[Federal Register Volume 76, Number 38 (Friday, February 25, 2011)]
[Notices]
[Pages 10598-10600]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-4294]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-2326-FN]
Medicare and Medicaid Programs; Approval of the Joint Commission
for Deeming Authority for Psychiatric Hospitals
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final notice.
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SUMMARY: This notice announces our decision to approve the Joint
Commission for recognition as a national accreditation program for
psychiatric hospitals seeking to participate in the Medicare or
Medicaid programs. This initial 4-year approval is effective February
25, 2011, through February 25, 2015.
DATES: Effective Date: This final notice is effective February 25,
2011.
FOR FURTHER INFORMATION CONTACT: L. Tyler Whitaker, (410) 786-5236;
Patricia Chmielewski, (410) 786-6899.
SUPPLEMENTARY INFORMATION:
I. Background
Under the Medicare program, eligible beneficiaries may receive
covered services in 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. The regulations at 42 CFR part 482, subpart
E specify, among other things, the conditions that a psychiatric
hospital must meet to participate in the Medicare program. Regulations
concerning provider agreements are located at 42 CFR part 489 and those
pertaining to survey and certification of facilities are at 42 CFR part
488.
Generally, in order to enter into a provider agreement, a
psychiatric hospital must first be certified by a State survey agency
as complying with the conditions or requirements set forth in section
1861(f) of the Act, and 42 CFR part 482, including the special
provisions applying to psychiatric hospitals in subpart E of our
regulations. Thereafter, the psychiatric hospital is subject to ongoing
review by a State survey agency to determine whether it continues to
meet the Medicare 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 (AO) that all applicable Medicare conditions
are met or exceeded, we may ``deem'' that provider entity as having met
the requirements. Accreditation by an AO is
[[Page 10599]]
voluntary and is not required for Medicare participation. A national AO
applying for deeming authority under 42 CFR 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 conditions.
II. Deeming Application Approval Process
Section 1865(a)(3)(A) of the Act provides a statutory timetable to
ensure that our review of applications for deeming authority is
conducted in a timely manner. The statute provides 210 calendar days
after the date of receipt of a complete application, with any
documentation necessary to make a 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 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 a
notice in the Federal Register approving or denying the application.
III. Provisions of the Proposed Notice and Response to Comments
In the October 22, 2010 Federal Register (75 FR 65360), we
published a proposed notice announcing the Joint Commission's request
for approval as a deeming organization for psychiatric hospitals. In
that notice, we detailed our evaluation criteria. Under section
1865(a)(2) of the Act and Sec. 488.4 (Application and reapplication
procedures for accreditation organizations), we conducted a review of
the Joint Commission'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 the Joint Commission'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 the Joint Commission's psychiatric
hospital accreditation standards to our current Medicare psychiatric
hospital conditions of participation (CoPs).
A documentation review of the Joint Commission's survey
processes to:
+ Determine the composition of the survey team, surveyor
qualifications, and the Joint Commission's ability to provide
continuing surveyor training.
+ Compare the Joint Commission'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 the Joint Commission's procedures for monitoring
psychiatric hospitals determined to be out of compliance with the Joint
Commission's program requirements. The monitoring procedures are used
only when the Joint Commission identifies noncompliance. If
noncompliance is identified through validation reviews, the State
survey agency monitors corrections as specified at Sec. 488.7(d).
+ Assess the Joint Commission's ability to report deficiencies to
the surveyed facilities and respond to the facility's plan of
correction in a timely manner.
+ Establish the Joint Commission's ability to provide us with
electronic data and reports necessary for effective validation and
assessment of the Joint Commission's survey process.
+ Determine the adequacy of staff and other resources.
+ Review the Joint Commission's ability to provide adequate funding
for performing required surveys.
+ Confirm the Joint Commission's policies with respect to whether
surveys are announced or unannounced.
+ Obtain the Joint Commission'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 October
22, 2010 proposed notice also solicited public comments regarding
whether the Joint Commission's requirements met or exceeded the
Medicare CoPs for psychiatric hospitals. We received 4 comments in
response to our proposed notice.
All of the commenters expressed strong support for the Joint
Commission's application for psychiatric hospital deeming authority.
The commenters stated that the Joint Commission's standards are clearly
written and closely align with the Medicare CoPs, and that the Joint
Commission's accreditation program provides psychiatric hospitals with
a viable alternative to other healthcare accreditation organizations.
IV. Provisions of the Final Notice
A. Differences Between the Joint Commission's Standards and
Requirements for Accreditation and Medicare's Conditions and Survey
Requirements
We compared the Joint Commission's psychiatric hospital
accreditation requirements and survey process with the Medicare CoPs
and survey process as outlined in the State Operations Manual (SOM).
Our review and evaluation of the Joint Commission's deeming
application, which were conducted as described in section III. of this
final notice, yielded the following:
To meet the requirements at Appendix AA of the SOM, the
Joint Commission revised its policies to ensure surveyors draw a
representative number of patients from each distinct program area for
observation and interview based on the size of that program.
To meet the requirements at Sec. 482.13(e), the Joint
Commission revised its crosswalk to address the requirement that all
patients have the right to be free from physical or mental and corporal
punishment.
To meet the requirements at Sec. 482.24(b)(2), the Joint
Commission revised its standards to address the requirement that the
medical record system must allow for timely retrieval of patient
information by diagnosis and procedure.
To meet the requirements at Sec. 482.26(b)(1), the Joint
Commission revised its crosswalk to ensure the hospital maintains
proper safety precautions against radiation hazards.
To meet the requirements at Sec. 482.41(a), the Joint
Commission modified its standards to prevent hospitals from conducting
back-to-back emergency preparedness response drills.
To meet the requirements at Sec. 482.41(a)(1), the Joint
Commission revised its standards to include all of the essential
electrical system specific requirements, per National Fire Protection
Association (NFPA) 99:1999: 12-3.3 and corresponding Chapter 3
requirements.
To meet the requirements at Sec. 482.41(b)(1)(i), the
Joint Commission revised its standards to address the availability of
the fire safety plan, and ensure that all required fire safety elements
are addressed. In addition, the Joint Commission revised its standards
to require quarterly testing of tamper and water flow devices, and
ensure no gaps exist around penetrations.
To meet the requirements at Sec. 482.41(b)(9)(i) through
(iii) and Sec. 482.41(b)(9)(v), the Joint Commission
[[Page 10600]]
revised its Web site to ensure it includes all of the alcohol-based
hand rub dispenser requirements.
To meet the requirements at Sec. 482.45(b)(3), the Joint
Commission revised its standards to address the hospital's
responsibility to provide organ transplant data directly to the
Department of Health and Human Services when requested by the
Secretary.
To meet the requirements at Sec. 482.56, the Joint
Commission revised its crosswalk to ensure that if the hospital
provides rehabilitation, physical therapy, occupational therapy,
audiology, or speech pathology services, the services are organized and
staffed to ensure the health and safety of patients.
To meet the requirements at Sec. 482.61(a)(3), the Joint
Commission revised its standards to ensure psychiatric hospitals
clearly document the reason for admission as stated by the patient and/
or others significantly involved in the patient's care.
To meet the requirements at Sec. 482.61(a)(5), the Joint
Commission revised its standards to address the requirement that, when
indicated, a complete neurological examination be recorded at the time
of the admission physical examination.
To meet the requirements at Sec. 482.61(c)(1)(ii), the
Joint Commission revised its standards to include both short-term and
long-range patient goals.
To meet the requirements at Sec. 482.61(c)(1)(iv), the
Joint Commission revised its standards to ensure the patient's
treatment plan includes the responsibilities of each member of the
treatment team.
To meet the requirements at Sec. 482.62, the Joint
Commission revised its crosswalk to address the psychiatric hospital's
responsibility to formulate written, individualized, comprehensive
treatment plans, provide active treatment measures, and engage in
discharge planning.
To meet the requirements at Sec. 482.62(f), the Joint
Commission revised its standard to ensure that the hospital has a
director of social services who monitors and evaluates the quality and
appropriateness of social services furnished.
The Joint Commission revised its psychiatric hospital
survey procedures to ensure all applicable hospital CoPs at 42 CFR part
482 are adequately evaluated for compliance.
B. Term of Approval
Based on the review and observations described in section III. of
this final notice, we have determined that the Joint Commission's
requirements for psychiatric hospitals meet or exceed our requirements.
Therefore, we approve the Joint Commission as a national accreditation
organization for psychiatric hospitals that request participation in
the Medicare program effective February 25, 2011 through February 25,
2015.
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).
VI. Regulatory Impact Statement
In accordance with the provisions of Executive Order 12866, this
regulation was not reviewed by the Office of Management and Budget.
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)
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: February 18, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2011-4294 Filed 2-24-11; 8:45 am]
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