N.Y. Comp. Codes R. & Regs. tit. 14 § 553.5

Current through Register Vol. 46, No. 45, November 2, 2024

Section 553.5 - Deemed status

(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.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 553.5

Amended New York State Register January 27, 2016/Volume XXXVIII, Issue 04, eff. 1/27/2016