Current through Register Vol. 46, No. 39, September 25, 2024
(a) Applicability.
For purposes of this section, the term hospital shall mean a general hospital,
as defined in article 28 of the Public Health Law, which provides services for
persons with mental illness pursuant to an operating certificate issued by the
Commissioner under article 31 of the Mental Hygiene Law, operating in
accordance with applicable provisions of this Title. The provisions of this
section shall apply to such hospitals.
(b) Reviews conducted pursuant to this
section of hospitals that have sought and obtained deemed status shall be made
by personnel of a nationally accredited review organization, who possess the
necessary skills and competencies in behavioral health to conduct
inspections.
(c) Hospitals must
comply with all operational standards set forth in applicable provisions of
this Title. As evidence of compliance with such provisions, the commissioner
may accept accreditation by The Joint Commission or an accreditation agency to
which the Centers for Medicare and Medicaid Services has granted deeming status
and which the commissioner has determined has accrediting standards sufficient
to assure the commissioner that hospitals so accredited are in compliance with
such operational standards, a list of which shall be made available on the
public website of the office, provided that:
(1) the hospital has a history of compliance
with applicable laws, rules, and regulations and a record of providing care of
good quality, as determined by the commissioner;
(2) a copy of the survey report and the
certification of accreditation of The Joint Commission or other approved
accrediting organization is submitted by the accrediting body to the
commissioner, within seven days of issuance to the hospital;
(3) The Joint Commission or other approved
accrediting organization has agreed to, and does evaluate, as part of its
accreditation survey, any minimal operational standards established by the
commissioner which are in addition to the minimal operational standards of
accreditation of The Joint Commission or other approved accrediting
organization;
(4) there are no
constraints placed upon access by the commissioner to The Joint Commission or
other approved accreditation organization's survey reports, plans of
correction, interim self-evaluation reports, notices of noncompliance, progress
reports on correction of areas of noncompliance, or any other related reports,
information, communications, or materials regarding such hospital;
(5) the hospital at all times shall remain
subject to inspection and visitation by the commissioner to determine
compliance with applicable law, regulations, standards, or conditions as
determined to be necessary by the commissioner; and
(6) the hospital at all times shall remain
subject to the full range of licensing enforcement authority of the
commissioner.
(d) Any
hospital that is under deemed status pursuant to this section must immediately
provide written notice to the commissioner of any of the following:
(1) receipt of notice of failure to be
accredited, re-accredited or the loss of accreditation by the accreditation
organization;
(2) any communication
the hospital has received that indicates that the accrediting organization will
be recommending that such hospital not be accredited, not have its
accreditation renewed, or have its accreditation terminated;
(3) receipt of notice or other communication
from the Centers for Medicare and Medicaid Services regarding a determination
that the hospital will be terminated from participation in the Medicare program
because it is not in compliance with one or more conditions of participation in
such program, or has deficiencies that either individually, or in combination
with others, jeopardizes the health and safety of persons receiving services,
or are of such nature as to seriously compromise the provider's ability to
render adequate care;
(4) a change
of the hospital's accreditation organization; or
(5) a decision by the hospital to terminate
its agreement with its accrediting organization.
(e) Failure to adhere to the requirements set
forth in subdivisions (c) and (d) of this section may be grounds for revocation
of deemed status.
(f) In the event
that the commissioner determines that a hospital's deemed status must be denied
or revoked, the hospital may request an informal administrative review of such
decision.
(1) The hospital must request such
review in writing within 15 days of the date it receives notice of the denial
or revocation of its deemed status by the commissioner or designee. The request
shall state specific reasons why the hospital considers the denial or
revocation of deemed status incorrect and shall be accompanied by any
supporting evidence or arguments.
(2) The commissioner or designee shall notify
the hospital, in writing, of the results of the informal administrative review
within 20 days of receipt of the request for review. Failure of the
commissioner or designee to respond within that time shall be considered
confirmation of the denial or revocation of deemed status.
(3) The commissioner's determination after
informal administrative review shall be final and not subject to further
administrative review.
