§ 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.