Provides that the commissioner may accept accreditation by The Joint Commission as evidence of compliance of operational standards for psychiatric hospitals

Summary of provisions

Section 1 of the bill would add a new Mental Hygiene Law (MHL) § 31.08 to: (1) authorize the Commissioner of OMH to accept as fulfillment of the annual inspection requirement established in MHL § 31.07 for OMH-li- censed psychiatric units of general hospitals, accreditation by TJC or any other accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS), in certain instances and that the Commis- sioner has determined has accrediting standards sufficient to assure the commissioner that hospitals are in compliance with applicable statutory provisions, rules and regulations; (2) require that, prior to exempting any hospital from inspection requirements, the hospital has or shall have a demonstrated history of compliance and record of providing quali- ty of care; (3) require that, prior to accepting evidence of such accreditation, the hospital must provide a copy of the TJC or other accrediting agency's survey report to OMH within seven days of receipt by the hospital; (4) require that, prior to accepting evidence of such accreditation as fulfillment of minimum operational standards, the accrediting agency must agree to evaluate and does evaluate minimum operational standards established by the Commissioner of OMH and that no constraints are placed upon access of any of the accreditation agency's documents related to such hospital; (5) provide that any hospital subject to this section may be subject to inspection at any time by the Commissioner of OMH; (6) require any such hospital to notify the Commis- sioner immediately upon notification by the accrediting agency that the hospital will not be recommended to receive accreditation, loss of accreditation, or failure to achieve re-accreditation; and (7) provide that any hospital which fails to be accredited or re-accredited shall be subject to the full range of licensing enforcement authority and actions of OMH.

Section 2 of the bill would make it effective immediately.

Existing law

MHL § 31.07 requires that OMH at least annually conduct one unannounced inspection for providers of services, including psychiatric inpatient units. New programs and programs that have a history of compliance prob- lems must be inspected without prior notice by OMH at least twice per year.

MHL § 31.09 empowers the Commissioner or his or her authorized represen- tative to inspect facilities for purposes of quality control.

MHL § 31.11 requires facilities to assist and cooperate with those inspections.

MHL § 1.03 (10) defines "hospital" to include a ward, wing, unit or other part of a general hospital, operated as part of such hospital for the purpose of providing inpatient care and treatment to mentally ill persons, which also receives an operating certificate from OMH.

Legislative history

This is a new proposal.

Statement in support

This bill would grant "deemed status" to behavioral health inpatient units that have been accredited by national accrediting organizations, including TJC and any other accrediting organization approved by CMS. Achieving deemed status will reduce duplicative and burdensome oversight activities for hospitals while focusing OMH oversight activities on what is clinically meaningful and permitting OMH licensing staff to better use their time and resources.

In this regard, for the last decade, the New York State Department of Health (DOH) and TJC have collaborated for general hospital certif- ication and licensure purposes. This approach has worked well for all parties involved - the hospital, TJC and DOH. TJC accreditation is a recognizable "gold seal of approval" for hospitals in the United States. The provisions of this legislation are modeled after 10 NYCRR Part 720.1, which provides a similar process for general hospitals.

TJC has accredited hospitals for more than 50 years and today it accred- its approximately 4,250 general, children's, long term acute, psychiat- ric, rehabilitation and surgical specialty hospitals. Approximately 88 percent of the nation's hospitals are currently accredited by TJC. In addition, other accrediting organizations approved by CMS should be authorized to be used to receive such deemed status.

Budget implications

This bill has no fiscal impact.

Effective date

This bill would take effect immediately.