Application From the Joint Commission (TJC) for Continued Approval of Its Psychiatric Hospital Accreditation Program, 4818-4820 [2019-02673]
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4818
Federal Register / Vol. 84, No. 33 / Tuesday, February 19, 2019 / Notices
Centers for Medicare & Medicaid
Services
[CMS–3364–FN]
Application From the Joint
Commission (TJC) for Continued
Approval of Its Psychiatric Hospital
Accreditation Program
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final notice.
AGENCY:
This final notice announces
our decision to approve the Joint
Commission for continued recognition
as a national accrediting organization
for psychiatric hospitals that wish to
participate in the Medicare or Medicaid
programs.
DATES: The approval announced in this
final notice is effective February 25,
2019 through February 25, 2023.
FOR FURTHER INFORMATION CONTACT:
Mary Ellen Palowitch (410) 786–4496,
Monda Shaver (410) 786–3410, Tara
Lemons (410) 786–3030.
SUPPLEMENTARY INFORMATION:
SUMMARY:
I. Background
[FR Doc. 2019–02672 Filed 2–15–19; 8:45 am]
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Under the Medicare program, eligible
beneficiaries may receive covered
services from a psychiatric hospital
provided certain requirements are met.
Section 1861(f) of the Social Security
Act (the Act) establishes distinct criteria
for facilities seeking designation as a
psychiatric 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 42 CFR
part 488. The regulations at 42 CFR part
482 subparts A, B, C and E specify the
minimum conditions that a psychiatric
hospital must meet to participate in the
Medicare program, the scope of covered
services and the conditions for Medicare
payment for psychiatric hospitals.
Generally, to enter into an agreement,
a psychiatric hospital must first be
certified by a State Survey Agency as
complying with the conditions or
requirements set forth in part 482
subpart A, B, C and E of our regulations.
Thereafter, the psychiatric hospital is
subject to regular surveys by a State
Survey Agency to determine whether it
continues to meet these requirements.
There is an alternative, however, 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
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applicable Medicare conditions are met
or exceeded, we may treat the provider
entity as having met those conditions,
that is, we may ‘‘deem’’ the provider
entity 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 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. A national accrediting
organization applying for approval of its
accreditation program under part 488,
subpart A, must provide the Centers for
Medicare & Medicaid Services (CMS)
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 § 488.5. The regulations at
§ 488.5(e)(2)(i) require accrediting
organizations to reapply for continued
approval of its accreditation program
every 6 years or sooner as determined
by CMS.
The Joint Commission’s current term
of approval for their psychiatric hospital
accreditation program expires February
25, 2019.
II. Application Approval Process
Section 1865(a)(3)(A) of the Act
provides a statutory timetable to ensure
that our review of applications for CMSapproval 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.
III. Provisions of the Proposed Notice
On August 15, 2018, we published a
proposed notice in the Federal Register
(83 FR 40514), announcing the Joint
Commission’s (TJC’s) request for
continued approval of its Medicare
psychiatric hospital accreditation
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
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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 TJC’s Medicare psychiatric
hospital accreditation renewal
application in accordance with the
criteria specified by our regulations,
which include, but are not limited to the
following:
• An onsite administrative review of
TJC’s: (1) Corporate policies; (2)
financial and human resources available
to accomplish the proposed surveys; (3)
procedures for training, monitoring, and
evaluation of its psychiatric hospital
surveyors; (4) ability to investigate and
respond appropriately to complaints
against accredited psychiatric hospitals;
and, (5) survey review and decisionmaking process for accreditation.
• A comparison of TJC’s Medicare
hospital accreditation program
standards to our current Medicare
hospital Conditions of Participation
(CoPs) and psychiatric hospital special
conditions.
• A documentation review of TJC’s
psychiatric hospital’s survey process to:
++ Determine the composition of the
survey team, surveyor qualifications,
and TJC’s ability to provide continuing
surveyor training.
++ Compare TJC’s processes to those
CMS require of state survey agencies,
including periodic resurvey and the
ability to investigate and respond
appropriately to complaints against
accredited psychiatric hospitals.
++ Evaluate TJC’s procedures for
monitoring psychiatric hospitals it has
found to be out of compliance with
TJC’s program requirements. (This
pertains only to monitoring procedures
when TJC 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 TJC’s ability to report
deficiencies to the surveyed hospital
and respond to the psychiatric
hospital’s plan of correction in a timely
manner.
++ Establish TJC’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 TJC’s
staff and other resources.
++ Confirm TJC’s ability to provide
adequate funding for performing
required surveys.
++ Confirm TJC’s policies with
respect to surveys being unannounced.
++ Obtain TJC’s agreement to provide
CMS with a copy of the most current
accreditation survey together with any
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Jkt 247001
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 August 15,
2018 proposed notice also solicited
public comments regarding whether
TJC’s requirements met or exceeded the
Medicare CoPs for psychiatric hospitals.
We received no comments in response
to our proposed notice.
IV. Provisions of the Final Notice
A. Differences Between TJC’s Standards
and Requirements for Accreditation and
Medicare Conditions and Survey
Requirements
We compared TJC’s psychiatric
hospital accreditation program
requirements and survey process with
the Medicare CoPs at part 482 and the
survey and certification process
requirements of parts 488 and 489. Our
review and evaluation of TJC’s
psychiatric hospital 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, TJC has revised its standards
and certification processes in order to
meet the requirements at:
• Section 482.12(a)(10), to address
that consultation will occur directly
with the individual assigned the
responsibility for the organization and
conduct of the hospital’s medical staff,
or his/her designee and the timeframe
for which direct consultation must
occur.
• Section 482.41(b)(3), to provide
information related to our rule stating
that Life Safety Code provisions do not
apply in a State where CMS finds that
a fire and safety code imposed by State
law adequately protects patients in
hospitals.
• Section 482.41(b)(5), to address
cooperation with local firefighting
authorities.
• Section 482.41(b)(7), to address
installing alcohol-based hand rub
dispensers in a manner that adequately
protects against inappropriate access.
• Section 482.41(e), to address the
omission of a standard to correspond to
references and documents in this CMS
requirement.
• Section 482.42(b)(1), to address and
clarify that ‘‘make certain’’ is defined as
‘‘must.’’
• Section 482.42(b)(2), to address and
clarify that ‘‘make certain’’ is defined as
‘‘must.’’
• Section 482.43(b)(2), to address
who may develop or supervise the
development of the discharge
evaluation.
• Section 482.43(c)(1), to address who
must develop or supervise the
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4819
development of a discharge plan if the
discharge planning evaluation indicates
a need for a discharge plan.
• Section 482.51(a)(3), to address that
a qualified registered nurse is
immediately available to respond to
emergencies.
• Section 482.51(b)(3), to address and
include the required equipment that
must be available to the operating room
suites.
• Section § 488.5(a)(4)(i), to ensure
that all surveys are unannounced.
• Section § 488.5(a)(4)(ii), to ensure
that its surveyors are provided clear
instruction for assessing only the
applicable CoPs for the psychiatric
hospital accreditation program.
• Section 488.5(a)(4)(iv), to ensure
that TJC psychiatric hospital surveyors
document findings of noncompliance
with accreditation standards at the
comparable Medicare CoP; and to
ensure that all findings of observed
noncompliance noted on surveyor
worksheets are clearly and accurately
reflected in the final survey deficiency
report.
• Section 488.5(a)(4)(v), to ensure that
a minimum sample of patient records
are reviewed for all elements required
by the regulations.
• Sections 488.5(a)(11)(ii), to ensure
that data submitted to CMS is timely,
complete and accurate.
• Section 488.5(a)(12), to ensure that
TJC has a clearly defined complaint
investigation process that is comparable
to CMS; to ensure that the process for
protecting complainant anonymity does
not impede the required complaint
investigation; to ensure that complaints
are investigated, based on the submitted
allegations, irrespective of receiving a
‘‘waiver of anonymity’’ from the
complainant; to ensure that complaints
are reviewed and investigated within
the comparable timelines established by
CMS; and to ensure that all complaints
that would result in condition-level
non-compliance, based on allegations
described therein, are required to be
investigated through an onsite survey.
• Section 488.5(a)(19)(ii), to ensure
that TJC proposed survey process and
crosswalked standards will not be
implemented without prior written
notice of approval from CMS.
• Section 488.26, to ensure TJC’s
survey process meets or exceeds the
Medicare program requirements; and to
ensure that surveyors assess all required
facility locations and services during the
survey process.
• Section 489.13, to ensure that the
granting of accreditation and
recommendations to CMS for Medicare
participation occurs only after the
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Federal Register / Vol. 84, No. 33 / Tuesday, February 19, 2019 / Notices
facility has demonstrated full
compliance with all requirements.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
B. Term of Approval
Administration for Children and
Families
Based on our review and observations
described in section III of this final
notice, we approve TJC as a national
accreditation organization for
psychiatric hospitals that request
participation in the Medicare program,
effective February 25, 2019 through
February 25, 2023.
To verify TJC’s continued compliance
with the provisions of this final notice,
CMS expects to conduct a follow-up
corporate on-site visit and survey
observation within 18 months of the
publication date of this notice.
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: February 7, 2019.
Seema Verma,
Administrator, Centers for Medicare &
Medicaid Services.
[FR Doc. 2019–02673 Filed 2–15–19; 8:45 am]
BILLING CODE 4120–01–P
Proposed Information Collection
Activity; ACF’s Generic Clearance for
Grant Reviewer Recruitment Forms
(OMB #0970–0477)
Office of Planning, Research,
and Evaluation; Administration for
Children and Families; HHS.
ACTION: Request for public comment.
AGENCY:
The Administration for
Children and Families (ACF), Office of
Planning, Research, and Evaluation
(OPRE) is proposing an extension of a
currently approved generic clearance
(OMB no. 0970–0477) for Grant
Reviewer Recruitment (GRR) forms. The
GRR forms will be used to select
reviewers who will participate in the
grant review process for the purpose of
selecting successful applications.
DATES: Comments due within 60 days of
publication. In compliance with the
requirements of Section 3506(c)(2)(A) of
the Paperwork Reduction Act of 1995,
the Administration for Children and
Families is soliciting public comment
on the specific aspects of the
information collection described above.
ADDRESSES: Copies of the proposed
collection of information can be
obtained and comments may be
SUMMARY:
forwarded by writing to the
Administration for Children and
Families, Office of Planning, Research,
and Evaluation, 330 C Street SW,
Washington, DC 20201, Attn: OPRE
Reports Clearance Officer. Email
address: OPREinfocollection@
acf.hhs.gov. All requests should be
identified by the title of the information
collection.
SUPPLEMENTARY INFORMATION:
Description: Under this generic
approval, ACF conducts and proposes to
continue to conduct more than one
information collection that is very
similar, voluntary, low-burden and
uncontroversial. The purpose is to select
qualified reviewers for the grant peer
review process based on professional
qualifications using data entered by
candidates and the uploaded writing
sample and/or curriculum vitae and/or
resume. The grant review process is in
accordance with the U.S. Department of
Health and Human Services’ (DHHS)
Grants Policy Directive (GPD) 2.04
‘‘Awarding Grants’’, the DHHS
Awarding Agency Grants
Administration Manual (AAGAM),
Chapter 2.04.104C ‘‘Objective Review of
Grant Applications’’, and the Public
Health Service (PHS) Act, Sections
799(f) and 806(e).
Respondents: Individuals who may
apply to review ACF grant applications.
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ANNUAL BURDEN ESTIMATES
Instrument
Total
number of
respondents
Number of
responses per
respondent
Average
burden hours
per response
Annual
burden hours
Grant Reviewer Recruitment Form ..................................................................
3,000
1
.5
1,500
Estimated Total Annual Burden
Hours: 1,500.
Comments: The Department
specifically requests comments on (a)
whether the proposed collection of
information is necessary for the proper
performance of the functions of the
agency, including whether the
information shall have practical utility;
(b) the accuracy of the agency’s estimate
of the burden of the proposed collection
of information; (c) the quality, utility,
and clarity of the information to be
collected; and (d) ways to minimize the
burden of the collection of information
on respondents, including through the
use of automated collection techniques
or other forms of information
technology. Consideration will be given
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to comments and suggestions submitted
within 60 days of this publication.
Mary B. Jones,
ACF/OPRE Certifying Officer.
[FR Doc. 2019–02624 Filed 2–15–19; 8:45 am]
BILLING CODE 4184–79–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Administration for Children and
Families
Submission for OMB Review;
Strengthening Relationship Education
and Marriage Services (STREAMS)
Evaluation (OMB#0970–0481)
Office of Planning, Research,
and Evaluation; Administration for
Children and Families; HHS.
AGENCY:
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ACTION:
Request for public comment.
The Office of Family
Assistance (OFA) within the
Administration for Children and
Families (ACF) at the U.S. Department
of Health and Human Services has
issued grants to organizations to provide
healthy marriage and relationship
education (HMRE) services. Under a
previously approved data collection
activity (OMB#0970–0481), the Office of
Planning, Research, and Evaluation
(OPRE) within ACF is conducting the
Strengthening Relationship Education
and Marriage Services (STREAMS)
evaluation with five HMRE grantees.
The purpose of STREAMS is to measure
the effectiveness and quality of HMRE
programs designed to strengthen
intimate relationships. This data
collection request is for an extension of
SUMMARY:
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[Federal Register Volume 84, Number 33 (Tuesday, February 19, 2019)]
[Notices]
[Pages 4818-4820]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-02673]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3364-FN]
Application From the Joint Commission (TJC) for Continued
Approval of Its Psychiatric Hospital Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final notice.
-----------------------------------------------------------------------
SUMMARY: This final notice announces our decision to approve the Joint
Commission for continued recognition as a national accrediting
organization for psychiatric hospitals that wish to participate in the
Medicare or Medicaid programs.
DATES: The approval announced in this final notice is effective
February 25, 2019 through February 25, 2023.
FOR FURTHER INFORMATION CONTACT: Mary Ellen Palowitch (410) 786-4496,
Monda Shaver (410) 786-3410, Tara Lemons (410) 786-3030.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services from a psychiatric hospital provided certain
requirements are met. Section 1861(f) of the Social Security Act (the
Act) establishes distinct criteria for facilities seeking designation
as a psychiatric 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 42 CFR part 488. The
regulations at 42 CFR part 482 subparts A, B, C and E specify the
minimum conditions that a psychiatric hospital must meet to participate
in the Medicare program, the scope of covered services and the
conditions for Medicare payment for psychiatric hospitals.
Generally, to enter into an agreement, a psychiatric hospital must
first be certified by a State Survey Agency as complying with the
conditions or requirements set forth in part 482 subpart A, B, C and E
of our regulations. Thereafter, the psychiatric hospital is subject to
regular surveys by a State Survey Agency to determine whether it
continues to meet these requirements. There is an alternative, however,
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 may treat the provider entity as having met those
conditions, that is, we may ``deem'' the provider entity 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 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. A national accrediting
organization applying for approval of its accreditation program under
part 488, subpart A, must provide the Centers for Medicare & Medicaid
Services (CMS) 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. 488.5. The regulations at Sec. 488.5(e)(2)(i)
require accrediting organizations to reapply for continued approval of
its accreditation program every 6 years or sooner as determined by CMS.
The Joint Commission's current term of approval for their
psychiatric hospital accreditation program expires February 25, 2019.
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 August 15, 2018, we published a proposed notice in the Federal
Register (83 FR 40514), announcing the Joint Commission's (TJC's)
request for continued approval of its Medicare psychiatric hospital
accreditation
[[Page 4819]]
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 TJC's Medicare psychiatric hospital
accreditation renewal application in accordance with the criteria
specified by our regulations, which include, but are not limited to the
following:
An onsite administrative review of TJC's: (1) Corporate
policies; (2) financial and human resources available to accomplish the
proposed surveys; (3) procedures for training, monitoring, and
evaluation of its psychiatric hospital surveyors; (4) ability to
investigate and respond appropriately to complaints against accredited
psychiatric hospitals; and, (5) survey review and decision-making
process for accreditation.
A comparison of TJC's Medicare hospital accreditation
program standards to our current Medicare hospital Conditions of
Participation (CoPs) and psychiatric hospital special conditions.
A documentation review of TJC's psychiatric hospital's
survey process to:
++ Determine the composition of the survey team, surveyor
qualifications, and TJC's ability to provide continuing surveyor
training.
++ Compare TJC's processes to those CMS require of state survey
agencies, including periodic resurvey and the ability to investigate
and respond appropriately to complaints against accredited psychiatric
hospitals.
++ Evaluate TJC's procedures for monitoring psychiatric hospitals
it has found to be out of compliance with TJC's program requirements.
(This pertains only to monitoring procedures when TJC 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 Sec. 488.9(c)).
++ Assess TJC's ability to report deficiencies to the surveyed
hospital and respond to the psychiatric hospital's plan of correction
in a timely manner.
++ Establish TJC'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 TJC's staff and other resources.
++ Confirm TJC's ability to provide adequate funding for performing
required surveys.
++ Confirm TJC's policies with respect to surveys being
unannounced.
++ Obtain TJC'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 August 15,
2018 proposed notice also solicited public comments regarding whether
TJC's requirements met or exceeded the Medicare CoPs for psychiatric
hospitals. We received no comments in response to our proposed notice.
IV. Provisions of the Final Notice
A. Differences Between TJC's Standards and Requirements for
Accreditation and Medicare Conditions and Survey Requirements
We compared TJC's psychiatric hospital accreditation program
requirements and survey process with the Medicare CoPs at part 482 and
the survey and certification process requirements of parts 488 and 489.
Our review and evaluation of TJC's psychiatric hospital 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, TJC
has revised its standards and certification processes in order to meet
the requirements at:
Section 482.12(a)(10), to address that consultation will
occur directly with the individual assigned the responsibility for the
organization and conduct of the hospital's medical staff, or his/her
designee and the timeframe for which direct consultation must occur.
Section 482.41(b)(3), to provide information related to
our rule stating that Life Safety Code provisions do not apply in a
State where CMS finds that a fire and safety code imposed by State law
adequately protects patients in hospitals.
Section 482.41(b)(5), to address cooperation with local
firefighting authorities.
Section 482.41(b)(7), to address installing alcohol-based
hand rub dispensers in a manner that adequately protects against
inappropriate access.
Section 482.41(e), to address the omission of a standard
to correspond to references and documents in this CMS requirement.
Section 482.42(b)(1), to address and clarify that ``make
certain'' is defined as ``must.''
Section 482.42(b)(2), to address and clarify that ``make
certain'' is defined as ``must.''
Section 482.43(b)(2), to address who may develop or
supervise the development of the discharge evaluation.
Section 482.43(c)(1), to address who must develop or
supervise the development of a discharge plan if the discharge planning
evaluation indicates a need for a discharge plan.
Section 482.51(a)(3), to address that a qualified
registered nurse is immediately available to respond to emergencies.
Section 482.51(b)(3), to address and include the required
equipment that must be available to the operating room suites.
Section Sec. 488.5(a)(4)(i), to ensure that all surveys
are unannounced.
Section Sec. 488.5(a)(4)(ii), to ensure that its
surveyors are provided clear instruction for assessing only the
applicable CoPs for the psychiatric hospital accreditation program.
Section 488.5(a)(4)(iv), to ensure that TJC psychiatric
hospital surveyors document findings of noncompliance with
accreditation standards at the comparable Medicare CoP; and to ensure
that all findings of observed noncompliance noted on surveyor
worksheets are clearly and accurately reflected in the final survey
deficiency report.
Section 488.5(a)(4)(v), to ensure that a minimum sample of
patient records are reviewed for all elements required by the
regulations.
Sections 488.5(a)(11)(ii), to ensure that data submitted
to CMS is timely, complete and accurate.
Section 488.5(a)(12), to ensure that TJC has a clearly
defined complaint investigation process that is comparable to CMS; to
ensure that the process for protecting complainant anonymity does not
impede the required complaint investigation; to ensure that complaints
are investigated, based on the submitted allegations, irrespective of
receiving a ``waiver of anonymity'' from the complainant; to ensure
that complaints are reviewed and investigated within the comparable
timelines established by CMS; and to ensure that all complaints that
would result in condition-level non-compliance, based on allegations
described therein, are required to be investigated through an onsite
survey.
Section 488.5(a)(19)(ii), to ensure that TJC proposed
survey process and crosswalked standards will not be implemented
without prior written notice of approval from CMS.
Section 488.26, to ensure TJC's survey process meets or
exceeds the Medicare program requirements; and to ensure that surveyors
assess all required facility locations and services during the survey
process.
Section 489.13, to ensure that the granting of
accreditation and recommendations to CMS for Medicare participation
occurs only after the
[[Page 4820]]
facility has demonstrated full compliance with all requirements.
B. Term of Approval
Based on our review and observations described in section III of
this final notice, we approve TJC as a national accreditation
organization for psychiatric hospitals that request participation in
the Medicare program, effective February 25, 2019 through February 25,
2023.
To verify TJC's continued compliance with the provisions of this
final notice, CMS expects to conduct a follow-up corporate on-site
visit and survey observation within 18 months of the publication date
of this notice.
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: February 7, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2019-02673 Filed 2-15-19; 8:45 am]
BILLING CODE 4120-01-P