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

<NOTICE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Centers for Medicare & Medicaid Services</SUBAGY> <DEPDOC>[CMS-3468-FN]</DEPDOC> <SUBJECT>Medicare and Medicaid Programs; Application From The Joint Commission for Continued CMS Approval of its Hospital 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 final notice announces our decision to approve The Joint Commission for continued CMS-recognition as a national accrediting organization for hospitals that wish to participate in the Medicare or Medicaid programs. </SUM> <DATES> <HD SOURCE="HED">DATES:</HD> The decision announced in this final notice is effective July 15, 2025, through July 15, 2030. </DATES> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Caecilia Andrews, (410) 786-2190. </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">I. Background</HD> Under the Medicare program, eligible beneficiaries may receive covered services from a hospital, provided certain requirements are met. Section 1861(e) of the Social Security Act (the 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 42 CFR part 488. The regulations at 42 CFR part 482 specify the minimum conditions that a hospital must meet to participate in the Medicare program. Generally, to enter into an agreement, a hospital must first be certified by a state survey agency (SA) as complying with the conditions or requirements set forth in part 482 of our regulations. Thereafter, the hospital is subject to regular surveys by an SA to determine whether it continues to meet these requirements. 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 set forth at §§ 488.4, 488.5 and 488.5(e)(2)(i). 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. The Joint Commission's (TJC's) current term of approval for their hospital accreditation program expires July 15, 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> approving or denying the application. <HD SOURCE="HD1">III. Provisions of the Proposed Notice</HD> On February 11, 2025, we published a proposed notice in the <E T="04">Federal Register</E> (90 FR 9341), announcing TJC's request for continued approval of its Medicare hospital accreditation program. In that proposed notice, we detailed our evaluation criteria. Under Section 1865(a)(2) of the Act and in our regulations at § 488.5 and § 488.8(h), we conducted a review of TJC's Medicare hospital accreditation program application in accordance with the criteria specified by our regulations, which include, but are not limited to, the following: • An 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 hospital surveyors; (4) ability to investigate and respond appropriately to complaints against accredited hospitals; and (5) survey review and decision-making process for accreditation. • A review of TJC's survey processes to confirm that a provider or supplier, under TJC's hospital deeming accreditation program, meets or exceeds the Medicare program requirements. • A documentation review of TJC's survey process to do the following: ++ 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 TJC-accredited hospitals. ++ Evaluate TJC's procedures for monitoring accredited 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 SA through a validation survey, the SA monitors corrections as specified at § 488.9(c)). ++ Assess TJC's ability to report deficiencies to the surveyed hospital and respond to the 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. ++ 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 February 11, 2025, proposed notice also solicited public comments regarding whether TJC's requirements met or exceeded the Medicare conditions of participate (CoPs) for hospitals. We received several comments. <E T="03">Comment:</E> Two commenters believed the application should be approved. One of the commenters stated that the processes in place by TJC ensure frequent in-person surveys and assist the organizations being surveyed, while making online resources available. Another commenter was in support of approval and noted their belief that TJC's requirements meet or exceed the Medicare CoPs for hospitals. This commenter noted having experienced surveys by TJC of their facility and that TJC's survey process is an effective means of ensuring that the facility is a safe place for patients to be treated. The commenter suggested one area of improvement would be to increase survey frequency and believed that more frequent surveys would better establish everyday readiness for facilities. <E T="03">Response:</E> We appreciate the commenters' support of TJC as a CMS-approved AO for hospitals. CMS requires AOs to conduct surveys at least every 36 months in accordance with § 488.5(a)(4)(i). We note that AOs have the discretion to require and perform surveys more frequently than every 36 months. <E T="03">Comment:</E> CMS received another comment of support for TJC's continued recognition of its hospital accreditation program and suggested that TJC's accreditation process helps in maintaining high hospital standards. While in support of TJC's continued approval, the commenter suggests that there should be more transparency in its survey process and stronger safeguards to prevent conflicts of interest. <E T="03">Response:</E> We appreciate the commenter's general support and agree that further transparency in survey processes is instrumental in ensuring comparability between the AO processes and those of CMS. We also agree that AOs must prevent conflicts of interests. As part of CMS' review of AOs for continued recognition, and in accordance with § 488.5(a)(10), CMS reviews AOs' 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. <E T="03">Comment:</E> One commenter raised concern related to TJC's standard at EC.02.03.03 EP 1, which requires one hour between fire drills. The commenter stated that the National Fire Protection Association (NFPA) Code 101-2012: 18/19:7.1.7 does not require a 1-hour variance, but that there should be varied conditions. The commenter encouraged CMS to address this inconsistency and ensure TJC ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 26k characters. Full document text is stored and available for version comparison. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━