Medicare and Medicaid Programs; Application From The Joint Commission for Continued Approval of its Hospice Accreditation Program

<NOTICE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Centers for Medicare & Medicaid Services</SUBAGY> <DEPDOC>[CMS-3469-FN]</DEPDOC> <SUBJECT>Medicare and Medicaid Programs; Application From The Joint Commission for Continued Approval of its Hospice Accreditation Program</SUBJECT> <HD SOURCE="HED">AGENCY:</HD> Centers for Medicare & Medicaid Services (CMS), HHS. <HD SOURCE="HED">ACTION:</HD> Notice. <SUM> <HD SOURCE="HED">SUMMARY:</HD> This notice announces our decision to approve The Joint Commission for continued recognition as a national accrediting organization for hospices that wish to participate in the Medicare or Medicaid programs. </SUM> <DATES> <HD SOURCE="HED">DATES:</HD> The decision announced in this notice is applicable from June 18, 2025 through June 18, 2030. </DATES> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Joann Fitzell, (410) 786-4280 or Lillian Williams, (410) 786-8636. </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">I. Background</HD> Under the Medicare program, eligible beneficiaries may receive covered services in a hospice, provided certain requirements are met by the hospice. Section 1861(dd) of the Social Security Act (the Act) establishes distinct criteria for facilities seeking designation as a hospice. 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 418 specify the conditions that a hospice must meet in order to participate in the Medicare program, the scope of covered services, and the conditions for Medicare payment for hospices. Generally, to enter into an agreement, a hospice must first be certified as complying with the conditions set forth in part 418 and recommended to the Centers for Medicare & Medicaid (CMS) for participation by a State survey agency. Thereafter, the hospice is subject to periodic surveys by a State survey agency to determine whether it continues to meet these conditions. However, there is an alternative to certification surveys by State agencies. Accreditation by a nationally recognized Medicare accreditation program approved by CMS may substitute for both initial and ongoing State review. Section 1865(a)(1) of the Act provides that, if the Secretary of the Department of Health and Human Services (the Secretary) finds that accreditation of a provider entity by an approved national accrediting organization (AO) meets or exceeds all applicable Medicare conditions, CMS may treat the provider entity as having met those conditions; that is, we may “deem” the provider entity to be in compliance. Accreditation by an AO is voluntary and is not required for Medicare participation. If an AO is recognized by the Secretary as having standards for accreditation that meet or exceed Medicare requirements, any provider entity accredited by the national AO's approved program may be deemed to meet the Medicare conditions. A national AO applying for CMS approval of its accreditation program under part 488, must provide 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 of participation (CoPs). Our regulations concerning the approval of AOs are set forth at § 488.5. Section 488.5(e)(2)(i) requires an AO to reapply for continued approval of its Medicare accreditation program every 6 years or sooner as determined by CMS. The Joint Commission's (TJC's) term of approval as a recognized accreditation program for hospices expires June 18, 2025. <HD SOURCE="HD1">II. Application Approval Process</HD> 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 <E T="04">Federal Register</E> 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 <E T="04">Federal Register</E> of our decision to approve or deny the application. <HD SOURCE="HD1">III. Provisions of the Proposed Notice</HD> On January 13, 2025 we published a proposed notice in the <E T="04">Federal Register</E> (90 FR 2706), announcing TJC's request for continued approval of its Medicare hospice accreditation program. In the January 13, 2025 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 hospice accreditation program application in accordance with the criteria specified by our regulations, which include, but are not limited to, the following: • A virtual 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 hospice surveyors; (4) ability to investigate and respond appropriately to complaints against accredited hospices; and (5) survey review and decision-making process for accreditation. • The comparison of TJC's Medicare hospice accreditation program standards to our current Medicare hospice CoPs. • A documentation review of TJC'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 we require of State survey agencies, including periodic resurvey and the ability to investigate and respond appropriately to complaints against accredited hospices. ++ Evaluate TJC's procedures for monitoring hospices it has found to be out of compliance with TJC's program requirements. (This pertains only to monitoring procedures when TJC identifies noncompliance. 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 hospice and respond to the hospice'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. ++ Confirm TJC's policies and procedures to avoid conflicts of interest, including the appearance of conflicts of interest, involving individuals who conduct surveys or participate in accreditation decisions. ++ 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. <HD SOURCE="HD1">IV. Analysis of and Responses to Public Comments on the Proposed Notice</HD> In accordance with section 1865(a)(3)(A) of the Act, the January 13, 2025 proposed notice also solicited public comments regarding whether TJC's requirements met or exceeded the Medicare CoPs for hospices. We received no comments in response to our proposed notice. <HD SOURCE="HD1">V. Provisions of the Final Notice</HD> <HD SOURCE="HD2">A. Differences Between TJC's Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements</HD> We compared TJC's hospice accreditation requirements and survey process with the Medicare CoPs of part 418, and the survey and certification process requirements of parts 488 and 489. Our review and evaluation of TJC's hospice application, which were conducted as described in section III of this notice, yielded the following areas where, as of the date of this notice, TJC has completed revising its standards and certification processes in order to meet the requirements at: • Section 418.52(b)(4)(iii), to include reference to the State survey agency. • Section 418.52(c)(5), to include reference to “45 CFR parts 160 and 164”. • Section 418.52(c)(6), to address the right of a patient to be free of the misappropriation of the patient's property. • Section 418.54(e), to address the hospice's quality assessment and performance improvement program. • Section 418.58(c)(1)(ii), to address the program activity requirement to consider the incidence, prevalence, and severity of problems in those areas. • Section 418.60(c), to address the requirement for contracted providers, patients, family members, and other caregivers. • Section 418.66(a), to address the requirement that the hospice must provide evidence to CMS that it has made a good faith effort to hire a sufficient number of nurses to provide services. • Section 418.76(b)(3)(xiii), to address the requirement the hospice is responsible for training hospice aids, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. • Section 418.100(f)(1), to address the Medicare approval requirement. • Section 418.102(a)(1)(ii), to address the requirement that the contract must specify the physician who assumes the medical director's responsibilities and obligations. • Section 418.104(e)(2), to address the requirement that if a patient revokes the election of hospice care or is discharged from hospice in accordance with § 418.26, the hospice ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 15k characters. 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