N.Y. Mental Hygiene Law § 31.08: Compliance with operational standards by general hospitals

§ 31.08 Compliance with operational standards by general hospitals.

(a) Notwithstanding the provisions of section 31.07 of this article,

with respect to a general hospital, as defined in article twenty-eight

of the public health law, which provides services for persons with

mental illness pursuant to an operating certificate issued by the

commissioner, the requirements of section 31.07 of this article may be

deemed to be met if such hospital has been accredited by The Joint

Commission, or any other hospital accrediting organization to which the

Centers for Medicare and Medicaid Services has granted deeming status,

and which the commissioner shall have determined has accrediting

standards sufficient to assure the commissioner that hospitals so

accredited are in compliance with the provisions of this chapter and

applicable laws, rules and regulations in regard to services provided at

such hospital. Such accreditation shall have the same legal effect as a

determination by the commissioner under section 31.07 of this article

that the hospital is in compliance with such provisions. The

commissioner may exempt any such hospital from the annual inspection and

visitation requirements established in section 31.07 of this article,

provided that:

1. such hospital has a history of compliance with such provisions of

law, rules and regulations and a record of providing good quality care,

as determined by the commissioner;

2. a copy of the survey report and the certificate of accreditation of

The Joint Commission or other approved accrediting organization is

submitted by the accrediting body or the hospital to the commissioner,

within seven days of issuance to the hospital;

3. The Joint Commission or other 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 accrediting organization; and

4. there are no constraints placed upon access by the commissioner to

The Joint Commission or other approved accrediting organization 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.

(b) Any general hospital as defined in article twenty-eight of the

public health law, which is governed by the provisions of subdivision

(a) of this section shall at all times be subject to inspection or

visitation by the commissioner to determine compliance with applicable

law, regulations, standards or conditions as deemed necessary by the

commissioner. Any such hospital shall be subject to the full range of

licensing enforcement authority of the commissioner.

(c) Any general hospital as defined in article twenty-eight of the

public health law, which is governed by the provisions of subdivision

(a) of this section shall notify the commissioner immediately upon

receipt of notice by The Joint Commission or other approved accrediting

organization, or any communication the hospital may receive that such

organization will be recommending that such hospital not be accredited,

not have its accreditation renewed, or have its accreditation

terminated, or upon 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 jeopardize the health and safety of

patients or are of such character as to seriously limit the provider's

capacity to render adequate care.