Medicare & Medicaid Programs: Application From the Accreditation Commission for Health Care for Continued CMS-Approval of Its Hospice…
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Final notice.
Citation: "78 FR 66364"
Document Number: "CMS-3110-FN"
"Notices"
SUMMARY: This final notice announces our decision to approve the
   DATES: Effective: This final notice is effective
   FOR FURTHER INFORMATION CONTACT:
   SUPPLEMENTARY INFORMATION:
I. Background
   Under the
   Generally, to enter into an agreement, a hospice must first be certified by a state survey agency as complying with the conditions or requirements set forth in part 418. Thereafter, the hospice 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 an approved national accrediting organization that all applicable
   If an accrediting organization is recognized by the Secretary of the
   Our regulations concerning the approval of accrediting organizations are set forth at
   The ACHC's current term of approval for their hospice accreditation program expires
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
III. Provisions of the Proposed Notice
   On
    * An onsite administrative review of ACHC'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.
    * The comparison of ACHC's accreditation requirements to our current
    * A documentation review of ACHC's survey process to determine the following:
   ++ The composition of the survey team, surveyor qualifications, and ACHC's ability to provide continuing survey or training.
   ++ Comparability of ACHC's processes to those of state survey agencies, including survey frequency, and the ability to investigate and respond appropriately to complaints against accredited facilities.
   ++ ACHC's procedures for monitoring hospices out of compliance with ACHC's program requirements. The monitoring procedures are used only when ACHC identifies noncompliance. If noncompliance is identified through validation reviews, the State survey agency monitors corrections as specified at
   ++ ACHC's ability to report deficiencies to the surveyed facilities and respond to the facility's plan of correction in a timely manner.
   ++ ACHC's ability to provide CMS with electronic data and reports necessary for effective validation and assessment of the organization's survey process.
   ++ The adequacy of staff and other resources.
   ++ ACHC's ability to provide adequate funding for performing required surveys.
   ++ ACHC's policies with respect to whether surveys are announced or unannounced.
   ++ ACHC'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
IV. Provisions of the Final Notice
A. Differences Between ACHC's Standards and Requirements for Accreditation and
   We compared ACHC's hospice requirements and survey process with the
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirement at
    * To meet the requirements of Appendix M of the SOM, ACHC instituted processes and audits to ensure that the Medicare Enrollment Application Form CMS-855A is verified by the assigned Medicare Administrative Contractor (MAC) prior to conducting an initial survey.
B. Term of Approval
   Based on our review and observations described in section III of this final notice, we have determined that ACHC's hospice accreditation program requirements meet or exceed our requirements. Therefore, we approve ACHC as a national accreditation organization for hospices that request participation in the
V. Collection of Information Requirements
   This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the
(Catalog of Federal Domestic Assistance Program No. 93.778,
   Dated:
Administrator,
[FR Doc. 2013-26374 Filed 11-4-13;
BILLING CODE 4120-01-P
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