continuing surveyor 
training.
    ++ Compare CIHQ's processes to those we require of State Survey 
Agencies, including periodic re-survey and the ability to investigate 
and respond appropriately to complaints against accredited psychiatric 
hospitals.
    ++ Evaluate CIHQ's procedures for monitoring psychiatric hospitals 
it has found to be out of compliance with CIHQ's program requirements. 
(This pertains only to monitoring procedures when CIHQ 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.  488.9(c)(1)).
    ++ Assess CIHQ's ability to report deficiencies to the surveyed 
hospital and respond to the psychiatric hospital's plan of correction 
in a timely manner.
    ++ Establish CIHQ'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 CIHQ's staff and other resources.
    ++ Confirm CIHQ's ability to provide adequate funding for 
performing required surveys.
    ++ Confirm CIHQ's policies with respect to surveys being 
unannounced.
    ++ Confirm CIHQ'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 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 we may require, including corrective action 
plans.
    ++ As authorized under Sec.  488.8(h), CMS reserves the right to 
conduct onsite observations of accrediting organization operations at 
any time as part of the ongoing review and continuing oversight of an 
AO's performance.
    In accordance with section 1865(a)(3)(A) of the Act, the May 22, 
2023 proposed notice also solicited public comments regarding whether 
CIHQ's requirements met or exceeded the Medicare CoPs for psychiatric

[[Page 67757]]

hospitals. No comments were received in response to the proposed 
notice.

IV. Provisions of the Final Notice

A. Differences Between CIHQ's Standards and Requirements for 
Accreditation and Medicare Conditions and Survey Requirements

    We compared CIHQ's psychiatric hospital accreditation program 
requirements and survey process with the Medicare CoPs at 42 CFR part 
482 subpart A, B, C and E, and the survey and certification process 
requirements of parts 488 and 489. Our review and evaluation of CIHQ's 
psychiatric hospital application, which were conducted as described in 
section III of this final notice, yielded the following areas where, as 
of the date of this final notice, CIHQ has revised its standards and 
certification processes in order to meet the requirements at Sec.  
488.26(b). CIHQ revised its requirements to provide additional guidance 
and instruction to surveyors on determining the appropriate level of 
citation for Life Safety Code deficiencies.

B. Term of Approval

    Based on our review and observations described in section III of 
this final notice, we have determined that CIHQ's psychiatric hospital 
accreditation program requirements meet or exceed our requirements, and 
its survey processes are also comparable. Therefore, we approve CIHQ as 
a national AO for psychiatric hospitals that request participation in 
the Medicare program, effective November 1, 2023 through November 1, 
2027.

V. 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 Chyana Woodyard, who is the Federal Register 
Liaison, to electronically sign this document for purposes of 
publication in the Federal Register.

    Dated: September 22, 2023.
Chyana Woodyard,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-21724 Filed 9-29-23; 8:45 am]
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