Medicare and Medicaid Programs; Application From Det Norske Veritas Healthcare (DNVHC) for Continued Approval of Its Hospital Accreditation Program, 17070-17072 [2012-6856]
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17070
Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices
• To meet the requirements at section
2008D of the SOM, AAAASF revised its
policies related to the accreditation
effective date.
• To meet the requirements at section
2200F of the SOM, AAAASF revised its
policies to ensure their surveys are
complete, accurate, and consistent.
• To meet the requirements at section
2700A of the SOM, AAAASF revised its
policies to ensure all RHC surveys are
conducted unannounced.
• To meet the requirements at section
2704 of the SOM, AAAASF revised its
RHC Accreditation Facility Handbook to
include pre-survey preparation
requirements.
• To meet the requirements at section
2728 of the SOM, AAAASF modified its
policies regarding timeframes for
sending and receiving a plan of
correction.
• To meet the requirements at section
3010 of the SOM, AAAASF revised its
policies on immediate jeopardy.
• To meet the requirements at chapter
five of the SOM, AAAASF revised its
policies to ensure all complaints are
appropriately triaged, investigated and
resolved.
• To meet the requirements at Exhibit
7 of the SOM, AAAASF revised its
policies to ensure survey deficiencies
are cited at the appropriate level based
on the surveyor documentation.
• To verify AAAASF’s continued
compliance with the provisions of this
final notice, CMS will conduct a followup survey observation within 1 year of
the date of publication of this notice.
srobinson on DSK4SPTVN1PROD with NOTICES
B. Term of Approval
Based on our review and observations
described in section III of this final
notice, we have determined that
AAAASF’s requirements for RHCs meet
or exceed our requirements. Therefore,
we approve AAAASF as a national
accreditation organization for RHCs that
request participation in the Medicare
program, effective March 23, 2012
through March 23, 2016.
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)
(Catalog of Federal Domestic Assistance
Program No. 93.773, Medicare—Hospital
Insurance; and Program No. 93.774,
VerDate Mar<15>2010
17:14 Mar 22, 2012
Jkt 226001
Medicare—Supplementary Medical
Insurance Program)
Dated: March 8, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare
& Medicaid Services.
[FR Doc. 2012–6331 Filed 3–22–12; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–3258–PN]
Medicare and Medicaid Programs;
Application From Det Norske Veritas
Healthcare (DNVHC) for Continued
Approval of Its Hospital Accreditation
Program
Centers for Medicare and
Medicaid Services, HHS.
ACTION: Proposed notice.
AGENCY:
This proposed notice with
comment period acknowledges the
receipt of an application from 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.
DATES: To be assured consideration,
comments must be received at one of
the addresses provided below, no later
than 5 p.m. on April 23, 2012.
ADDRESSES: In commenting, please refer
to file code CMS–3258–PN. Because of
staff and resource limitations, we cannot
accept comments by facsimile (Fax)
transmission.
You may submit comments in one of
four ways (please choose only one of the
ways listed):
1. Electronically. You may submit
electronic comments on this regulation
to https://www.regulations.gov. Follow
the ‘‘Submit a comment’’ instructions.
2. By regular mail. You may mail
written comments (one original and two
copies) to the following address ONLY:
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, Attention: CMS–3258–
PN, P.O. Box 8016, Baltimore, MD
21244–8016.
Please allow sufficient time for mailed
comments to be received before the
close of the comment period.
3. By express or overnight mail. You
may send written comments (one
original and two copies) to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
SUMMARY:
PO 00000
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CMS–3258–PN, Mail Stop C4–26–05,
7500 Security Boulevard, Baltimore, MD
21244–1850.
4. By hand or courier. If you prefer,
you may deliver (by hand or courier)
your written comments before the close
of the comment period to either of 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.
(Because access to the interior of the
Hubert H. Humphrey Building is not
readily available to persons without
Federal government identification,
commenters are encouraged to leave
their comments in the CMS drop slots
located in the main lobby of the
building. A stamp-in clock is available
for persons wishing to retain a proof of
filing by stamping in and retaining an
extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
If you intend to deliver your comments
to the Baltimore address, please call
telephone number (410) 786–7195 in
advance to schedule your arrival with
one of our staff members.
Comments mailed to the addresses
indicated as appropriate for hand or
courier delivery may be delayed and
received after the comment period.
For information on viewing public
comments, see the beginning of the
SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Barbara Easterling (410) 786–0482,
Patricia Chmielewski, (410) 786–6899,
or Cindy Melanson, (410) 786–0310.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All
comments received before the close of
the comment period are available for
viewing by the public, including any
personally identifiable or confidential
business information that is included in
a comment. We post all comments
received before the close of the
comment period on the following Web
site as soon as possible after they have
been received: https://www.regulations.
gov. Follow the search instructions on
that Web site to view public comments.
Comments received timely will also
be available for public inspection as
they are received, generally beginning
approximately 3 weeks after publication
of a document, at the headquarters of
the Centers for Medicare & Medicaid
Services, 7500 Security Boulevard,
E:\FR\FM\23MRN1.SGM
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Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices
program every 6 years or sooner as
determined by us.
DNVHC’s current term of approval for
their hospital accreditation program
expires September 26, 2012.
I. Background
srobinson on DSK4SPTVN1PROD with NOTICES
Baltimore, Maryland 21244, Monday
through Friday of each week from
8:30 a.m. to 4 p.m. To schedule an
appointment to view public comments,
phone 1–800–743–3951.
II. Approval of Deeming Organizations
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 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 part 488.
The regulations at part 482 specify the
conditions that a hospital must meet in
order to participate in the Medicare
program, the scope of covered services
and the conditions for Medicare
payment for hospitals.
Generally, in order 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.
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 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
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 us
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
identifying the national accrediting
body making the request, describing the
nature of the request, and providing at
least a 30-day public comment period.
We have 210 days from the receipt of a
complete application to publish notice
of approval or denial of the application.
The purpose of this proposed notice
is to inform the public of DNVHC’s
request for continued approval of its
hospital accreditation program. This
notice also solicits public comment on
whether DNVHC’s requirements meet or
exceed the Medicare conditions for
participation for hospitals.
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17:14 Mar 22, 2012
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III. Evaluation of Deeming Authority
Request
DNVHC submitted all the necessary
materials to enable us to make a
determination concerning its request for
continued approval of its hospital
accreditation program. This application
was determined to be complete on
January 27, 2012. Section 1865(a)(3)(A)
of the Social Security Act (the Act),
requires that within 60 days of receipt
of an organization’s complete
application to be a CMS-approved
accrediting organization, we publish 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. Under section
1865(a)(2) of the Act and our regulations
at § 488.8 (Federal review of accrediting
organizations), our review and
evaluation of DNVHC will be conducted
in accordance with, but not necessarily
limited to, the following factors:
PO 00000
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17071
• The equivalency of DNVHC’s
standards for a hospital as compared
with CMS’ hospital conditions of
participation.
• DNVHC’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 DNVHC’s
processes to those of State agencies,
including survey frequency, and the
ability to investigate and respond
appropriately to complaints against
accredited facilities.
+ DNVHC’s processes and procedures
for monitoring a hospital found out of
compliance with DNVHC’s program
requirements. These monitoring
procedures are used only when DNVHC
identifies noncompliance. If
noncompliance is identified through
validation reviews or complaint
surveys, the State survey agency
monitors corrections as specified at
§ 488.7(d).
+ DNVHC’s capacity to report
deficiencies to the surveyed facilities
and respond to the facility’s plan of
correction in a timely manner.
+ DNVHC’s capacity to provide us
with electronic data and reports
necessary for effective validation and
assessment of the organization’s survey
process.
+ The adequacy of DNVHC’s staff and
other resources, and its financial
viability.
+ DNVHC’s capacity to adequately
fund required surveys.
+ DNVHC’s policies with respect to
whether surveys are announced or
unannounced, to assure that surveys are
unannounced.
+ DNVHC’s agreement to provide us
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).
IV. 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).
V. Response to Public Comments
Because of the large number of public
comments we normally receive on
Federal Register documents, we are not
able to acknowledge or respond to them
individually. We will consider all
E:\FR\FM\23MRN1.SGM
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17072
Federal Register / Vol. 77, No. 57 / Friday, March 23, 2012 / Notices
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.
Upon completion of our evaluation,
including evaluation of comments
received as a result of this notice, we
will publish a final notice in the Federal
Register announcing the result of our
evaluation.
Authority: Section 1865 of the Social
Security Act (42 U.S.C. 1395bb)
(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: March 13, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare
& Medicaid Services.
[FR Doc. 2012–6856 Filed 3–22–12; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–2377–FN]
Medicare and Medicaid Programs;
Approval of the Community Health
Accreditation Program for Continued
CMS-Approval of its Home Health
Agency Accreditation Program
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final notice.
AGENCY:
This notice announces our
decision to approve the Community
Health Accreditation Program (CHAP)
for recognition as a national
accreditation program for home health
agencies (HHAs) seeking to participate
in the Medicare or Medicaid programs.
DATES: This final notice is effective
March 31, 2012 through March 31, 2018.
FOR FURTHER INFORMATION CONTACT:
Lillian Williams, (410) 786–8636, or
Patricia Chmielewski, (410) 786–6899.
SUPPLEMENTARY INFORMATION:
srobinson on DSK4SPTVN1PROD with NOTICES
SUMMARY:
I. Background
Under the Medicare program, eligible
beneficiaries may receive covered
services in a home health agency (HHA)
provided certain requirements are met.
Sections 1861(m) and (o) and 1891 and
1895 of the Social Security Act (the Act)
establish distinct criteria for facilities
seeking designation as an HHA. Under
VerDate Mar<15>2010
17:14 Mar 22, 2012
Jkt 226001
this authority, the minimum
requirements that an HHA must meet to
participate in Medicare are set forth in
regulations at 42 CFR part 484, which
determine the basis and scope of HHA
covered services, and the conditions for
Medicare payment for home health care.
Regulations concerning provider
agreements are at part 489 and those
pertaining to activities relating to the
survey and certification of facilities are
at part 488.
Generally, in order to enter into a
provider agreement with the Medicare
program, HHAs must first be certified by
a State survey agency as complying with
conditions or requirements set forth in
part 484. Thereafter, the HHA 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 State
compliance surveys. Accreditation 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 accreditation organization that
all applicable Medicare conditions are
met or exceeded, we may ‘‘deem’’ those
provider entities as having met the
requirements. Accreditation by an
accreditation organization is voluntary
and is not required for Medicare
participation.
If an accreditation organization is
recognized by the Secretary as having
standards for accreditation that meet or
exceed Medicare requirements, a
provider entity accredited by the
national accrediting body’s approved
program may be deemed to meet the
Medicare conditions. A national
accreditation organization applying for
CMS-approval of its accreditation
program under part 488, subpart A must
provide us with reasonable assurance
that the accreditation organization
requires the accredited provider entities
to meet requirements that are at least as
stringent as the Medicare conditions.
Our regulations concerning the
reapproval of accreditation
organizations are set forth at § 488.4 and
§ 488.8(d)(3). Section 488.8(d)(3)
requires accreditation organizations to
reapply for continued CMS-approval of
its accreditation program every six
years, or sooner as determined by us.
CHAP’s term of approval as a
recognized accreditation program for
HHAs expires March 31, 2012.
II. Deeming Applications Approval
Process
Section 1865(a)(3)(A) of the Act
provides a statutory timetable to ensure
PO 00000
Frm 00072
Fmt 4703
Sfmt 4703
that our review of deeming applications
is conducted in a timely manner. The
Act provides us with 210 calendar days
after the date of receipt of an application
to complete our survey activities and
application review process. Within 60
days of receiving a completed
application, we must publish a notice in
the Federal Register that identifies the
national accreditation 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 an
approval or denial of the application.
III. Proposed Notice
In the September 23, 2011, Federal
Register (76 FR 59136), we published a
proposed notice announcing CHAP’s
request for continued CMS approval of
its HHA accreditation program. In the
proposed notice, we detailed our
evaluation criteria. Under section
1865(a)(2) of the Act and our regulations
at § 488.4 (Application and
reapplication procedures for
accreditation organizations), we
conducted a review of CHAP’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
CHAP’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.
• A comparison of CHAP’s HHA
accreditation standards to our current
Medicare HHA conditions for
participation.
• A documentation review of CHAP’s
survey processes to:
≈≈ Determine the composition of the
survey team, surveyor qualifications,
and the ability of CHAP to provide
continuing surveyor training.
≈≈ Compare CHAP’s processes to
those of State survey agencies, including
survey frequency, and the ability to
investigate and respond appropriately to
complaints against accredited facilities.
≈≈ Evaluate CHAP’s procedures for
monitoring providers or suppliers found
to be out of compliance with CHAP
program requirements. The monitoring
procedures are used only when the
CHAP identifies noncompliance. If
noncompliance is identified through
validation reviews, the survey agency
monitors corrections as specified at
§ 488.7(d).
E:\FR\FM\23MRN1.SGM
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]]>Agencies
[Federal Register Volume 77, Number 57 (Friday, March 23, 2012)]
[Notices]
[Pages 17070-17072]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-6856]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3258-PN]
Medicare and Medicaid Programs; Application From Det Norske
Veritas Healthcare (DNVHC) for Continued Approval of Its Hospital
Accreditation Program
AGENCY: Centers for Medicare and Medicaid Services, HHS.
ACTION: Proposed notice.
-----------------------------------------------------------------------
SUMMARY: This proposed notice with comment period acknowledges the
receipt of an application from 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.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on April 23, 2012.
ADDRESSES: In commenting, please refer to file code CMS-3258-PN.
Because of staff and resource limitations, we cannot accept comments by
facsimile (Fax) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to https://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments (one original and
two copies) to the following address ONLY: Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Attention:
CMS-3258-PN, P.O. Box 8016, Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments (one
original and two copies) to the following address ONLY: Centers for
Medicare & Medicaid Services, Department of Health and Human Services,
Attention: CMS-3258-PN, Mail Stop C4-26-05, 7500 Security Boulevard,
Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of 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.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850. If you intend to deliver your
comments to the Baltimore address, please call telephone number (410)
786-7195 in advance to schedule your arrival with one of our staff
members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Barbara Easterling (410) 786-0482,
Patricia Chmielewski, (410) 786-6899, or Cindy Melanson, (410) 786-
0310.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: https://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
[[Page 17071]]
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
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 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 part 488. The regulations at part 482 specify the
conditions that a hospital must meet in order to participate in the
Medicare program, the scope of covered services and the conditions for
Medicare payment for hospitals.
Generally, in order 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.
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 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
Sec. 488.4 and Sec. 488.8(d)(3). The regulations at Sec. 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.
DNVHC's current term of approval for their hospital accreditation
program expires September 26, 2012.
II. Approval of Deeming Organizations
Section 1865(a)(2) of the Act and our regulations at Sec. 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
us 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 identifying the national accrediting body making the request,
describing the nature of the request, and providing at least a 30-day
public comment period. We have 210 days from the receipt of a complete
application to publish notice of approval or denial of the application.
The purpose of this proposed notice is to inform the public of
DNVHC's request for continued approval of its hospital accreditation
program. This notice also solicits public comment on whether DNVHC's
requirements meet or exceed the Medicare conditions for participation
for hospitals.
III. Evaluation of Deeming Authority Request
DNVHC submitted all the necessary materials to enable us to make a
determination concerning its request for continued approval of its
hospital accreditation program. This application was determined to be
complete on January 27, 2012. Section 1865(a)(3)(A) of the Social
Security Act (the Act), requires that within 60 days of receipt of an
organization's complete application to be a CMS-approved accrediting
organization, we publish 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. Under
section 1865(a)(2) of the Act and our regulations at Sec. 488.8
(Federal review of accrediting organizations), our review and
evaluation of DNVHC will be conducted in accordance with, but not
necessarily limited to, the following factors:
The equivalency of DNVHC's standards for a hospital as
compared with CMS' hospital conditions of participation.
DNVHC'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 DNVHC's processes to those of State
agencies, including survey frequency, and the ability to investigate
and respond appropriately to complaints against accredited facilities.
+ DNVHC's processes and procedures for monitoring a hospital found
out of compliance with DNVHC's program requirements. These monitoring
procedures are used only when DNVHC identifies noncompliance. If
noncompliance is identified through validation reviews or complaint
surveys, the State survey agency monitors corrections as specified at
Sec. 488.7(d).
+ DNVHC's capacity to report deficiencies to the surveyed
facilities and respond to the facility's plan of correction in a timely
manner.
+ DNVHC's capacity to provide us with electronic data and reports
necessary for effective validation and assessment of the organization's
survey process.
+ The adequacy of DNVHC's staff and other resources, and its
financial viability.
+ DNVHC's capacity to adequately fund required surveys.
+ DNVHC's policies with respect to whether surveys are announced or
unannounced, to assure that surveys are unannounced.
+ DNVHC's agreement to provide us 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).
IV. 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).
V. Response to Public Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all
[[Page 17072]]
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.
Upon completion of our evaluation, including evaluation of comments
received as a result of this notice, we will publish a final notice in
the Federal Register announcing the result of our evaluation.
Authority: Section 1865 of the Social Security Act (42 U.S.C.
1395bb)
(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: March 13, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2012-6856 Filed 3-22-12; 8:45 am]
BILLING CODE 4120-01-P
