Medicare and Medicaid Programs: Approval of an Application From the Center for Improvement in Healthcare Quality for Continued CMS Approval of Its Hospital Accreditation Program, 28853-28855 [2017-13207]
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sradovich on DSK3GMQ082PROD with NOTICES
Federal Register / Vol. 82, No. 121 / Monday, June 26, 2017 / Notices
Physicians who provide certain
imaging services (MRI, CT, and PET)
under the in-office ancillary services
exception to the physician self-referral
prohibition are required to provide the
disclosure notice as well as the list of
other imaging suppliers to the patient.
The patient will then be able to use the
disclosure notice and list of suppliers in
making an informed decision about his
or her course of care for the imaging
service. CMS would use the collected
information for enforcement purposes.
Specifically, if we were investigating the
referrals of a physician providing
advanced imaging services under the inoffice ancillary services exception, we
would review the written disclosure in
order to determine if it satisfied the
requirement. Form Number: CMS–
10332 (OMB control number: 0938–
1133); Frequency: Occasionally;
Affected Public: State, Local, and Tribal
Governments; Number of Respondents:
7,100; Total Annual Responses:
759,700; Total Annual Hours: 19,638.
(For policy questions regarding this
collection contact Laura Dash at 410–
786–8623.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Conditions of
Participation for Critical Access
Hospitals (CAH) and Supporting
Regulations; Use: At the outset of the
critical access hospital (CAH) program,
the information collection requirements
for all CAHs were addressed together
under the following information
collection request: CMS–R–48 (OCN:
0938–0328). As the CAH program has
grown in both scope of services and the
number of providers, the burden
associated with CAHs with distinct part
units (DPUs) was separated from the
CAHs without DPUs. Section
1820(c)(2)(E)(i) of the Social Security
Act provides that a CAH may establish
and operate a psychiatric or
rehabilitation DPU. Each DPU may
maintain up to10 beds and must comply
with the hospital requirements specified
in 42 CFR subparts A, B, C, and D of
part 482. Presently, 105 CAHs have
rehabilitation or psychiatric DPUs. The
burden associated with CAHs that have
DPUs continues to be reported under
CMS–R–48, along with the burden for
all 4,890 accredited and non-accredited
hospitals.
The CAH conditions of participation
and accompanying information
collection requirements specified in the
regulations are used by surveyors as a
basis for determining whether a CAH
meets the requirements to participate in
the Medicare program. We, along with
the healthcare industry, believe that the
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availability to the facility of the type of
records and general content of records,
which this regulation specifies, is
standard medical practice and is
necessary in order to ensure the wellbeing and safety of patients and
professional treatment accountability.
Form Number: CMS–10239 (OMB
Control number: 0938–1043);
Frequency: Yearly; Affected Public:
Private sector—Business or other forprofit; Number of Respondents: 1,215;
Total Annual Responses: 144,585; Total
Annual Hours: 24,183. (For policy
questions regarding this collection
contact Mary Collins at 410–786–3189.)
Dated: June 20, 2017.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2017–13198 Filed 6–23–17; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–3338–FN]
Medicare and Medicaid Programs:
Approval of an Application From the
Center for Improvement in Healthcare
Quality for Continued CMS Approval of
Its Hospital Accreditation Program
Centers for Medicare and
Medicaid Services, HHS.
ACTION: Final notice.
AGENCY:
This final notice announces
our decision to approve the Center for
Improvement in Healthcare Quality
(CIHQ) 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 July
26, 2017 through July 26, 2023.
FOR FURTHER INFORMATION CONTACT:
Lillian Williams (410) 786–8638, Monda
Shaver, (410) 786–3410, or Patricia
Chmielewski, (410) 786–6899.
SUPPLEMENTARY INFORMATION:
SUMMARY:
I. Background
A healthcare provider may enter into
an agreement with Medicare to
participate in the program as a hospital
provided certain requirements are met.
Section 1861(e) of the Social Security
Act (the Act) establishes criteria for
providers seeking participation in
Medicare as a hospital. Regulations
concerning Medicare provider
agreements in general are at 42 CFR part
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28853
489 and those pertaining to the survey
and certification for Medicare
participation of providers and certain
types of suppliers are at 42 CFR part
488. The regulations at 42 CFR part 482
specify the specific conditions that a
provider must meet to participate in the
Medicare program as a hospital.
Hospitals that wish to be paid under the
Medicaid program must be approved to
participate in Medicare, in accordance
with 42 CFR 440.10(a)(3)(iii).
Generally, to enter into a Medicare
hospital provider agreement, a facility
must first be certified as complying with
the conditions set forth in part 482 and
recommended to the Centers for
Medicare & Medicaid Services (CMS) for
participation by a State survey agency.
Thereafter, the hospital is 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 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 accrediting
organization is voluntary and is not
required for Medicare participation.
Part 488 subpart A implements the
provisions of section 1865 of the Act
and requires that a national accrediting
organization applying for approval of its
Medicare accreditation program must
provide CMS with reasonable assurance
that the accrediting organization
requires its 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 § 488.5. The regulations at
§ 488.5(e)(2)(i) require an accrediting
organization to reapply for continued
approval of its Medicare accreditation
program every 6 years or sooner as
determined by CMS. The Center for
Improvement in Healthcare Quality’s
(CIHQ’s) term of approval as a
recognized Medicare accreditation
program for hospitals expires July 26,
2017.
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Federal Register / Vol. 82, No. 121 / Monday, June 26, 2017 / Notices
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 30day 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.
sradovich on DSK3GMQ082PROD with NOTICES
III. Provisions of the Proposed Notice
On February 24, 2017, we published
a proposed notice in the Federal
Register (82 FR 11579) announcing
CIHQ’s request for continued approval
of its Medicare 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 § 488.5, we conducted a
review of CIHQ’s Medicare hospital
accreditation application in accordance
with the criteria specified by our
regulations, which include, but are not
limited to the following:
• An onsite administrative review of
CIHQ’s: (1) Corporate policies; (2)
financial and human resources available
to accomplish the proposed surveys; (3)
procedures for training, monitoring, and
evaluation of its hospital surveyors; (4)
ability to investigate and respond
appropriately to complaints against
accredited hospitals; and, (5) survey
review and decision-making process for
accreditation.
• A comparison of CIHQ’s Medicare
accreditation program standards to our
current Medicare hospital Conditions of
Participation (CoPs).
• A documentation review of CIHQ’s
survey process to do the following:
++ Determine the composition of the
survey team, surveyor qualifications,
and CIHQ’s ability to provide
continuing surveyor training.
++ Compare CIHQ’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 hospitals.
++ Evaluate CIHQ’s procedures for
monitoring hospitals it has found to be
out of compliance with CIHQ’s program
requirements. (This pertains only to
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monitoring procedures when CIHQ
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 CIHQ’s ability to report
deficiencies to the surveyed hospitals
and respond to the hospital’s plan of
correction in a timely manner.
++ Establish CIHQ’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 CIHQ’s
staff and other resources.
++ Confirm CIHQ’s ability to provide
adequate funding for performing
required surveys.
++ Confirm CIHQ’s policies with
respect to surveys being unannounced.
++ Obtain 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 we may require, including
corrective action plans.
In accordance with section
1865(a)(3)(A) of the Act, the February
24, 2017 proposed notice also solicited
public comments regarding whether
CIHQ’s requirements met or exceeded
the Medicare CoP for hospitals. There
were no comments submitted.
IV. Provisions of the Final Notice
A. Differences Between CIHQ’s
Standards and Requirements for
Accreditation and Medicare Conditions
and Survey Requirements
We compared CIHQ’s hospital
accreditation requirements and survey
process with the Medicare CoPs at part
482, and the survey and certification
process requirements of parts 488 and
489. CIHQ’s standards crosswalk, which
maps CIHQ’s standards with the
corresponding requirements under the
Medicare CoPs, was also examined to
ensure that the appropriate CMS
regulation was included in citations as
appropriate. We reviewed and evaluated
CIHQ’s hospital application, conducted
as described earlier. As a result, CIHQ
has revised its materials, standards, and
certification processes to reflect the
following Medicare requirements:
• § 482.12: Updated the summary
description of this provision in the
crosswalk to be consistent with its
accreditation standards.
• § 482.12(a)(1) through (10): Updated
the summary description of this
provision in the crosswalk to be
consistent with its accreditation
standards.
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• § 482.12(a)(10): Revised its
standards to address the hospital’s
responsibility to consult directly with
the medical staff.
• § 482.12(c): Updated the summary
description of this provision in the
crosswalk to be consistent with its
accreditation standards.
• § 482.12(c)(1)(ii): Updated the CFR
citation to properly reference the
regulatory requirement on its standards
crosswalk.
• § 482.12(c)(2): Updated the CFR
citation to properly reference the
regulatory requirement on its standards
crosswalk.
• § 482.12(c)(4)(i): Clarified the use of
the word ‘‘develops’’ to indicate if the
condition was present on admission or
developed during the hospitalization on
its standards crosswalk.
• § 482.12(f)(2): Revised its standards
to ensure the medical staff have written
policies and procedures for appraisals of
emergencies, initial treatment and
referral.
• § 482.13(a)(1) and § 482.13(a)(2):
Updated the summary description of
these provisions in the crosswalk to be
consistent with its accreditation
standards.
• § 482.13(a)(2)(i): Revised its
standards to ensure the patient’s right to
submit ‘‘written or verbal’’ grievances.
• § 482.13(a)(2)(ii), § 482.13(b)(3),
§ 482.13(b)(4) and § 482.13(c)(2):
Updated the summary description of
these provisions in the crosswalk to be
consistent with its accreditation
standards.
• § 482.13(e)(5): Updated the CFR
citation to properly reference the
regulatory requirement.
• § 482.13(e)(6), § 482.13(f)(1)(ii),
§ 482.13(g), § 482.13(g)(2), § 482.13(h),
§ 482.21(b)(1), § 482.21(d)(2) and
§ 482.21(d)(4): Updated the summary
description of these provisions in the
crosswalk to be consistent with its
accreditation standards.
• § 482.22(a)(2): Updated its
standards to reflect that temporary
practice privileges are granted by the
governing body.
• § 482.22(b)(1): Updated the
summary description of this provision
in the crosswalk to be consistent with
its accreditation standards.
• § 482.22(b)(3): Revised its standards
to reflect CMS requirements for medical
staff organization and accountability.
• § 482. 22(b)(4): Updated the
summary description of this provision
in the crosswalk to be consistent with
its accreditation standards.
• § 482.23(c)(4): Updated its
standards to fully address requirements
for blood transfusions.
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Federal Register / Vol. 82, No. 121 / Monday, June 26, 2017 / Notices
• § 482.24(b): Updated its standards
to fully address requirements for the
form and retention of medical records.
• § 482.24(c)(2) through (c)(4)(viii):
Updated the Medicare regulatory
language on its standards crosswalk to
ensure that its accreditation standards
are consistent with Medicare standards.
• § 482.25(b)(2)(ii): Updated the
crosswalk and standard to add
references to the Comprehensive Drug
Abuse Prevention and Control Act of
1970.
• § 482.26: Updated the summary
description of this provision in the
crosswalk to be consistent with its
accreditation standards.
• § 482.41: Revised its standards to
reflect the requirements of the ‘‘Physical
Environment’’.
• § 482.43: Revised its standards to
ensure that the hospital discharge
planning process applies to all patients.
• § 482.51(b)(6) and § 482.56(a)(2):
Updated the summary description of
these provisions in the crosswalk to be
consistent with its accreditation
standards.
• § 482.56(b)(2): Revised its standards
to address the requirements at § 409.17
related to physical therapy,
occupational therapy, and speech
language pathology services.
• § 482.57(b)(3): Updated the CFR
citation to properly reference the
regulatory requirement on its crosswalk.
• § 482.57(b)(4): Updated the CFR
citation to properly reference the
regulatory requirement on its crosswalk
and in its accreditation standards.
• § 488.4(a)(6): Revised its standards
to include a process to track and trend
complaints received.
• § 488.5(a)(4)(ii): Revised its
standards to ensure that an appropriate
number of open, inpatient medical
records are fully reviewed during the
survey process.
• § 488.5(a)(4)(iv): Revised its
standards to assure that findings of noncompliance are documented under all
appropriate CMS standards where noncompliance is found; and that adverse
findings for each CoP are reviewed for
manner and degree of non-compliance
and subsequently cited at the
appropriate level (that is, condition
versus standard level).
• § 488.5(a)(7) through (9): Revised its
standards to ensure that newly hired
surveyors receive orientation so as to
ensure AO compliance with these
provisions.
• § 488.26(b): Revised its standards to
improve surveyor documentation to
include the appropriately detailed
deficiency statements that clearly
support the determination of
noncompliance and level of deficiency.
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• § 489.13: Revised its standards to
reflect CMS policy regarding effective
dates of participation in the Medicare
program and develop a plan for
monitoring for sustained compliance.
• CIHQ revised its complaint policy
and procedure to clearly identify the
individual(s) that are responsible for
triaging complaints submitted to the
accrediting organization.
• CIHQ revised its policy to clarify
that an ‘‘Immediate Jeopardy’’ finding
remains cited at the Conditional level,
even if abated while onsite.
B. Term of Approval
Based on our review and observations
described in section III of this final
notice, we have determined that CIHQ’s
hospital program requirements meet or
exceed our requirements. Therefore, we
approve CIHQ as a national
accreditation organization for hospitals
that request participation in the
Medicare program, effective July 26,
2017 through July 26, 2023.
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.).
Dated: June 20, 2017.
Seema Verma,
Administrator, Centers for Medicare &
Medicaid Services.
[FR Doc. 2017–13207 Filed 6–23–17; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Administration for Children and
Families
Submission for OMB Review;
Comment Request
Proposed Projects
Title: Multistate Financial Institution
Data Match and Federally Assisted State
Transmitted Levy (MSFIDM/FAST
Levy).
OMB No.: 0970–0196.
Description: Section 466(a)(17) of the
Social Security Act (the Act) requires
states to establish procedures for their
child support agencies to enter into
agreements with financial institutions
doing business in their state for the
purpose of securing information leading
to the enforcement of child support
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28855
orders. Under 452(m) and
466(a)(17)(A)(i) of the Act, the Secretary
may aid state agencies conducting data
matches with financial institutions
doing business in two or more states by
establishing a centralized and
standardized matching program through
the Federal Parent Locator Service.
To further assist states collect child
support, the federal Office of Child
Support Enforcement (OCSE) worked
with child support agencies and
financial institutions to develop the
Federally Assisted State Transmitted
(FAST) Levy system.
FAST Levy is a central, standardized,
and secure electronic process for child
support agencies and financial
institutions to exchange information
about levying financial accounts to
collect past-due support. OCSE picks up
files created by child support agencies
that contain FAST Levy requests and
distributes them to financial institutions
that use the FAST Levy system. Those
financial institutions create response
files that OCSE picks up and distributes
to the child support agencies.
The MSFIDM/FAST-Levy information
collection activities are authorized by:
42 U.S.C. 652(m), which authorizes
OCSE, through the Federal Parent
Locator Service, to aid state child
support agencies and financial
institutions doing business in two or
more states reach agreements regarding
the receipt from financial institutions,
and the transfer to the state child
support agencies, of information
pertaining to the location of accounts
held by obligors who owe past-due
support; 42 U.S.C. 666(a)(2) and
(c)(1)(G)(ii), which require state child
support agencies in cases in which there
is an arrearage to establish procedures to
secure assets to satisfy any current
support obligation and the arrearage by
attaching and seizing assets of the
obligor held in financial institutions; 42
U.S.C. 666(a)(17)(A), which requires
state child support agencies to establish
procedures under which the state child
support agencies shall enter into
agreements with financial institutions
doing business in the State to develop
and operate, in coordination with
financial institutions, and the Federal
Parent Locator Service (in the case of
financial institutions doing business in
two or more States), a data match
system, using automated data exchanges
to the maximum extent feasible, in
which a financial institution is required
to quarterly provide information
pertaining to a noncustodial parent
owing past-due support who maintains
an account at the institution and, in
response to a notice of lien or levy,
encumber or surrender, assets held; 42
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Agencies
[Federal Register Volume 82, Number 121 (Monday, June 26, 2017)]
[Notices]
[Pages 28853-28855]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-13207]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3338-FN]
Medicare and Medicaid Programs: Approval of an Application From
the Center for Improvement in Healthcare Quality for Continued CMS
Approval of Its Hospital Accreditation Program
AGENCY: Centers for Medicare and Medicaid Services, HHS.
ACTION: Final notice.
-----------------------------------------------------------------------
SUMMARY: This final notice announces our decision to approve the Center
for Improvement in Healthcare Quality (CIHQ) 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 July 26, 2017 through July 26,
2023.
FOR FURTHER INFORMATION CONTACT: Lillian Williams (410) 786-8638, Monda
Shaver, (410) 786-3410, or Patricia Chmielewski, (410) 786-6899.
SUPPLEMENTARY INFORMATION:
I. Background
A healthcare provider may enter into an agreement with Medicare to
participate in the program as a hospital provided certain requirements
are met. Section 1861(e) of the Social Security Act (the Act)
establishes criteria for providers seeking participation in Medicare as
a hospital. Regulations concerning Medicare provider agreements in
general are at 42 CFR part 489 and those pertaining to the survey and
certification for Medicare participation of providers and certain types
of suppliers are at 42 CFR part 488. The regulations at 42 CFR part 482
specify the specific conditions that a provider must meet to
participate in the Medicare program as a hospital. Hospitals that wish
to be paid under the Medicaid program must be approved to participate
in Medicare, in accordance with 42 CFR 440.10(a)(3)(iii).
Generally, to enter into a Medicare hospital provider agreement, a
facility must first be certified as complying with the conditions set
forth in part 482 and recommended to the Centers for Medicare &
Medicaid Services (CMS) for participation by a State survey agency.
Thereafter, the hospital is 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 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 accrediting organization is voluntary and is not required for
Medicare participation.
Part 488 subpart A implements the provisions of section 1865 of the
Act and requires that a national accrediting organization applying for
approval of its Medicare accreditation program must provide CMS with
reasonable assurance that the accrediting organization requires its
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 Sec. 488.5. The
regulations at Sec. 488.5(e)(2)(i) require an accrediting organization
to reapply for continued approval of its Medicare accreditation program
every 6 years or sooner as determined by CMS. The Center for
Improvement in Healthcare Quality's (CIHQ's) term of approval as a
recognized Medicare accreditation program for hospitals expires July
26, 2017.
[[Page 28854]]
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 February 24, 2017, we published a proposed notice in the Federal
Register (82 FR 11579) announcing CIHQ's request for continued approval
of its Medicare 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 Sec. 488.5, we conducted a review of
CIHQ's Medicare hospital accreditation application in accordance with
the criteria specified by our regulations, which include, but are not
limited to the following:
An onsite administrative review of CIHQ's: (1) Corporate
policies; (2) financial and human resources available to accomplish the
proposed surveys; (3) procedures for training, monitoring, and
evaluation of its hospital surveyors; (4) ability to investigate and
respond appropriately to complaints against accredited hospitals; and,
(5) survey review and decision-making process for accreditation.
A comparison of CIHQ's Medicare accreditation program
standards to our current Medicare hospital Conditions of Participation
(CoPs).
A documentation review of CIHQ's survey process to do the
following:
++ Determine the composition of the survey team, surveyor
qualifications, and CIHQ's ability to provide continuing surveyor
training.
++ Compare CIHQ'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 hospitals.
++ Evaluate CIHQ's procedures for monitoring hospitals it has found
to be out of compliance with CIHQ's program requirements. (This
pertains only to monitoring procedures when CIHQ identifies non-
compliance. If non-compliance is identified by a State survey agency
through a validation survey, the State survey agency monitors
corrections as specified at Sec. 488.9(c)).
++ Assess CIHQ's ability to report deficiencies to the surveyed
hospitals and respond to the hospital's plan of correction in a timely
manner.
++ Establish CIHQ'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 CIHQ's staff and other resources.
++ Confirm CIHQ's ability to provide adequate funding for
performing required surveys.
++ Confirm CIHQ's policies with respect to surveys being
unannounced.
++ Obtain 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 we may require, including corrective action
plans.
In accordance with section 1865(a)(3)(A) of the Act, the February
24, 2017 proposed notice also solicited public comments regarding
whether CIHQ's requirements met or exceeded the Medicare CoP for
hospitals. There were no comments submitted.
IV. Provisions of the Final Notice
A. Differences Between CIHQ's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared CIHQ's hospital accreditation requirements and survey
process with the Medicare CoPs at part 482, and the survey and
certification process requirements of parts 488 and 489. CIHQ's
standards crosswalk, which maps CIHQ's standards with the corresponding
requirements under the Medicare CoPs, was also examined to ensure that
the appropriate CMS regulation was included in citations as
appropriate. We reviewed and evaluated CIHQ's hospital application,
conducted as described earlier. As a result, CIHQ has revised its
materials, standards, and certification processes to reflect the
following Medicare requirements:
Sec. 482.12: Updated the summary description of this
provision in the crosswalk to be consistent with its accreditation
standards.
Sec. 482.12(a)(1) through (10): Updated the summary
description of this provision in the crosswalk to be consistent with
its accreditation standards.
Sec. 482.12(a)(10): Revised its standards to address the
hospital's responsibility to consult directly with the medical staff.
Sec. 482.12(c): Updated the summary description of this
provision in the crosswalk to be consistent with its accreditation
standards.
Sec. 482.12(c)(1)(ii): Updated the CFR citation to
properly reference the regulatory requirement on its standards
crosswalk.
Sec. 482.12(c)(2): Updated the CFR citation to properly
reference the regulatory requirement on its standards crosswalk.
Sec. 482.12(c)(4)(i): Clarified the use of the word
``develops'' to indicate if the condition was present on admission or
developed during the hospitalization on its standards crosswalk.
Sec. 482.12(f)(2): Revised its standards to ensure the
medical staff have written policies and procedures for appraisals of
emergencies, initial treatment and referral.
Sec. 482.13(a)(1) and Sec. 482.13(a)(2): Updated the
summary description of these provisions in the crosswalk to be
consistent with its accreditation standards.
Sec. 482.13(a)(2)(i): Revised its standards to ensure the
patient's right to submit ``written or verbal'' grievances.
Sec. 482.13(a)(2)(ii), Sec. 482.13(b)(3), Sec.
482.13(b)(4) and Sec. 482.13(c)(2): Updated the summary description of
these provisions in the crosswalk to be consistent with its
accreditation standards.
Sec. 482.13(e)(5): Updated the CFR citation to properly
reference the regulatory requirement.
Sec. 482.13(e)(6), Sec. 482.13(f)(1)(ii), Sec.
482.13(g), Sec. 482.13(g)(2), Sec. 482.13(h), Sec. 482.21(b)(1),
Sec. 482.21(d)(2) and Sec. 482.21(d)(4): Updated the summary
description of these provisions in the crosswalk to be consistent with
its accreditation standards.
Sec. 482.22(a)(2): Updated its standards to reflect that
temporary practice privileges are granted by the governing body.
Sec. 482.22(b)(1): Updated the summary description of
this provision in the crosswalk to be consistent with its accreditation
standards.
Sec. 482.22(b)(3): Revised its standards to reflect CMS
requirements for medical staff organization and accountability.
Sec. 482. 22(b)(4): Updated the summary description of
this provision in the crosswalk to be consistent with its accreditation
standards.
Sec. 482.23(c)(4): Updated its standards to fully address
requirements for blood transfusions.
[[Page 28855]]
Sec. 482.24(b): Updated its standards to fully address
requirements for the form and retention of medical records.
Sec. 482.24(c)(2) through (c)(4)(viii): Updated the
Medicare regulatory language on its standards crosswalk to ensure that
its accreditation standards are consistent with Medicare standards.
Sec. 482.25(b)(2)(ii): Updated the crosswalk and standard
to add references to the Comprehensive Drug Abuse Prevention and
Control Act of 1970.
Sec. 482.26: Updated the summary description of this
provision in the crosswalk to be consistent with its accreditation
standards.
Sec. 482.41: Revised its standards to reflect the
requirements of the ``Physical Environment''.
Sec. 482.43: Revised its standards to ensure that the
hospital discharge planning process applies to all patients.
Sec. 482.51(b)(6) and Sec. 482.56(a)(2): Updated the
summary description of these provisions in the crosswalk to be
consistent with its accreditation standards.
Sec. 482.56(b)(2): Revised its standards to address the
requirements at Sec. 409.17 related to physical therapy, occupational
therapy, and speech language pathology services.
Sec. 482.57(b)(3): Updated the CFR citation to properly
reference the regulatory requirement on its crosswalk.
Sec. 482.57(b)(4): Updated the CFR citation to properly
reference the regulatory requirement on its crosswalk and in its
accreditation standards.
Sec. 488.4(a)(6): Revised its standards to include a
process to track and trend complaints received.
Sec. 488.5(a)(4)(ii): Revised its standards to ensure
that an appropriate number of open, inpatient medical records are fully
reviewed during the survey process.
Sec. 488.5(a)(4)(iv): Revised its standards to assure
that findings of non-compliance are documented under all appropriate
CMS standards where non-compliance is found; and that adverse findings
for each CoP are reviewed for manner and degree of non-compliance and
subsequently cited at the appropriate level (that is, condition versus
standard level).
Sec. 488.5(a)(7) through (9): Revised its standards to
ensure that newly hired surveyors receive orientation so as to ensure
AO compliance with these provisions.
Sec. 488.26(b): Revised its standards to improve surveyor
documentation to include the appropriately detailed deficiency
statements that clearly support the determination of noncompliance and
level of deficiency.
Sec. 489.13: Revised its standards to reflect CMS policy
regarding effective dates of participation in the Medicare program and
develop a plan for monitoring for sustained compliance.
CIHQ revised its complaint policy and procedure to clearly
identify the individual(s) that are responsible for triaging complaints
submitted to the accrediting organization.
CIHQ revised its policy to clarify that an ``Immediate
Jeopardy'' finding remains cited at the Conditional level, even if
abated while onsite.
B. Term of Approval
Based on our review and observations described in section III of
this final notice, we have determined that CIHQ's hospital program
requirements meet or exceed our requirements. Therefore, we approve
CIHQ as a national accreditation organization for hospitals that
request participation in the Medicare program, effective July 26, 2017
through July 26, 2023.
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.).
Dated: June 20, 2017.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2017-13207 Filed 6-23-17; 8:45 am]
BILLING CODE 4120-01-P