2023 New York Laws › MHY - Mental Hygiene › Title E - General Provisions › Article 31 - Regulation and Quality Control of Services for the Mentally Disabled › 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.