N.Y. Comp. Codes R. & Regs. tit. 14 § 810.14

Current through Register Vol. 46, No. 45, November 2, 2024

Section 810.14 - Inspection and reviews

(a) Certified providers of services shall be inspected at least two times per year, once without prior notice, for compliance with rules, regulations, policies, procedures and requirements of the office. In the sole discretion of the office, providers with established records of substantial compliance may be inspected only once per year, provided such inspection is without notice.

(b) Activities which shall constitute inspections for purposes of satisfying the requirements of subdivision (a) of this section include, but are not limited to:

(1) a recertification review, made pursuant to this section;

(2) an interim regulatory compliance review, made pursuant to subdivision (f) of this section;

(3) an interim or annual performance review, made pursuant to Office policy;

(4) a focused or targeted review, made pursuant to Office policy;

(5) a facilities evaluation, made pursuant to Office policy;

(6) a fiscal audit or review, made pursuant to Office policy;

(7) corrective action plan monitoring;

(8) a cursory on-site visit; and

(9) an accreditation survey, completed by a nationally recognized accrediting organization.

(c) Prior to the expiration of an operating certificate, the office shall conduct a recertification review for purposes of assessing a provider's compliance with applicable laws, rules and regulations and to determine the renewal term of the operating certificate.

(1) Recertification reviews shall be conducted on an unannounced basis and may include, but not be limited to, the following areas of review:

(i) inspection of facility appearance, conditions and general safety;

(ii) evaluation of the governing authority;

(iii) interviews of staff and patients/clients;

(iv) examination of staffing patterns, staff credentials and qualifications;

(v) compliance with the requirements of Part 836 of this Title, guidance issued by the Office and applicable rules and regulations of the Justice Center; and

(vi) such other operating areas or activities as may be necessary to determine compliance with applicable laws, rules and regulations.

(2) Fiscal viability reviews shall include an assessment of the financial information of the provider of services. Such information shall be submitted in intervals and in a form prescribed by the Office, for compliance with minimum standards established by the office, in order to determine the provider's fiscal capability to effectively support the authorized services.

(3) The specific renewal term shall be based on the results of the recertification review and fiscal viability review, utilizing the lowest compliance rating achieved by the provider of services on either the recertification review or fiscal viability review, except as otherwise provided in subdivision (i) of this section.

(d) The inspection process shall include appropriate reporting and corrective action follow-up subsequent to the review, including the possibility of initiating an unannounced interim inspection which may encompass the areas of review listed under subdivision (e) of this section, to assure attention to and correction of cited deficiencies.

(1) Upon completion of an inspection, office staff shall, within forty-five 45 days of such completion, submit a written report to the provider of services describing the results of such review, including each regulatory deficiency identified, if any.

(2) The provider of services shall take all actions necessary to correct the deficiencies reported. If instructed the provider of services shall submit a corrective action plan, which is deemed satisfactory by the Office, within a specified period of time, as directed by the Office, stating the specific actions taken or planned to achieve compliance with identified requirements. Any planned actions described in the corrective action plan must be accompanied with a timetable for their implementation.

(3) If the provider of services fails, within the specified or an otherwise reasonable time, to correct any reported deficiencies, or fails to maintain satisfactory compliance with applicable laws, rules and regulations, the Commissioner may revoke, suspend or limit the operating certificate or levy a civil fine for such failures, in accordance with section 810.16 of this Part.

(e) The office shall not perform fiscal viability reviews of governmental agencies or hospitals authorized by the Office and/or the Department of Health.

(f) Any fines imposed by the Commissioner against the provider of services must be paid in full before an operating certificate may be renewed.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 810.14

Adopted New York State Register September 9, 2015/Volume XXXVII, Issue 36, eff. 9/9/2015

Amended New York State Register August 2, 2023/Volume XLV, Issue 31, eff. 8/2/2023