Federal Register / Vol. 78, No. 167 / Wednesday, August 28, 2013 / Notices 53149 

meeting. Electronic copies of all meeting 

materials will be posted on the CMS and 

NCHS Web sites prior to the meeting at 

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

ICD9ProviderDiagnosticCodes/03_

meetings.asp#TopOfPage and http://

www.cdc.gov/nchs/icd/icd9cm_

maintenance.htm 

Contact Persons for Additional 

Information: Donna Pickett, Medical 

Systems Administrator, Classifications 

and Public Health Data Standards Staff, 

NCHS, 3311 Toledo Road, Room 2337, 

Hyattsville, Maryland 20782, email 

dfp4@cdc.gov, telephone 301–458–4434 

(diagnosis); Mady Hue, Health 

Insurance Specialist, Division of Acute 

Care, CMS, 7500 Security Boulevard, 

Baltimore, Maryland, 21244, email 

marilu.hue@cms.hhs.gov, telephone 

410–786–4510 (procedures). 

The Director, Management Analysis 

and Services Office, has been delegated 

the authority to sign Federal Register 

notices pertaining to announcements of 

meetings and other committee 

management activities, for both the 

Centers for Disease Control and 

Prevention, and the Agency for Toxic 

Substances and Disease Registry. 

Catherine Ramadei, 

Acting Director, Management Analysis and 

Services Office, Centers for Disease Control 

and Prevention. 

[FR Doc. 2013–20976 Filed 8–27–13; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3281–FN] 

Medicare and Medicaid Programs: 

Continued Approval of American 

Osteopathic Association/Healthcare 

Facilities Accreditation Program (AOA/ 

HFAP’s) Hospital Accreditation 

Program 

AGENCY: Centers for Medicare & 

Medicaid Services, HHS. 

ACTION: Final notice. 

SUMMARY: This final notice announces 

our decision to approve American 

Osteopathic Association/Healthcare 

Facilities Accreditation Program (AOA/ 

HFAP) for continued recognition as a 

national accrediting organization for 

hospitals that wish to participate in the 

Medicare or Medicaid programs. 

DATES: This final notice is effective 

September 25, 2013 through September 

25, 2019. 

FOR FURTHER INFORMATION CONTACT: 

Valarie Lazerowich, (410) 786–4750. 

Cindy Melanson, (410) 786–0310. 

Patricia Chmielewski, (410) 786–6899. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Under the Medicare program, eligible 

beneficiaries may receive covered 

services in a hospital provided certain 

requirements are met. Section 1861(e) of 

the Social Security Act (the Act) 

establishes distinct criteria for facilities 

seeking designation as a 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 part 482 specify the 

conditions that a hospital must meet to 

participate in the Medicare program, the 

scope of covered services, and the 

conditions for Medicare payment for 

hospitals. 

Generally, to enter into an agreement, 

a hospital must first be certified by a 

State survey agency as complying with 

the conditions or requirements set forth 

in part 482. Thereafter, the hospital is 

subject to regular surveys by a State 

survey agency to determine whether it 

continues to meet these requirements. 

However, there is an alternative 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 that all 

applicable Medicare conditions are met 

or exceeded, CMS will deem those 

provider entities as having met the 

requirements. Accreditation by an 

accrediting organization is voluntary 

and is not required for Medicare 

participation. 

If an accrediting organization 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 

would be deemed to have met the 

Medicare conditions. A national 

accrediting organization applying for 

approval of its accreditation program 

under part 488, subpart A, must provide 

CMS with reasonable assurance that the 

accrediting organization requires the 

accredited provider entities to meet 

requirements that are at least as 

stringent as the Medicare conditions. 

Our regulations concerning the 

approval of accrediting organizations 

are set forth at § 488.4 and § 488.8(d)(3). 

The regulations at § 488.8(d)(3) require 

accrediting organizations to reapply for 

continued approval of its accreditation 

program every 6 years or sooner as 

determined by CMS. 

The American Osteopathic 

Association/Healthcare Facilities 

Accreditation Program’s (AOA/HFAP) 

current term of approval for their 

hospital accreditation program expires 

September 25, 2013. 

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 March 22, 2013, we published a 

proposed notice in the Federal Register 

(78 FR 17677) announcing AOA/HFAP’s 

request for approval of its hospital 

accreditation program. In the proposed 

notice, we detailed our evaluation 

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

Act and in our regulations at § 488.4 and 

§ 488.8, we conducted a review of AOA/ 

HFAP’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 

AOA/HFAP’s: (1) Corporate policies; (2) 

financial and human resources available 

to accomplish the proposed surveys; (3) 

procedures for training, monitoring, and 

evaluation of its surveyors; (4) ability to 

investigate and respond appropriately to 

complaints against accredited facilities; 

and (5) survey review and decisionmaking process for accreditation. 

• The comparison of AOA/HFAP’s 

accreditation to our current Medicare 

hospital conditions of participation. 

• A documentation review of AOA/

HFAP’s survey process to: 

++ Determine the composition of the 

survey team, surveyor qualifications, 

and AOA/HFAP’s ability to provide 

continuing surveyor training. 

++ Compare AOA/HFAP’s processes 

to those of state survey agencies, 

including survey frequency, and the 


wreier-aviles on DSK5TPTVN1PROD with NOTICES
53150 Federal Register / Vol. 78, No. 167 / Wednesday, August 28, 2013 / Notices 

ability to investigate and respond 

appropriately to complaints against 

accredited facilities. 

++ Evaluate AOA/HFAP’s procedures 

for monitoring hospitals out of 

compliance with AOA/HFAP’s program 

requirements. The monitoring 

procedures are used only when AOA/

HFAP identifies noncompliance. If 

noncompliance is identified through 

validation reviews, the State survey 

agency monitors corrections as specified 

at § 488.7(d). 

++ Assess AOA/HFAP’s ability to 

report deficiencies to the surveyed 

facilities and respond to the facility’s 

plan of correction in a timely manner. 

++ Establish AOA/HFAP’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 staff 

and other resources. 

++ Confirm AOA/HFAP’s ability to 

provide adequate funding for 

performing required surveys. 

++ Confirm AOA/HFAP’s policies 

with respect to whether surveys are 

announced or unannounced. 

++ Obtain AOA/HFAP’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. 

In accordance with section 

1865(a)(3)(A) of the Act, the March 22, 

2013 proposed notice also solicited 

public comments regarding whether 

AOA/HFAP’s requirements met or 

exceeded the Medicare conditions of 

participation for hospitals. We received 

no comments in response to our 

proposed notice. 

IV. Provisions of the Final Notice 

A. Differences Between AOA/HFAP’s 

Standards and Requirements for 

Accreditation and Medicare’s 

Conditions and Survey requirements 

We compared AOA/HFAP’s hospital 

requirements and survey process with 

the Medicare conditions of participation 

and survey process as outlined in the 

State Operations Manual (SOM). Our 

review and evaluation of AOA/HFAP’s 

hospital application, which were 

conducted as described in section III of 

this final notice, yielded the following: 

• To meet the requirements at 

§ 482.41(a)(1), AOA/HFAP revised its 

standards to include the requirement for 

Type 1 Essential Electrical Systems 

(EES) generators in all hospitals. 

• To meet the requirements at 

§ 482.41(b)(1)(ii), AOA/HFAP revised its 

standards to ensure roller latches no 

longer exist on hospital corridor doors. 

• To meet the requirements at 

§ 482.41(c)(4), AOA/HFAP revised its 

standards to include the National Fire 

Protection Association (NFPA) 99:1999: 

5–4.1.1 requirement that addresses the 

capability of controlling the relative 

humidity at a level of 35 percent or 

greater within anesthetizing locations. 

• To meet the requirements at § 488.4 

(a) (6), AOA/HFAP revised its 

‘‘Complaint/Incident Management 

Policy,’’ to ensure all onsite complaint 

surveys are documented on a survey 

report. 

• To meet the requirements of Section 

2728 of the SOM, AOA/HFAP will 

continue to use its internal monitoring 

plan to ensure timeframes for sending or 

receiving a plan of correction (PoC) are 

met. 

• To meet the requirements of Section 

2728B of the SOM, AOA/HFAP will 

continue to conduct monthly internal 

audits to ensure accepted PoC’s contain 

all of the required elements. 

B. Term of Approval 

Based on our review and observations 

described in section III of this final 

notice, we have determined that AOA/ 

HFAP’s hospital accreditation program 

requirements meet or exceed our 

requirements. Therefore, we approve 

AOA/HFAP as a national accreditation 

organization for hospitals that request 

participation in the Medicare program, 

effective September 25, 2013 through 

September 25, 2019. 

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). 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program; No. 93.773 Medicare—Hospital 

Insurance Program; and No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: July 19, 2013. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services, HHS. 

[FR Doc. 2013–21008 Filed 8–23–13; 4:15 pm] 

BILLING CODE P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Health Resources and Services 

Administration 

Advisory Committee on the Maternal, 

Infant and Early Childhood Home 

Visiting Program Evaluation; Notice of 

Meeting 

ACTION: Notice of Meeting: Advisory 

Committee on the Maternal, Infant and 

Early Childhood Home Visiting Program 

Evaluation (MIECHVE). 

Authority: Section 10(a)(2) of the Federal 

Advisory Committee Act (Pub. L. 92–463), 

notice is hereby given of the following 

meeting: 

Name: Advisory Committee on the 

Maternal, Infant, and Early Childhood 

Home Visiting Program Evaluation. 

Date and Time: September 12, 2013, 

2–6 PM ET. 

Place: Webinar. 

The Advisory Committee on the 

Maternal, Infant and Early Childhood 

Home Visiting Program Evaluation 

(Committee) will meet for its fourth 

session on September 12, 2013, 2–6 PM 

ET. The purpose of the meeting is to 

allow the Committee to comment on the 

progress of the analysis plan of the 

MIHOPE project. The general public can 

join the meeting via webinar by logging 

onto https://www4.gotomeeting.com/

register/330659039, and then follow the 

instructions for registering. Participants 

should launch the webinar no later than 

1:40 a.m. EST in order for the logistics 

to be established for participation in the 

call. If there are technical problems 

gaining access to the call or webinar, 

please call 888–569–3848 or press *0 

during the call, and for GoToWebinar 

technical support call (800 263 6317) 

Meeting Registration: General public 

participants are asked to register for the 

conference by going to the registration 

Web site at https://

www4.gotomeeting.com/register/

330659039. 

Special Accommodations: Attendees 

with special needs requiring 

accommodations such as large print 

materials or other accommodations may 

make requests when registering at the 

online Web site by answering the 

‘‘Special accommodations’’ question on 

the registration page: https://

www4.gotomeeting.com/register/

330659039. 

Agenda: The meeting will include 

updates on the progress of the 

evaluation, the outline for the report, 


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