Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Notices 89015 

++ QUAD A’s capacity to adequately 

fund required surveys. 

++ QUAD A’s policies with respect to 

whether surveys are announced or 

unannounced, to ensure that surveys are 

unannounced. 

++ QUAD A’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. 

++ QUAD A’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 June 13, 

2024 proposed notice also solicited 

public comments regarding whether 

QUAD A’s requirements met or 

exceeded the Medicare CfCs for ASCs. 

No public comments were received in 

response to our proposed notice. 

V. Provisions of the Final Notice 

A. Differences Between QUAD A’s 

Standards and Requirements for 

Accreditation and Medicare Conditions 

and Survey Requirements 

We compared QUAD A’s ASC 

accreditation requirements and survey 

process with the Medicare CfCs of parts 

416, and the survey and certification 

process requirements of parts 488 and 

489. Our review and evaluation of 

QUAD A’s ASC application, which were 

conducted as described in section III. of 

this final notice, yielded the following 

areas where, as of the date of this notice, 

QUAD A has completed revising its 

standards and certification processes in 

order to do all of the following: 

• Meet the standard’s requirements of 

all of the following regulations: 

++ Section 416.40, to ensure that 

ASCs comply with state licensure 

requirements. 

++ Section 416.44(b)(2), to clarify that 

an AO may recommend a waiver of 

specific provisions of the Life Safety 

Code (LSC), which would result in 

unreasonable hardship upon an ASC, 

but only if the waiver will not adversely 

affect the health and safety of the 

patients. 

We also reviewed QUAD A’s 

comparable survey processes, which 

were conducted as described in section 

III. of this final notice, and yielded the 

following areas where, as of the date of 

this notice, QUAD A has completed 

revising its survey processes in order to 

demonstrate that it uses survey 

processes that are comparable to state 

survey agency processes by: 

++ Updating QUAD A’s survey 

procedures to ensure all areas of the 

Health Care Facilities Code (HCFC) are 

surveyed and reflected in QUAD A’s 

policies and surveyor guides. 

++ Providing clarification to QUAD 

A’s survey scheduling policies to 

explain the number of LSC surveyors 

required for survey teams at small, 

medium, and large ASCs. 

++ Revising QUAD A policy to ensure 

surveyor qualifications include 

experience with the LSC and HCFC. 

++ Providing additional surveyor 

training to ensure that LSC deficiency 

citations contain a sufficient level of 

detail and quantifiable information 

comparable to what is required by the 

CMS Principles of Documentation in 

Chapter 9 of the State Operations 

Manual. 

++ Providing a process to ensure that 

any findings on the ASC surveyor 

infection control worksheet are cited 

appropriately in the final survey report. 

++ Providing a process to ensure the 

appropriate sample of patient records, 

including open and closed records, is 

reviewed during surveys based on the 

ASC’s case volume. 

B. Term of Approval 

Based on our review described in 

section III. and section V. of this final 

notice, we approve QUAD A as a 

national AO for ASCs that request 

participation in the Medicare program. 

The decision announced in this final 

notice is effective November 27, 2024 

through November 27, 2029. In 

accordance with § 488.5(e)(2)(i) the term 

of the approval will not exceed 6 years. 

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 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. 2024–26124 Filed 11–8–24; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3457–FN] 

Medicare and Medicaid Programs; 

Approval of Application by Community 

Health Accreditation Partner (CHAP) 

Inc. for Continued CMS-Approval of Its 

Hospice Accreditation Program 

AGENCY: Centers for Medicare & 

Medicaid Services, HHS. 

ACTION: Notice. 

SUMMARY: This notice acknowledges the 

approval of an application by 

Community Health Accreditation 

Partner Inc., for continued CMSapproval as a national accrediting 

organization for its hospice programs 

that wish to participate in the Medicare 

or Medicaid programs. 

DATES: The decision announced in this 

notice is applicable November 20, 2024 

through November 20, 2029. 

FOR FURTHER INFORMATION CONTACT: 

Lillian Williams, (410) 786–8636. 

Erin Imhoff, (410) 786–2337. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Under the Medicare program, eligible 

beneficiaries may receive covered 

services in a hospice provided certain 

requirements are met by the hospice. 

Section 1861(dd) of the Social Security 

Act (the Act) establishes distinct criteria 

for facilities seeking designation as a 

hospice. 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 418 specify 

the conditions that a hospice must meet 

in order to participate in the Medicare 

program, the scope of covered services, 

and the conditions for Medicare 

payment for hospices. 

Generally, to enter into an agreement, 

a hospice must first be certified as 

complying with the conditions set forth 

in part 418 and recommended to the 

Centers for Medicare & Medicaid (CMS) 

for participation by a state survey 

agency. Thereafter, the hospice is 


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89016 Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Notices 

subject to periodic surveys by a state 

survey agency to determine whether it 

continues to meet these conditions. 

However, there is an alternative to 

certification surveys by state agencies. 

Accreditation by a nationally recognized 

Medicare accreditation program 

approved by CMS may substitute for 

both initial and ongoing state review. 

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

that, if the Secretary of the Department 

of Health and Human Services (the 

Secretary) finds that accreditation of a 

provider entity by an approved national 

accrediting organization (AO) meets or 

exceeds all applicable Medicare 

conditions, we may treat the provider 

entity as having met those conditions; 

that is, we may ‘‘deem’’ the provider 

entity to be in compliance. 

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 AO’s 

approved program may be deemed to 

meet the Medicare conditions. A 

national AO applying for CMS approval 

of their accreditation program under 42 

CFR 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. Section 488.5(e)(2)(i) requires 

AOs to reapply for continued approval 

of its Medicare accreditation program 

every 6 years or sooner as determined 

by CMS. The Community Health 

Accreditation Partner’s (CHAP’S) term 

of approval as a recognized 

accreditation program for its hospice 

accreditation program expires 

November 20, 2024. 

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 

In the June 7, 2024, Federal Register 

(89 FR 48646), we published a proposed 

notice announcing CHAP’s request for 

continued approval of its Medicare 

hospice accreditation program. In the 

June 7, 2024, 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 CHAP’s Medicare hospice 

accreditation application in accordance 

with the criteria specified by our 

regulations, which include, but are not 

limited to the following: 

• A virtual 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 hospice surveyors; (4) 

ability to investigate and respond 

appropriately to complaints against 

accredited hospices; and (5) survey 

review and decision-making process for 

accreditation. 

• The comparison of CHAP’s 

Medicare hospice accreditation program 

standards to our current Medicare 

hospice CoPs. 

• A documentation review of CHAP’s 

survey process to— 

++ Determine the composition of the 

survey team, surveyor qualifications, 

and CHAP’s ability to provide 

continuing surveyor training. 

++ Compare CHAP’s processes to 

those we require of state survey 

agencies, including periodic resurvey 

and the ability to investigate and 

respond appropriately to complaints 

against accredited hospices. 

++ Evaluate CHAP’s procedures for 

monitoring hospices it has found to be 

out of compliance with CHAP’s program 

requirements. (This pertains only to 

monitoring procedures when CHAP 

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 § 488.9(c)). 

++ Assess CHAP’s ability to report 

deficiencies to the surveyed hospice and 

respond to the hospice’s plan of 

correction in a timely manner. 

++ Establish CHAP’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 CHAP’s 

staff and other resources. 

++ Confirm CHAP’s ability to provide 

adequate funding for performing 

required surveys. 

++ Confirm CHAP’s policies with 

respect to surveys being unannounced. 

++ Confirm CHAP’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 CHAP’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. 

In accordance with section 

1865(a)(3)(A) of the Act, the June 7, 

2024 proposed notice also solicited 

public comments regarding whether 

CHAP’s requirements met or exceeded 

the Medicare CoPs for hospices. We 

received one comment, which was out 

of the scope of the proposed notice. 

IV. Provisions of the Final Notice 

A. Differences Between CHAP’s 

Standards and Requirements for 

Accreditation and Medicare Conditions 

and Survey Requirements 

We compared CHAP’s hospice 

accreditation requirements and survey 

process with the Medicare CoPs of part 

418, and the survey and certification 

process requirements of parts 488 and 

489. Our review and evaluation of 

CHAP’s hospice application, which 

were conducted as described in section 

III. of this final notice, yielded the 

following areas where, as of the date of 

this notice, CHAP has completed 

revising its standards and certification 

processes in order to meet the 

requirements at: 

• Section 418.52(c)(5), to include 

reference to 45 CFR parts 160 and 164. 

• Section 418.62(a), to include 

reference to § 418.114. 

• Section 418.64(b)(2), to address the 

requirement that state law permits 

registered nurses to see, treat, and write 

orders for patients, then registered 

nurses may provide services to 

beneficiaries receiving hospice care. 

• Section 418.64(c), to indicate that 

services are not only provided under the 

direction of a physician but also by a 

qualified social worker. 

• Section 418.66(a)(3)(i) through (iv), 

to include all the requirements that are 

entailed in ‘‘good faith efforts’’ to hire 

nurses. 

• Section 418.74(d), to address the 

requirement that if a hospice wishes to 

receive a 1-year extension, it must 

submit a request to CMS before the 

expiration of the waiver period and 

certify that conditions under which it 

originally requested the waiver have not 

changed since the initial waiver was 

granted. 


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Federal Register / Vol. 89, No. 218 / Tuesday, November 12, 2024 / Notices 89017 

• Section 418.76(k)(2), to address the 

requirement for instructions to be 

prepared by the interdisciplinary group. 

• Section 418.104(c), to include 

reference to 45 CFR parts 160 and 164. 

• Section 418.106(b)(1)(iii), to address 

this requirement to allow a physician 

assistant to order drugs in accordance 

with state scope of practice 

requirements and hospice policy. 

• Section 418.110(d)(2), to address 

the regulatory Life Safety Code (LSC) 

waiver requirement. 

• Section 418.110(d)(3), to address 

the requirement that the provisions of 

the adopted edition of the LSC do not 

apply in a State if we find that a fire and 

safety code imposed by State law 

adequately protects patients in hospices. 

• Section 418.110(e)(2), to address the 

Health Care Facilities Code waiver 

allowance. 

In addition to the standards review, 

we also reviewed CHAP’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, 

CHAP has completed revising its survey 

processes to demonstrate that it uses 

survey processes that are comparable to 

state survey agency processes by: 

• Revising CHAP’s surveyor guide to 

include comparable guidance relating to 

situations that might require 

discontinuation or refusal to conduct 

exit conference activities or share with 

CMS additional materials that are used 

by CHAP hospice program surveyors. 

• Revising CHAP’s surveyor guidance 

to be comparable with Appendix M 

related to inpatient hospice care. 

• Revising CHAP’s surveyor guide to 

include comparable guidance on 

reviewing personnel records for training 

requirements. 

• Revising CHAP’s Hospice 

Accreditation Processes and resources 

to include the applicable sections of the 

Health Care Facilities Code (HCFC) and 

National Fire Protection Agency (NFPA 

101) in accordance with § 418.110. 

• Ensuring that all Hospice LSC 

surveyors have received comparable, 

adequate training or have sufficient 

experience to make them qualified to 

survey health care facilities to both the 

2012 editions of LSC and HCFC, and 

2013 edition of the Fire Safety 

Evaluation System NFPA 101A Fire 

Safety for Health Care Occupancies. 

• Revising CHAP’s survey process to 

require pre-survey preparation to 

include review of the 2012 editions of 

the LSC and HCFC. 

• Revising CHAP’s LSC Survey 

Checklist and LSC citation 

documentation process to ensure all 

applicable regulations, LSC/HCFC 

sections, and CHAP standards are 

referenced in the survey report and 

provide surveyor training, as necessary. 

B. Term of Approval 

Based on our review and observations 

described in section III. of this final 

notice, we approve CHAP as a national 

accreditation organization for hospices 

that request participation in the 

Medicare program, effective November 

20, 2024 through November 20, 2029. 

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 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. 2024–26123 Filed 11–8–24; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

[Document Identifier: OS–4040–0019] 

Agency Information Collection 

Request; 60-Day Public Comment 

Request 

AGENCY: Office of the Secretary, 

Department of Health and Human 

Services. 

ACTION: Notice. 

SUMMARY: In compliance with the 

requirement of the Paperwork 

Reduction Act of 1995, the Office of the 

Secretary (OS), Department of Health 

and Human Services, is publishing the 

following summary of a proposed 

collection for public comment. 

DATES: Comments on the ICR must be 

received on or before January 13, 2025. 

ADDRESSES: Submit your comments to 

sagal.musa@hhs.gov or by calling (202) 

205–2634. 

FOR FURTHER INFORMATION CONTACT: 

When submitting comments or 

requesting information, please include 

the document identifier 4040–0019–60D 

and project title for reference, to Sagal 

Musa, email: sagal.musa@hhs.gov, or 

call (202) 205–2634 the Reports 

Clearance Officer. 

SUPPLEMENTARY INFORMATION: Interested 

persons are invited to send comments 

regarding this burden estimate or any 

other aspect of this collection of 

information, including any of the 

following subjects: (1) The necessity and 

utility of the proposed information 

collection for the proper performance of 

the agency’s functions; (2) the accuracy 

of the estimated burden; (3) ways to 

enhance the quality, utility, and clarity 

of the information to be collected; and 

(4) the use of automated collection 

techniques or other forms of information 

technology to minimize the information 

collection burden. 

Title of the Collection: Project 

Abstract Summary. 

Type of Collection: Extension. 

OMB No. 4040–0019. 

Abstract: The Project Abstract 

Summary form provides the Federal 

grant-making agencies an alternative to 

the Standard Form 424 data set and 

form. Agencies may use Project Abstract 

Summary form for grant programs not 

required to collect all the data that is 

required on the SF–424 core data set 

and form. Project Abstract Summary 

form is used by organizations to apply 

for Federal financial assistance in the 

form of grants. This form is evaluated by 

Federal agencies as part of the overall 

grant application. This IC expires on 

February 28, 2025. Grants.gov seeks a 

three-year clearance of these collections. 


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