Source: http://thefederalregister.com/2012/08/24/2012-20199.html
Timestamp: 2018-09-21 02:03:19
Document Index: 493346036

Matched Legal Cases: ['art 488', '§ 488', '§ 488', '§ 488', '§ 488', '§ 488', '§ 488', '§ 482', '§ 482', '§ 482', '§ 489', '§ 489', '§ 489', '§ 482', '§ 489', '§ 488']

Federal Register | Medicare and Medicaid Programs; Continued Approval of Det Nor
[CMS-3258-FN]
SUMMARY: This final notice announces our decision to approve the Det Norske Veritas Healthcare (DNVHC) for continued recognition as a national accrediting organization for hospitals that wish to participate in the Medicare or Medicaid programs. A hospital that participates in Medicaid must also meet the Medicare conditions of participation as referenced in 42 CFR 488.5(3)(b) and 42 CFR 488.6(b). This approval is effective September 26, 2012, through September 26, 2018.
DATES: This final notice is effective September 26, 2012, through September 26, 2018.
FOR FURTHER INFORMATION CONTACT: Barbara Easterling, (410) 786-0482; Cindy Melanson, (410) 786-0310; or Patricia Chmielewski, (410) 786-6899.
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 us 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 us.
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 statute provides CMS 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 theFederal Registerthat 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 theFederal Registerapproving or denying the application.
In the March 23, 2012Federal Register(77 FR 17070), we published a proposed notice in the announcing DNVHC's request for approval of its hospital accreditation program. In the March 23, 2012 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 DNVHC'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 DNVHC'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 decision-making process for accreditation.
• The comparison of DNVHC's accreditation to our current Medicare hospital conditions of participation.
• A documentation review of DNVHC's survey process to determine the following:
+ Evaluate DNVHC's procedures for monitoring hospitals out of compliance with DNVHC's program requirements. The monitoring procedures are used only when DNVHC identifies noncompliance. If noncompliance is identified through validation reviews, the state survey agency monitors corrections as specified at § 488.7(d).
IV. Provisions of the Final Notice A. Differences Between DNVHC's Standards and Requirements for Accreditation and Medicare's Conditions and Survey Requirements
• To meet the requirements at § 482.13(a), DNVHC revised its standards to include language to address the hospital's responsibility to protect and promote each patient's rights.
• To meet the requirements at § 482.13(a)(2), DNVHC revised its standards to require prompt resolution of patient grievances.
• To meet the requirements at § 482.13(b)(3), DNVHC revised its standards to include the requirements at § 489.100, § 489.102, § 489.104 regarding advanced directive.
• To meet the requirements at § 482.52(b), DNVHC revised its standards to ensure anesthesia services are consistent with the needs and resources of the hospital.
• To meet the requirements at § 489.13, DNVHC modified its policies related to the accreditation effective date.
• To meet the survey process requirements in Appendix A of the SOM, DNVHC revised its policy outlining the minimum number of inpatient records required for review during an accreditation survey.
• To meet the requirements at § 488.4, DNVHC revised its policies to require a copy of the surveyor's annual evaluation be included in the surveyor's file.
• DNVHC revised its complaint policies to ensure all complaint investigations are conducted inaccordance with the requirements at SOM chapter five.
• DNVHC revised its policies and procedures to clarify that they do not have authority to advise facilities regarding certification issues. Instead, DNVHC must contact the CMS Regional Office on facility specific certification issues for consultation and direction.
(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: August 9, 2012. Marilyn Tavenner, Acting Administrator, Centers for Medicare & Medicaid Services.