100498 Federal Register / Vol. 89, No. 239 / Thursday, December 12, 2024 / Notices 

Useful. A measure is useful if it 

provides information useful for quality 

improvement programs, with the ability 

to capture variation in performance 

across reporting entities. 

Additional Considerations. In 

addition to the criteria listed above, 

AHRQ aims to consider the extent to 

which measures: 

• Identify an important gap in 

diagnostic performance; 

• Contribute to the solution of a 

diagnostic safety problem; 

• Are broadly applicable to a 

population-level diagnostic safety 

opportunity; 

• Could be used to lessen health 

disparities. 

AHRQ requests responses to the 

following questions: 

1. Are you currently working on any 

initiatives related to diagnostic 

excellence, diagnostic safety, or 

diagnostic quality? If so, please 

describe. If you are working on 

diagnostic excellence initiatives, which 

ones would benefit from publicly 

available measurement tools or 

resources? Are there specific resources 

that you would like to see from AHRQ? 

If so, please describe. 

2. If you are currently measuring 

diagnostic excellence in your 

organization, what measure(s) are you 

using? How do you use these measures 

(e.g., for quality improvement efforts, to 

track population health) and what 

motivated the use of such measures? 

What data sources are you using? What 

data model are you using to map data 

to standardized concepts (e.g., 

Observational Medical Outcomes 

Partnership (OMOP) Common Data 

Model, others)? Please specify your 

organization type (e.g., state/local health 

department, professional society, 

healthcare system, research 

organization, etc.) in your answer. 

3. If you or your organization are not 

currently measuring diagnostic 

excellence, what diagnostic excellence 

measures might be helpful to your 

organization? Please specify your 

organization type in your answer. 

4. If standardized measures with 

national benchmarks were made 

available through software by AHRQ, 

how likely would you be to use them? 

What characteristics (e.g., risk 

adjustment, frequency counts) or 

features (e.g., statistical programming 

languages, data model platforms, 

technology [web or cloud-based 

applications]) of such measures would 

facilitate their use and usefulness 

within your organization? 

5. AHRQ is considering the diagnostic 

excellence-related measures listed here: 

https://bit.ly/41mg3i6. We invite 

comments on: 

a. The extent to which these measures 

meet the ‘‘Criteria’’ listed above; and 

b. The extent to which these measures 

address the ‘‘Additional 

Considerations’’ listed above. 

6. AHRQ invites any additional 

comments related to potential AHRQ 

measures of diagnostic excellence. 

AHRQ is interested in all of the 

questions listed above, but respondents 

are welcome to address as many or as 

few as they choose and to address 

additional areas of interest not listed. It 

is helpful to identify the question to 

which a particular answer corresponds. 

This RFI is for planning purposes 

only and should not be construed as a 

policy, solicitation for applications, or 

as an obligation on the part of the 

Government to provide support for any 

ideas in response to it. AHRQ will use 

the information submitted in response 

toto this RFI at its discretion and will 

not provide comments to any 

respondent’s submission. However, 

responses to this RFI may be reflected 

in future solicitation(s) or policies. The 

information provided will be analyzed 

and may appear in reports. 

Dated: December 6, 2024. 

Marquita Cullom, 

Associate Director. 

[FR Doc. 2024–29134 Filed 12–11–24; 8:45 am] 

BILLING CODE P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3461–FN] 

Medicare and Medicaid Programs; 

Approval of Application by the 

Accreditation Association for 

Ambulatory Healthcare for Continued 

CMS-Approval of Its Ambulatory 

Surgical Center Accreditation Program 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice acknowledges the 

approval of an application by the 

Accreditation Association for 

Ambulatory Healthcare 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 November 20, 2024 

through November 20, 2029. 

FOR FURTHER INFORMATION CONTACT: 

Joy Webb, (410) 786–1667. 

Joann Fitzell, (410) 786–4280. 

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 certain requirements are met. 

Section 1832(a)(2)(F)(i) of the Social 

Security Act (the Act) establishes 

distinct criteria for a facility 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 in order 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 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 may deem that 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 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 Accreditation Association for 

Ambulatory Healthcare’s (AAAHC’s) 

current term of approval for its ASC 

program expires December 20, 2024. 


ddrumheller on DSK120RN23PROD with NOTICES1
Federal Register / Vol. 89, No. 239 / Thursday, December 12, 2024 / Notices 100499 

II. Application Approval Process 

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 June 27, 2024, we published a 

proposed notice in the Federal Register 

(89 FR 53626 through 53627), 

announcing AAAHC’s request for 

continued approval of its Medicare ASC 

accreditation program. In the proposed 

notice, we detailed our evaluation 

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

Act and in our regulations at § 488.5, we 

conducted a review of AAAHC’s 

Medicare ASC accreditation renewal 

application in accordance with the 

criteria specified by our regulations, 

which include, but are not limited to, 

the following: 

• An administrative review of 

AAAHC: (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 equivalency of AAAHC’s 

standards for ASCs as compared with 

Medicare’s Conditions for Coverage 

(CfCs) for ASCs. 

• AAAHC’s 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 AAAHC’s 

processes to those of State agencies, 

including survey frequency, and the 

ability to investigate and respond 

appropriately to complaints against 

accredited facilities. 

++ AAAHC’s processes and 

procedures for monitoring an ASC 

found out of compliance with AAAHC’s 

program requirements. These 

monitoring procedures are used only 

when AAAHC identifies 

noncompliance. If noncompliance is 

identified through validation reviews or 

complaint surveys, the State survey 

agency monitors corrections as specified 

at § 488.9(c)(1). 

++ AAAHC’s capacity to report 

deficiencies to the surveyed facilities 

and respond to the facility’s plan of 

correction in a timely manner. 

++ AAAHC’s capacity to provide 

CMS with electronic data and reports 

necessary for the effective validation 

and assessment of the organization’s 

survey process. 

++ The adequacy of AAAHC staff and 

other resources, and its financial 

viability. 

++ AAAHC’s capacity to adequately 

fund required surveys. 

++ AAAHC’s policies with respect to 

whether surveys are announced or 

unannounced, to ensure that surveys are 

unannounced. 

++ AAAHC’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. 

++ AAAHC’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). 

IV. Analysis of and Response to Public 

Comments on the Proposed Notice 

In accordance with section 

1865(a)(3)(A) of the Act, the June 27, 

2024 proposed notice also solicited 

public comments regarding whether 

AAAHC’s requirements met or exceeded 

the Medicare CfCs for ASCs. We did not 

receive any public comments. 

V. Provisions of the Final Notice 

A. Differences Between AAAHC’s 

Standards and Requirements for 

Accreditation and Medicare Conditions 

and Survey Requirements 

We compared AAAHC’s ASC 

accreditation program requirements and 

survey process with the Medicare CfCs 

at 42 CFR part 416, and the survey and 

certification process requirements of 

parts 488 and 489. Our review and 

evaluation of AAAHC’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, 

AAAHC has completed revising its 

standards and survey processes in order 

to do all of the following: 

• Section 488.5(a)(7), to ensure the 

ASC Life Safety Code (LSC) surveyors 

meet the minimum qualifications, 

competencies, and experience. 

Additionally, provide mentor training to 

future LSC site visitor trainees and 

retain evaluation records in the LSC site 

visitor training records. 

• Section 488.5(a)(4)(vii), to add the 

Health Care Facilities Code timeframes 

on waivers allowance. 

• Section 488.26(b), to clarify 

surveyor training, specific to manner 

and degree, including consideration of 

the risk of occupants associated with 

system deficiencies. 

• Principle of Documentation, Exhibit 

7A, to ensure that all Plans of Correction 

contain identifiers and survey reports 

are comparable to CMS’ standards. 

• Infection Control Surveyor 

Worksheet, Exhibit 351, to ensure that 

the Infection Control Worksheets are 

completed thoroughly to assess 

compliance with infection control 

breaches by gathering complete 

information. 

• State Operations Manual Appendix 

L, to address the sample selection of 

files reviewed to include open and 

closed record review. 

B. Term of Approval 

Based on our review and observations 

described in Sections III. and V. of this 

final notice, we approve AAAHC as a 

national accreditation organization for 

ASCs that request participation in the 

Medicare program, effective December 

20, 2024 through December 20, 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 


ddrumheller on DSK120RN23PROD with NOTICES1
100500 Federal Register / Vol. 89, No. 239 / Thursday, December 12, 2024 / Notices 

1See Further Consolidated Appropriations Act, 

2024, Public Law 118–47, div. C, title II sec. 216 

(incorporating by reference Consolidated 

Appropriations Act, 2020, Public Law 116–93, div. 

D, title II, sec. 216, prohibiting the Department of 

Homeland Security from using funds provided by 

the Act or any other Act, except in certain 

circumstances, ‘‘to place in detention, remove, refer 

for a decision whether to initiate removal 

proceedings, or initiate removal proceedings against 

a sponsor, potential sponsor, or member of a 

household of a sponsor or potential sponsor of an 

unaccompanied alien child (as defined in section 

462(g) of the Homeland Security Act of 2002 (6 

U.S.C. 279(g)) based on information shared by the 

Secretary of Health and Human Services,’’ with 

certain limited exceptions in sec. 216(b) regarding 

sponsors convicted of serious crimes affecting the 

welfare of the child); see also 45 CFR 410.1303(h). 

purposes of publication in the Federal 

Register. 

Vanessa Garcia, 

Federal Register Liaison, Centers for Medicare 

& Medicaid Services. 

[FR Doc. 2024–29152 Filed 12–11–24; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Privacy Act of 1974; System of 

Records 

AGENCY: Office of Refugee Resettlement 

(ORR), Administration for Children and 

Families (ACF), Department of Health 

and Human Services (HHS). 

ACTION: Notice of a modified system of 

records. 

SUMMARY: In accordance with the 

requirements of the Privacy Act of 1974, 

as amended, the Department of Health 

and Human Services (HHS) is modifying 

an existing system of records 

maintained by the Office of Refugee 

Resettlement (ORR) within HHS’ 

Administration for Children and 

Families (ACF), System No. 09–80– 

0321, ORR Division of Children’s 

Services Records (being renamed ORR 

Unaccompanied Children Bureau (UCB) 

Administrative Program Records). 

DATES: In accordance with 5 U.S.C. 

552a(e)(4) and (11), this system of 

records is effective January 13, 2025, 

subject to a 30-day period in which to 

comment on the new and revised 

routine uses, described below. Please 

submit any comments by January 13, 

2025. 

ADDRESSES: The public should address 

written comments on this notice to 

Hanan Abu Lebdeh, Senior Agency 

Officer for Privacy, by mail at 

Administration for Children and 

Families, Mary E. Switzer Building, 330 

C Street SW, Washington, DC 20201, or 

by email at hanan.abulebdeh@

acf.hhs.gov. 

FOR FURTHER INFORMATION CONTACT: 

General questions about the modified 

system of records may be submitted to 

Edward Nazarko, Technical Lead for UC 

Technology, Administration for 

Children and Families, by mail or email 

at 330 C Street SW, Washington, DC 

20201, or edward.nazarko@acf.hhs.gov, 

or by phone at (202) 839–0615. 

SUPPLEMENTARY INFORMATION: 

I. Background on ORR Responsibilities, 

Affecting SORN 09–80–0321 

Within ORR, the Unaccompanied 

Children Bureau (UCB) administers 

ORR’s responsibilities for the 

placement, care, and services provided 

to unaccompanied children who are in 

Federal custody by reason of their 

immigration status. Such 

responsibilities are carried out pursuant 

to ORR’s statutory and delegated 

authorities under section 462 of the 

Homeland Security Act of 2002 (HSA), 

6 U.S.C. 279, section 235 of the William 

Wilberforce Trafficking Victims 

Protection Reauthorization Act of 2008 

(TVPRA), 8 U.S.C. 1232, and regulations 

at 45 CFR parts 410 and 411. Systems 

of records maintained by ORR are 

‘‘mixed,’’ in that they contain, or could 

contain, records pertaining to both (1) 

individuals who are covered by the 

Privacy Act and (2) individuals who are 

not covered by the Privacy Act. SORN 

09–80–0321 includes a statement to this 

effect in the ‘‘Categories of Individuals’’ 

section. 

The Privacy Act applies only to 

individuals who are U.S. citizens or 

non-U.S. citizens lawfully admitted for 

permanent residence in the United 

States. As a matter of discretion, ORR 

treats information maintained in its 

mixed systems of records as being 

subject to the protections of the Privacy 

Act, regardless of whether the 

information relates to individuals 

covered by the Privacy Act. This policy 

implements a 1975 Office of 

Management and Budget (OMB) 

recommendation to apply, as a matter of 

discretion, the administrative provisions 

of the Privacy Act to records about 

individuals in mixed systems of records 

(referred to as the non-U.S. persons 

policy). See OMB Privacy Act 

Implementation: Guidelines and 

Responsibilities, 40 FR 28948, 28951 

(July 9, 1975). 

The Privacy Act defines a ‘‘routine 

use’’ with respect to the disclosure of a 

record to mean ‘‘the use of such record 

for a purpose which is compatible with 

the purpose for which it was collected.’’ 

5 U.S.C. 552a(a)(7). Because ORR is not 

an immigration enforcement agency— 

but rather is responsible for placing 

unaccompanied children with vetted 

and approved sponsors, providing care 

and services to unaccompanied children 

who are in Federal custody by reason of 

their immigration status, and identifying 

and assessing the suitability of a 

potential sponsor for each child—it is 

incompatible with ORR’s program 

purposes to share information in a 

system of records, particularly 

confidential mental health or behavioral 

information in children’s case files, for 

immigration enforcement purposes. See 

H.R. Rep No. 116–450, at 185 (2020) 

(directing ORR to ‘‘refrain from sharing 

any information with immigration 

courts for master calendar hearings, 

where the court is not making any 

decisions about the child’s custody,’’ 

and to ‘‘develop policies and protocols 

to ensure the confidentiality of 

counseling and mental health services 

provided to unaccompanied children, 

and of all related documentation, 

including case notes and records of 

therapists and other clinicians, and to 

incorporate these policies into the ORR 

policy guide . . .’’); see also id. at 230 

(noting the inclusion in that year’s 

appropriations a provision ‘‘prohibiting 

the use of funds to share information 

provided by unaccompanied children 

during mental health or therapeutic 

services with the Department of 

Homeland Security or the Department of 

Justice for the purposes of immigration 

enforcement.’’). In addition, consistent 

with TVPRA 8 U.S.C. 1232(c) and HSA, 

6 U.S.C. 279(b), information shared by 

HHS, with certain limited exceptions, 

cannot be used to enforce immigration 

laws against an unaccompanied child’s 

sponsor, potential sponsor or a member 

of their household.1 Accordingly, SORN 

09–80–0321 mentions at the start of the 

‘‘Routine Uses’’ section that disclosures 

for immigration enforcement purposes 

will not be made under routine uses, but 

would be made only with the subject 

individual’s prior written consent. 

ORR may share relevant information 

in the system of records for other law 

enforcement and child welfare 

purposes, such as anti-trafficking 

investigations, child welfare 

investigations, or other investigations 

that seek to ensure that children are 

‘‘protected from traffickers and other 

persons seeking to victimize or 

otherwise engage such children in 

criminal, harmful, or exploitative 

activity.’’ 8 U.S.C. 1232(c)(1). 

Accordingly, SORN 09–80–0321 


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