Source: https://www.federalregister.gov/documents/2013/02/22/2013-04093/medicare-and-medicaid-programs-application-from-the-center-for-improvement-in-healthcare-quality
Timestamp: 2017-08-17 05:09:00
Document Index: 186256683

Matched Legal Cases: ['art 489', 'art 488', 'art 482', 'art 482', 'art 488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488']

Federal Register :: Medicare and Medicaid Programs; Application From the Center for Improvement in Healthcare Quality (CIHQ) for CMS-Approval of Its Hospital Accreditation Program
A Notice by the Centers for Medicare & Medicaid Services on 02/22/2013
78 FR 12325
12325-12327 (3 pages)
CMS-3280-PN
2013-04093
CMS-2013-0045
https://www.federalregister.gov/d/2013-04093 https://www.federalregister.gov/d/2013-04093
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on March 25, 2013.
In commenting, refer to file code (CMS-3280-PN). Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (choose only one of the ways listed):
1. Electronically. You may submit electronic comments on specific issues in 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-3280-PN, P.O. Box 8016, Baltimore, MD 21244-8010.
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-3280-PN, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written ONLY to the following addresses.
a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.
Cindy Melanson, (410) 786-0310. Patricia Chmielewski, (410) 786-6899. Monda Shaver, (410) 786-3410.
End Further Info End Preamble Start Supplemental Information Start Printed Page 12326
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 criteria for facilities seeking designation as a hospital. Regulations concerning provider agreements are located at 42 CFR part 489 and those pertaining to activities relating to the survey and certification of facilities are located 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 programs, 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 of our regulations. Thereafter, the hospital is subject to regular surveys by a State survey agency 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 an approved national accrediting organization that all applicable Medicare conditions are met or exceeded, we 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 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 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 an accrediting organization to reapply for continued approval of its accreditation program every 6 years or sooner as determined by CMS.
Section 1865(a)(2) of the Act and our regulations at § 488.8(a) require that our findings concerning review and approval of a national accrediting organization's requirements, consider among other factors, the applying accrediting organization'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 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. We have 210 days from the receipt of a completed application to publish a notice of approval or denial of the application.
The purpose of this proposed notice is to inform the public of CIHQ's request for approval of its hospital accreditation program. This notice also solicits public comment on whether CIHQ's requirements meet or exceed Medicare's conditions of participation for hospitals.
CIHQ submitted all the necessary materials to enable us to make a determination concerning its request for approval of its hospital accreditation program. This application was determined to be complete on January 4, 2013. Under section 1865(a)(2) of the Act and our regulations at § 488.8 (Federal review of accrediting organizations), our review and evaluation of CIHQ will be conducted in accordance with, but not necessarily limited to, the following factors:
The equivalency of CIHQ's standards for a hospital as compared with CMS' hospital conditions of participation.
CIHQ's survey process to determine the following:
++ CIHQ's composition of the survey team, surveyor qualifications, and the ability of the organization to provide continuing surveyor training.
++ CIHQ's processes compared to those of State agencies, including survey frequency, and the ability to investigate and respond appropriately to complaints against accredited facilities.
++ CIHQ's processes and procedures for monitoring a hospital that is out of compliance with CIHQ's program requirements. These monitoring procedures are used only when CIHQ identifies noncompliance. If noncompliance is identified through validation reviews or complaint surveys, the State survey agency monitors corrections as specified at § 488.7(d).
++ CIHQ's capacity to report deficiencies to the surveyed facilities and respond to the facility's plan of correction in a timely manner.
++ CIHQ'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 CIHQ's staff and other resources, and its financial viability.
++ CIHQ's capacity to adequately fund required surveys.
++ CIHQ's policies with respect to whether surveys are announced or unannounced.
++ CIHQ'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).
Because of the large number of public comments we normally receive on Start Printed Page 12327 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.
[FR Doc. 2013-04093 Filed 2-21-13; 8:45 am]