N.Y. Mental Hygiene Law § 32.14: Compliance with operational standards by providers of services in general hospitals

§ 32.14 Compliance with operational standards by providers of services

in general hospitals.

(a) Notwithstanding the provisions of section 32.13 of this article,

with respect to a provider of services as defined in section 1.03 of

this chapter that is a general hospital, as defined in article

twenty-eight of the public health law, which provides services for

persons with mental disabilities pursuant to an operating certificate

issued by the commissioner, the requirements of section 32.13 of this

article may be deemed to be met if such hospital has been accredited by

The Joint Commission, or any other 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 such hospital so

accredited is 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 32.13 of this article

that the provider of services is in compliance with such provisions. The

commissioner may exempt any such provider of services from the annual

inspection and visitation requirements established in section 32.13 of

this article, provided that:

1. such provider of services 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 provider of services to the

commissioner, within seven days of issuance to such provider of

services;

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 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 provider of services.

(b) Any provider of services 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 provider of services shall be subject to the full

range of certification enforcement authority of the commissioner.

(c) Any provider of services 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 provider of services may receive

that such organization will be recommending that such provider of

services 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 provider of services will be

terminated from participation in the Medicare or Medicaid 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.