Evaluation of Deeming Authority Request. AAAASF submitted all the necessary materials to enable us to make a determination concerning its request for continued approval of its OPT accreditation program. This application was determined to be complete on September 29, 2014. Under Section 1865(a)(2) of the Act and our regulations at § 488.8 (Federal review of accrediting organizations), our review and evaluation of AAAASF will be conducted in accordance with, but not necessarily limited to, the following factors: • The equivalency of AAAASF’s standards for OPTs as compared with Medicare’s OPT CoPs. • AAAASF’s survey process to determine the following: —The composition of the survey team, surveyor qualifications, and the ability of the organization to provide continuing surveyor training. —The comparability of AAAASF’s —AAAASF’s capacity to report deficiencies to the surveyed facilities and respond to the facility’s plan of correction in a timely manner. —AAAASF’s capacity to provide CMS with electronic data and reports necessary for effective validation and assessment of the organization’s survey process. —The adequacy of AAAASF’s staff and other resources, and its financial viability. —AAAASF’s capacity to adequately fund required surveys. —AAAASF’s policies to assure that surveys are unannounced. —AAAASF’s agreement to provide CMS with a copy of the most current accreditation survey together with any other information related to the survey that CMS may request (including corrective action plans).
Evaluation of Deeming Authority Request. TJC submitted all the necessary materials to enable us to make a determination concerning its request for CMS-approval of its psychiatric hospital accreditation program. This application was determined to be complete on July 30, 2018. Under section 1865(a)(2) of the Act and our regulations at § 488.5 (Application and re-application procedures for national accrediting organizations), our review and evaluation of TJC will be conducted in accordance with, but not necessarily limited to, the following factors: • The equivalency of TJC’s standards for psychiatric hospitals as compared with CMS’ psychiatric hospital CoPs. • TJC’s survey process to determine the following: ++ The composition of the survey team, surveyor qualifications, and the ability of the organization to provide continuing surveyor training. ++ The comparability of TJC’s processes to those of State agencies, including survey frequency, and the ability to investigate and respond appropriately to complaints against accredited facilities. ++ TJC’s processes and procedures for monitoring a psychiatric hospital found out of compliance with the TJC’s program requirements. These monitoring procedures are used only when TJC identifies noncompliance. If noncompliance is identified through validation reviews or complaint surveys, the state survey agency monitors corrections as specified at § 488.9(c). ++ XXX’s capacity to report deficiencies to the surveyed facilities and respond to the facility’s plan of correction in a timely manner. ++ TJC’s capacity to provide CMS with electronic data and reports necessary for effective validation and assessment of the organization’s survey process. ++ The adequacy of TJC’s staff and other resources, and its financial viability. ++ TJC’s capacity to adequately fund required surveys. ++ XXX’s policies with respect to whether surveys are announced or unannounced, to assure that surveys are unannounced. ++ 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 CMS may require (including corrective action plans).
