Federal Register / Vol. 89, No. 25 / Tuesday, February 6, 2024 / Notices 8203 

in the Medicare Fee-for-Service (FFS), 

and Medicaid programs that 

successfully demonstrated meaningful 

use of CEHRT. In their first payment 

year, Medicaid EPs, eligible hospitals 

including MA organizations and CAHs 

could adopt, implement, or upgrade to 

certified EHR technology. It also 

allowed for negative payment 

adjustments in the Medicare FFS and 

MA programs starting in 2015 for EPs, 

eligible hospitals including MA 

organizations and CAHs participating in 

Medicare that are not meaningful users 

of CEHRT. The Medicaid Promoting 

Interoperability Program did not 

authorize negative payment 

adjustments, but its participants were 

eligible for incentive payments until 

December 31, 2021, when the program 

ended. 

In CY 2017, we began collecting data 

from eligible hospitals and CAHs to 

determine the application of the 

Medicare payment adjustments. This 

information collection was also used to 

make incentive payments to eligible 

hospitals in Puerto Rico from 2016 

through 2021. At this time, Medicare 

eligible professionals no longer reported 

to the EHR Incentive Program, as they 

began reporting under the Merit-based 

Incentive Payment System’s (MIPS) 

Promoting Interoperability Performance 

Category. In 2019, the EHR Incentives 

Program for eligible hospitals and CAHs 

was subsequently renamed the Medicare 

Promoting Interoperability Program. In 

subsequent years, we have focused on 

balancing reporting burden for eligible 

hospitals and CAHs while also 

implementing changes designed to 

incentivize the advanced use of CEHRT 

to support health information exchange, 

interoperability, advanced quality 

measurement, and maximizing clinical 

effectiveness and efficiencies. 

In the FY 2024 IPPS/LTCH PPS final 

rule, we finalized the following policy 

changes for eligible hospitals and CAHs 

that attest to CMS under the Medicare 

Promoting Interoperability Program. 

None of the policies we finalized will 

affect the information collection burden: 

(i) to adopt three electronic clinical 

quality measures (eCQMs) beginning 

with the CY 2025 reporting period: (1) 

Hospital Harm—Pressure Injury eCQM; 

(2) Hospital Harm—Acute Kidney Injury 

eCQM; and (3) Excessive Radiation Dose 

or Inadequate Image Quality for 

Diagnostic Computed Tomography 

(CMT) in Adults eCQM; (ii) to modify 

the Safety Assurance Factors for EHR 

Resilience (SAFER) Guides measure to 

require eligible hospitals and CAHs to 

submit a ‘‘yes’’ attestation to fulfill the 

measure beginning with the EHR 

reporting period in CY 2024; and (iii) to 

establish an EHR reporting period of a 

minimum of any continuous 180-day 

period in CY 2025. Form Number: 

CMS–10552 (OMB control number: 

0938–1278); Frequency: Annually; 

Affected Public: State, Local or Private 

Government; Business and for-profit 

and Not-for-profit; Number of 

Respondents: 4,500; Total Annual 

Responses: 4,500; Total Annual Hours: 

29,625. (For policy questions regarding 

this collection, contact Jessica Warren at 

410–786–7519.) 

William N. Parham, III, 

Director, Division of Information Collections 

and Regulatory Impacts, Office of Strategic 

Operations and Regulatory Affairs. 

[FR Doc. 2024–02306 Filed 2–5–24; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3454–PN] 

Medicare and Medicaid Programs; 

Application by DNV Healthcare USA 

Inc. (DNV) for Continued CMS 

Approval of Its Psychiatric Hospital 

Accreditation Program 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed notice. 

SUMMARY: This proposed notice 

acknowledges the receipt of a deeming 

application from DNV Healthcare USA 

Inc. (DNV) for continued Centers for 

Medicare & Medicaid Services (CMS) 

approval of its psychiatric hospital 

accreditation program. The statute 

requires that within 60 days of receipt 

of an organization’s complete 

application, CMS must 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. 

DATES: To be assured consideration, 

comments must be received at one of 

the addresses provided below, by March 

7, 2024. 

ADDRESSES: In commenting, refer to file 

code CMS–3454–PN. 

Comments, including mass comment 

submissions, must be submitted in one 

of the following three 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 to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–3454–PN, P.O. Box 8010, 

Baltimore, MD 21244–8010. 

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 to the 

following address ONLY: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, Attention: CMS–3454–PN, 

Mail Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: 

Joann Fitzell, (410) 786–4280. 

Lillian Williams, (410) 786–8636. 

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 

website as soon as possible after they 

have been received: http://

www.regulations.gov. Follow the search 

instructions on that website to view 

public comments. CMS will not post on 

Regulations.gov public comments that 

make threats to individuals or 

institutions or suggest that the 

commenter will take actions to harm an 

individual. CMS continues to encourage 

individuals not to submit duplicative 

comments. We will post acceptable 

comments from multiple unique 

commenters even if the content is 

identical or nearly identical to other 

comments. 

I. Background 

Under the Medicare program, eligible 

beneficiaries may receive covered 

services from a psychiatric hospital 

provided certain requirements are met. 

Section 1861(f) of the Social Security 

Act (the Act), establishes distinct 

criteria for facilities seeking designation 

as a psychiatric 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 42 CFR 

part 488. The regulations at 42 CFR 482 

subpart 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. 


ddrumheller on DSK120RN23PROD with NOTICES1
8204 Federal Register / Vol. 89, No. 25 / Tuesday, February 6, 2024 / Notices 

Generally, to enter into an agreement, 

a psychiatric hospital must first be 

certified by a state survey agency (SA) 

as complying with the conditions or 

requirements set forth in part 482, 

subpart E of our regulations. Thereafter, 

the psychiatric hospital is subject to 

regular surveys by an 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 will deem those 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 (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 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 §§ 488.4 and 

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. 

DNV Healthcare USA Inc.’s (DNV’s) 

current term of approval for their 

psychiatric hospital accreditation 

program expires July 30, 2024. 

II. Approval of Deeming Organization 

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

regulations at § 488.5 require that our 

findings concerning review and 

approval of a national 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 found not in compliance with 

the conditions or requirements; and 

ability to provide CMS 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. 

The Act provides us 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 DNV’s request 

for continued approval of its psychiatric 

hospital accreditation program. This 

notice also solicits public comment on 

whether DNV’s requirements meet or 

exceed the Medicare conditions of 

participation (CoPs) for psychiatric 

hospitals. 

III. Evaluation of Deeming Authority 

Request 

DNV submitted all the necessary 

materials to enable us to make a 

determination concerning its request for 

initial approval of its psychiatric 

hospital accreditation program. This 

application was determined to be 

complete on January 2, 2024. Under 

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

regulations at § 488.5 (Application and 

re-application procedures for national 

accrediting organizations), our review 

and evaluation of the DNV will be 

conducted in accordance with, but not 

necessarily limited to, the following 

factors: 

• The equivalency of the DNV 

standards for psychiatric hospitals as 

compared with CMS’ psychiatric 

hospital CoPs. 

• The DNV 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 DNV’s 

processes to those of state agencies, 

including survey frequency, and the 

ability to investigate and respond 

appropriately to complaints against 

accredited facilities. 

++ DNV’s processes and procedures 

for monitoring a psychiatric hospital 

found out of compliance with DNV’s 

program requirements. These 

monitoring procedures are used only 

when DNV identifies noncompliance. If 

noncompliance is identified through 

validation reviews or complaint 

surveys, the state SA monitors 

corrections as specified at § 488.9(c). 

++ DNV’s capacity to report 

deficiencies to the surveyed facilities 

and respond to the facility’s plan of 

correction in a timely manner. 

++ DNV’s capacity to provide CMS 

with electronic data and reports 

necessary for effective validation and 

assessment of the organization’s survey 

process. 

++ The adequacy of DNV’s staff and 

other resources, and its financial 

viability. 

++ DNV’s capacity to adequately 

fund required surveys. 

++ DNV’s policies with respect to 

whether surveys are announced or 

unannounced, to ensure that surveys are 

unannounced. 

++ DNV’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. 

++ DNV’s agreement to provide CMS 

with a copy of the most current 

accreditation survey together with any 

other information related to the survey 

as CMS may require (including 

corrective action plans). 

Upon completion of our evaluation, 

including evaluation of public 

comments received as a result of this 

notice, we will publish a final notice in 

the Federal Register announcing the 

result of our evaluation. 

IV. 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.). 

V. Response to 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 

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. 

The Administrator of the Centers for 

Medicare & Medicaid Services (CMS), 

Chiquita Brooks-LaSure, having 

reviewed and approved this document, 

authorizes Vanessa Garcia, who is the 

Federal Register Liaison, to 

electronically sign this document for 

purposes of publication in the Federal 

Register. 

Vanessa Garcia, 

Federal Register Liaison, Centers for Medicare 

& Medicaid Services. 

[FR Doc. 2024–02342 Filed 2–5–24; 8:45 am] 

BILLING CODE 4120–01–P 


ddrumheller on DSK120RN23PROD with NOTICES1