§ 31.08 Compliance with operational standards by general hospitals.\n (a) Notwithstanding the provisions of section 31.07 of this article,\nwith respect to a general hospital, as defined in article twenty-eight\nof the public health law, which provides services for persons with\nmental illness pursuant to an operating certificate issued by the\ncommissioner, the requirements of section 31.07 of this article may be\ndeemed to be met if such hospital has been accredited by The Joint\nCommission, or any other hospital accrediting organization to which the\nCenters for Medicare and Medicaid Services has granted deeming status,\nand which the commissioner shall have determined has accrediting\nstandards sufficient to assure the commissioner that hospitals so\naccredited are in compliance with the provisions of this chapter and\napplicable laws, rules and regulations in regard to services provided at\nsuch hospital. Such accreditation shall have the same legal effect as a\ndetermination by the commissioner under section 31.07 of this article\nthat the hospital is in compliance with such provisions. The\ncommissioner may exempt any such hospital from the annual inspection and\nvisitation requirements established in section 31.07 of this article,\nprovided that:\n 1. such hospital has a history of compliance with such provisions of\nlaw, rules and regulations and a record of providing good quality care,\nas determined by the commissioner;\n 2. a copy of the survey report and the certificate of accreditation of\nThe Joint Commission or other approved accrediting organization is\nsubmitted by the accrediting body or the hospital to the commissioner,\nwithin seven days of issuance to the hospital;\n 3. The Joint Commission or other accrediting organization has agreed\nto and does evaluate, as part of its accreditation survey, any minimal\noperational standards established by the commissioner which are in\naddition to the minimal operational standards of accreditation of The\nJoint Commission or other accrediting organization; and\n 4. there are no constraints placed upon access by the commissioner to\nThe Joint Commission or other approved accrediting organization survey\nreports, plans of correction, interim self-evaluation reports, notices\nof noncompliance, progress reports on correction of areas of\nnoncompliance, or any other related reports, information, communications\nor materials regarding such hospital.\n (b) Any general hospital as defined in article twenty-eight of the\npublic health law, which is governed by the provisions of subdivision\n(a) of this section shall at all times be subject to inspection or\nvisitation by the commissioner to determine compliance with applicable\nlaw, regulations, standards or conditions as deemed necessary by the\ncommissioner. Any such hospital shall be subject to the full range of\nlicensing enforcement authority of the commissioner.\n (c) Any general hospital as defined in article twenty-eight of the\npublic health law, which is governed by the provisions of subdivision\n(a) of this section shall notify the commissioner immediately upon\nreceipt of notice by The Joint Commission or other approved accrediting\norganization, or any communication the hospital may receive that such\norganization will be recommending that such hospital not be accredited,\nnot have its accreditation renewed, or have its accreditation\nterminated, or upon receipt of notice or other communication from the\nCenters for Medicare and Medicaid Services regarding a determination\nthat the hospital will be terminated from participation in the Medicare\nprogram because it is not in compliance with one or more conditions of\nparticipation in such program, or has deficiencies that either\nindividually or in combination jeopardize the health and safety of\npatients or are of such character as to seriously limit the provider's\ncapacity to render adequate care.\n
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