§ 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.