Medicare and Medicaid Programs: Application From the Center for Improvement in Healthcare Quality for Initial CMS-Approval of Its Critical Access Hospital Accreditation Program, 32770-32772 [2023-10824]
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Federal Register / Vol. 88, No. 98 / Monday, May 22, 2023 / Notices
requirement, CMS is publishing this
notice.
Interested parties are invited to
submit comments regarding our burden
estimates or any other aspect of the
collection, including: the necessity and
utility of the proposed information
collection for the proper performance of
our agency’s functions; the accuracy of
burden estimates; ways to enhance the
quality, utility, and clarity of the
information to be collected; and the use
of automated collection techniques or
other forms of information technology to
minimize the information collection
burden. See DATES and ADDRESSES for
instructions for submitting comments.
While we will review all comments
received, we may choose not to post offtopic or inappropriate comments.
Otherwise, all comments will be posted
without edit under the applicable
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provides. Our response to such
comments will be posted at reginfo.gov
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Medicaid and CHIP Program (MACPro)
At this time, MACPro is made up of
the main umbrella (see collection
number 1 in the following list) and nine
individual generic collections of
information (see collection numbers 2
through 10 in the following list). Details
such as the collection’s requirements
and burden estimates can be found in
the collection’s supporting statement
and associated materials (see ADDRESSES
for instructions for obtaining such
documents).
ddrumheller on DSK120RN23PROD with NOTICES1
Docket Information
1. Title: Medicaid and CHIP Program
(MACPro).
Type of Request: Revision of a
currently approved collection.
CMS ID Number: CMS–10434.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0080.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230080.
For Policy Related Questions, Contact:
William N. Parham at 410–786–4669.
2. Title: Initial Application.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #1.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0081.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230081.
For Policy Related Questions, Contact:
Stephanie Bell at 410–786–0617.
VerDate Sep<11>2014
18:54 May 19, 2023
Jkt 259001
3. Title: CHIP State Plan Eligibility.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #2.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0082.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230082.
For Policy Related Questions, Contact:
Stephanie Bell at 410–786–0617.
4. Title: Alternative Benefit Plans
(ABPs).
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #3.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0083.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230083.
For Policy Related Questions, Contact:
Adrienne Delozier at 410–786–0278.
5. Title: Medicaid State Plan
Eligibility.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #15.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0090.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230090.
For Policy Related Questions, Contact:
Suzette Seng at 410–786–4703.
6. Title: Health Home State Plan
Amendment (SPA).
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #22.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0084.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230084.
For Policy Related Questions, Contact:
Mary Pat Farkas at 410–786–5731.
7. Title: Medicaid Adult and Child
Core Set Measures.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #26.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0085.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230085.
For Policy Related Questions, Contact:
Virginia (Gigi) Raney at 410–786–6117.
8. Title: Maternal and Infant Health
Quality.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #45.
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Fmt 4703
Sfmt 4703
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0086.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230086.
For Policy Related Questions, Contact:
Virginia (Gigi) Raney at 410–786–6117.
9. Title: Health Home Core Sets.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #47.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0087.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230087.
For Policy Related Questions, Contact:
Mary Pat Farkas at 410–786–5731.
10. Title: Medicaid Extended
Postpartum Coverage and Continuous
Eligibility for Children.
Type of Request: Extension of a
currently approved collection.
CMS ID Number: CMS–10434 #77.
OMB Control Number: 0938–1188.
eRulemaking Docket ID Number:
CMS–2023–0088.
Docket Web Address: https://
www.regulations.gov/docket/CMS-20230088.
For Policy Related Questions, Contact:
Alexa Turner at 410–786–8823.
Dated: May 17, 2023.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2023–10860 Filed 5–19–23; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–3435–FN]
Medicare and Medicaid Programs:
Application From the Center for
Improvement in Healthcare Quality for
Initial CMS-Approval of Its Critical
Access Hospital Accreditation
Program
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Notice.
AGENCY:
This notice announces our
decision to approve the Center for
Improvement in Healthcare Quality for
initial recognition as a national
accrediting organization for critical
access hospitals that wish to participate
in the Medicare or Medicaid programs.
SUMMARY:
E:\FR\FM\22MYN1.SGM
22MYN1
Federal Register / Vol. 88, No. 98 / Monday, May 22, 2023 / Notices
The decision announced in this
notice is applicable June 1, 2023 to June
1, 2027.
FOR FURTHER INFORMATION CONTACT:
Caecilia Blondiaux, (410) 786–2190.
SUPPLEMENTARY INFORMATION:
DATES:
ddrumheller on DSK120RN23PROD with NOTICES1
I. Background
Under the Medicare program, eligible
beneficiaries may receive covered
services in a critical access hospital
(CAH) provided certain requirements
are met. Sections 1820(c)(2)(B), 1820(e)
and 1861(mm)(1) of the Social Security
Act (the Act) establishes distinct criteria
for facilities seeking designation as a
CAH. 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 485, subpart F, specify
the conditions of participation (CoPs)
that a CAH must meet to participate in
the Medicare program, the scope of
covered services, and the conditions for
Medicare payment for CAHs. The
regulations at 42 CFR 485.647 specify
that a CAH’s psychiatric or
rehabilitation distinct part unit (DPU), if
any, must meet the hospital
requirements specified in subparts A, B,
C, and D of part 482 and selected
provisions of 42 CFR part 412 in order
for the CAH DPU to participate in the
Medicare program.
Prior to becoming a CAH, to enter into
an agreement, a CAH must first be
certified by a state survey agency as a
hospital complying with the conditions
or requirements at part 482, then can
convert to a CAH by complying with the
conditions or requirements at part 485,
subpart F. The CAH 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. Certification 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 a Centers for
Medicare & Medicaid Services (CMS)
approved national accrediting
organization (AO) that all applicable
Medicare requirements are met or
exceeded, we will deem those provider
entities as having met such
requirements. Accreditation by an AO is
voluntary and is not required for
Medicare participation.
If an AO is recognized by the
Secretary of the Department of Health
and Human Services (the Secretary) as
having standards for accreditation that
meet or exceed Medicare requirements,
VerDate Sep<11>2014
18:54 May 19, 2023
Jkt 259001
any provider entity accredited by the
national accrediting body’s approved
program would be deemed to meet the
Medicare requirements. A national AO
applying for approval of its
accreditation program under part 488,
subpart A, must provide CMS with
reasonable assurance that the AO
requires the accredited provider entities
to meet requirements that are at least as
stringent as the Medicare requirements.
Our regulations concerning the
approval of AOs are at §§ 488.4 and
488.5. The regulations at § 488.5(e)(2)(i)
require an AO to reapply for continued
approval of its accreditation program
every 6 years or sooner, as determined
by CMS. This notice is to announce our
initial approval of the Center for
Improvement in Healthcare Quality’s
(CIHQ’s) CAH accreditation program.
CIHQ’s CAH deeming authority will be
reviewed for continued approval in
accordance with the regulations at
§§ 488.4 and 488.5 after this initial term
of approval.
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 December 7, 2022, we published
a proposed notice in the Federal
Register (87 FR 75049), announcing
CIHQ’s request for initial approval of its
Medicare critical hospital accreditation
program. In the December 2022
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 CAH
accreditation application in accordance
with the criteria specified by our
regulations, which include, but are not
limited to the following:
• A virtual administrative review of
CIHQ’s: (1) corporate policies; (2)
financial and human resources available
to accomplish the proposed surveys; (3)
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Frm 00051
Fmt 4703
Sfmt 4703
32771
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 CIHQ’s
accreditation to our current Medicare
CAH CoPs.
• A documentation review of CIHQ’s
survey process to:
++ Determine the composition of the
survey team, surveyor qualifications,
and CIHQ’s ability to provide
continuing surveyor training.
++ Compare CIHQ’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 CIHQ’s procedures for
monitoring CAH out of compliance with
CIHQ’s program requirements. The
monitoring procedures are used only
when CIHQ identifies noncompliance. If
noncompliance is identified through
validation reviews, the state survey
agency monitors corrections as specified
at § 488.7(d).
++ Assess CIHQ’s ability to report
deficiencies to the surveyed facilities
and respond to the facility’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 staff
and other resources.
++ Confirm CIHQ’s ability to provide
adequate funding for performing
required surveys.
++ Confirm CIHQ’s policies with
respect to whether surveys are
announced or 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.
IV. Analysis of and Responses to Public
Comments on the Proposed Notice
In accordance with section
1865(a)(3)(A) of the Act, the December
7, 2022 proposed notice also solicited
public comments regarding whether
CIHQ’s requirements met or exceeded
the Medicare CoPs for CAHs. We
received one comment, which was out
of the scope of the proposed notice.
E:\FR\FM\22MYN1.SGM
22MYN1
32772
Federal Register / Vol. 88, No. 98 / Monday, May 22, 2023 / Notices
ddrumheller on DSK120RN23PROD with NOTICES1
V. 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 CAH
requirements and survey process with
the Medicare CoPs and survey process
as outlined in the State Operations
Manual (SOM). Our review and
evaluation of CIHQ’s CAH application
were conducted as described in section
III of this notice and has yielded the
following areas where, as of the date of
this notice, CIHQ’s has completed
revising its standards and certification
processes in order to—
• Meet the standard’s requirements of
all of the following regulations:
++ Section 485.604(a)(2), to clarify
the requirements for clinical nurse
specialists’ education, including a
master’s or doctoral level degree in a
defined clinical area of nursing from an
accredited educational institution.
++ Section 485.616(c)(4)(iv), to
specify the requirement of an internal
review of a distant-site physician’s or
practitioner’s performance under
privileges at the CAH whose patients are
receiving the telemedicine services from
the physician or practitioner.
++ Section 485.623(b)(1), to ensure
that all essential mechanical, electrical
and patient care equipment is
maintained in safe operating condition.
++ Section 485.623(c)(1)(i), to align
CIHQ’s comparable standards with the
Life Safety Code (LSC) (National Fire
Protection Association (NFPA) 101 and
Tentative Interim Amendments (TIAs):
TIA 12–1, TIA 12–2, TIA 12–3, and TIA
12–4).
++ Section 485.627(a), to include
additional clarification or specific
language on ‘‘determining,
implementing and monitoring policies
governing the CAH’s total operation’’.
++ Section 485.635(b)(3), to include
reference to state law within its
standard for radiology services.
++ Section 485.638(a)(4)(iv), to
specify the qualifications of who may
make entries into the medical record,
which must be dated, and signed by the
individual who made the entry.
++ Section 485.639(a), to further
expand on the qualifications on the
practitioners who are allowed to
perform surgery for CAH patients, in
accordance with its approved policies
and procedures, and with state scope of
practice laws.
In addition to the standards review,
CMS also reviewed CIHQ’s comparable
survey processes, which were
conducted as described in section III of
this notice, and yielded the following
VerDate Sep<11>2014
18:54 May 19, 2023
Jkt 259001
areas where, as of the date of this notice,
CIHQ has completed revising its survey
processes in order to demonstrate that it
uses survey processes that are
comparable to state survey agency
processes by:
• Revising CIHQ’s surveyor guide to
ensure a comprehensive review of
environmental safety and life safety
requirements are performed.
• Clarifying CIHQ’s policies to align
with the SOM Appendix A-Hospitals,
Survey Protocol, Task 3, Survey
Locations, and Appendix W–CAHs
Entrance Activities, to include that all
hospital departments and services at the
primary hospital campus and remote
locations, satellite locations, inpatient
care locations, out-patient surgery
locations, complex out-patient care
locations, and a select sample of each
type of other services provided at
additional provider based locations,
including contracted patient care
activities or patient services will be
surveyed. These facility types may have
occupancy classifications other than
healthcare or ambulatory occupancies,
as determined by the LSC.
• Updating CIHQ’s position
summaries and description to include
that the LSC surveyor’s responsibilities
is comprised of an assessment of both
the LSC and Health Care Facilities Code.
B. Term of Approval
Based on our review and observations
described in sections III and V of this
notice, we approve CIHQ as a national
AO for CAHs that request participation
in the Medicare program. The decision
announced in this notice is effective
June 1, 2023 through June 1, 2027 (4
years).
VI. 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.).
The Administrator of the Centers for
Medicare & Medicaid Services (CMS),
Chiquita Brooks-LaSure, having
reviewed and approved this document,
authorizes Evell J. Barco Holland, who
is the Federal Register Liaison, to
electronically sign this document for
purposes of publication in the Federal
Register.
PO 00000
Frm 00052
Fmt 4703
Sfmt 4703
Dated: May 17, 2023.
Evell J. Barco Holland,
Federal Register Liaison, Centers for Medicare
& Medicaid Services.
[FR Doc. 2023–10824 Filed 5–19–23; 8:45 am]
BILLING CODE 4120–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[CMS–3443–PN]
Medicare and Medicaid Programs;
Application by the Center for
Improvement in Healthcare Quality
(CIHQ) for Initial CMS Approval of Its
Psychiatric Hospital Accreditation
Program
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Notice with request for
comment.
AGENCY:
This notice acknowledges the
receipt of an application from the Center
for Improvement in Healthcare Quality
(CIHQ) for initial recognition as a
national accrediting organization for
psychiatric 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, by June
21, 2023.
ADDRESSES: In commenting, refer to file
code CMS–3443–PN.
Comments, including mass comment
submissions, must be submitted in one
of the following three 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 to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
CMS–3443–PN, P.O. Box 8010,
Baltimore, MD 21244–8010.
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 to the
following address ONLY: Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services, Attention: CMS–3443–PN,
Mail Stop C4–26–05, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
SUMMARY:
E:\FR\FM\22MYN1.SGM
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]]>Agencies
[Federal Register Volume 88, Number 98 (Monday, May 22, 2023)]
[Notices]
[Pages 32770-32772]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-10824]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3435-FN]
Medicare and Medicaid Programs: Application From the Center for
Improvement in Healthcare Quality for Initial CMS-Approval of Its
Critical Access Hospital Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice announces our decision to approve the Center for
Improvement in Healthcare Quality for initial recognition as a national
accrediting organization for critical access hospitals that wish to
participate in the Medicare or Medicaid programs.
[[Page 32771]]
DATES: The decision announced in this notice is applicable June 1, 2023
to June 1, 2027.
FOR FURTHER INFORMATION CONTACT: Caecilia Blondiaux, (410) 786-2190.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services in a critical access hospital (CAH) provided certain
requirements are met. Sections 1820(c)(2)(B), 1820(e) and 1861(mm)(1)
of the Social Security Act (the Act) establishes distinct criteria for
facilities seeking designation as a CAH. 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 485, subpart F,
specify the conditions of participation (CoPs) that a CAH must meet to
participate in the Medicare program, the scope of covered services, and
the conditions for Medicare payment for CAHs. The regulations at 42 CFR
485.647 specify that a CAH's psychiatric or rehabilitation distinct
part unit (DPU), if any, must meet the hospital requirements specified
in subparts A, B, C, and D of part 482 and selected provisions of 42
CFR part 412 in order for the CAH DPU to participate in the Medicare
program.
Prior to becoming a CAH, to enter into an agreement, a CAH must
first be certified by a state survey agency as a hospital complying
with the conditions or requirements at part 482, then can convert to a
CAH by complying with the conditions or requirements at part 485,
subpart F. The CAH 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.
Certification 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 a Centers for Medicare & Medicaid
Services (CMS) approved national accrediting organization (AO) that all
applicable Medicare requirements are met or exceeded, we will deem
those provider entities as having met such requirements. Accreditation
by an AO is voluntary and is not required for Medicare participation.
If an AO is recognized by the Secretary of the Department of Health
and Human Services (the Secretary) as having standards for
accreditation that meet or exceed Medicare requirements, any provider
entity accredited by the national accrediting body's approved program
would be deemed to meet the Medicare requirements. A national AO
applying for approval of its accreditation program under part 488,
subpart A, must provide CMS with reasonable assurance that the AO
requires the accredited provider entities to meet requirements that are
at least as stringent as the Medicare requirements.
Our regulations concerning the approval of AOs are at Sec. Sec.
488.4 and 488.5. The regulations at Sec. 488.5(e)(2)(i) require an AO
to reapply for continued approval of its accreditation program every 6
years or sooner, as determined by CMS. This notice is to announce our
initial approval of the Center for Improvement in Healthcare Quality's
(CIHQ's) CAH accreditation program. CIHQ's CAH deeming authority will
be reviewed for continued approval in accordance with the regulations
at Sec. Sec. 488.4 and 488.5 after this initial term of approval.
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 December 7, 2022, we published a proposed notice in the Federal
Register (87 FR 75049), announcing CIHQ's request for initial approval
of its Medicare critical hospital accreditation program. In the
December 2022 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 CAH accreditation
application in accordance with the criteria specified by our
regulations, which include, but are not limited to the following:
A virtual 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 surveyors; (4) ability to investigate and respond
appropriately to complaints against accredited facilities; and, (5)
survey review and decision-making process for accreditation.
A comparison of CIHQ's accreditation to our current
Medicare CAH CoPs.
A documentation review of CIHQ's survey process to:
++ Determine the composition of the survey team, surveyor
qualifications, and CIHQ's ability to provide continuing surveyor
training.
++ Compare CIHQ'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 CIHQ's procedures for monitoring CAH out of compliance
with CIHQ's program requirements. The monitoring procedures are used
only when CIHQ identifies noncompliance. If noncompliance is identified
through validation reviews, the state survey agency monitors
corrections as specified at Sec. 488.7(d).
++ Assess CIHQ's ability to report deficiencies to the surveyed
facilities and respond to the facility'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 staff and other resources.
++ Confirm CIHQ's ability to provide adequate funding for
performing required surveys.
++ Confirm CIHQ's policies with respect to whether surveys are
announced or 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.
IV. Analysis of and Responses to Public Comments on the Proposed Notice
In accordance with section 1865(a)(3)(A) of the Act, the December
7, 2022 proposed notice also solicited public comments regarding
whether CIHQ's requirements met or exceeded the Medicare CoPs for CAHs.
We received one comment, which was out of the scope of the proposed
notice.
[[Page 32772]]
V. 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 CAH requirements and survey process with the
Medicare CoPs and survey process as outlined in the State Operations
Manual (SOM). Our review and evaluation of CIHQ's CAH application were
conducted as described in section III of this notice and has yielded
the following areas where, as of the date of this notice, CIHQ's has
completed revising its standards and certification processes in order
to--
Meet the standard's requirements of all of the following
regulations:
++ Section 485.604(a)(2), to clarify the requirements for clinical
nurse specialists' education, including a master's or doctoral level
degree in a defined clinical area of nursing from an accredited
educational institution.
++ Section 485.616(c)(4)(iv), to specify the requirement of an
internal review of a distant-site physician's or practitioner's
performance under privileges at the CAH whose patients are receiving
the telemedicine services from the physician or practitioner.
++ Section 485.623(b)(1), to ensure that all essential mechanical,
electrical and patient care equipment is maintained in safe operating
condition.
++ Section 485.623(c)(1)(i), to align CIHQ's comparable standards
with the Life Safety Code (LSC) (National Fire Protection Association
(NFPA) 101 and Tentative Interim Amendments (TIAs): TIA 12-1, TIA 12-2,
TIA 12-3, and TIA 12-4).
++ Section 485.627(a), to include additional clarification or
specific language on ``determining, implementing and monitoring
policies governing the CAH's total operation''.
++ Section 485.635(b)(3), to include reference to state law within
its standard for radiology services.
++ Section 485.638(a)(4)(iv), to specify the qualifications of who
may make entries into the medical record, which must be dated, and
signed by the individual who made the entry.
++ Section 485.639(a), to further expand on the qualifications on
the practitioners who are allowed to perform surgery for CAH patients,
in accordance with its approved policies and procedures, and with state
scope of practice laws.
In addition to the standards review, CMS also reviewed CIHQ's
comparable survey processes, which were conducted as described in
section III of this notice, and yielded the following areas where, as
of the date of this notice, CIHQ has completed revising its survey
processes in order to demonstrate that it uses survey processes that
are comparable to state survey agency processes by:
Revising CIHQ's surveyor guide to ensure a comprehensive
review of environmental safety and life safety requirements are
performed.
Clarifying CIHQ's policies to align with the SOM Appendix
A-Hospitals, Survey Protocol, Task 3, Survey Locations, and Appendix W-
CAHs Entrance Activities, to include that all hospital departments and
services at the primary hospital campus and remote locations, satellite
locations, inpatient care locations, out-patient surgery locations,
complex out-patient care locations, and a select sample of each type of
other services provided at additional provider based locations,
including contracted patient care activities or patient services will
be surveyed. These facility types may have occupancy classifications
other than healthcare or ambulatory occupancies, as determined by the
LSC.
Updating CIHQ's position summaries and description to
include that the LSC surveyor's responsibilities is comprised of an
assessment of both the LSC and Health Care Facilities Code.
B. Term of Approval
Based on our review and observations described in sections III and
V of this notice, we approve CIHQ as a national AO for CAHs that
request participation in the Medicare program. The decision announced
in this notice is effective June 1, 2023 through June 1, 2027 (4
years).
VI. 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.).
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Evell J. Barco Holland, who is the Federal
Register Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: May 17, 2023.
Evell J. Barco Holland,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2023-10824 Filed 5-19-23; 8:45 am]
BILLING CODE 4120-01-P
