NYSAMSS Annual Conference May 3, 2012 Kathy Ericsen NYS Department of Health Division of Certification and Surveillance Navigating Navigatingthe NYS Department.

NYSAMSS Annual NYSAMSS Annual Conference Conference May 3, 2012May 3, 2012

Kathy EricsenKathy EricsenNYS Department of HealthNYS Department of Health

Division of Certification and SurveillanceDivision of Certification and Surveillance

Navigating Navigating the the

NYS Department of Health Website NYS Department of Health Website

Website addressWebsite address

www.health.ny.gov

Site Contents

•Birth, Death, Marriage & Divorce Records•Health Insurance Programs•Employment Opportunities•Forms•Community, Family & Minority Health•Health Care Professionals & Patient Safety•Hospitals, Nursing Homes & Other Health Care Facilities•Diseases & Conditions•Health & Safety in the Home, Workplace & Outdoors•Healthy Lifestyles & Prevention•Laws & Regulations•Statistics & Data•Meetings & Training•Grants/Funding Opportunities•Permits, Licenses & Certification•Health Information Technology (Health IT)•Press Releases & Reports•Freedom of Information Law•Webcasts•Related Sites

Frequently Referenced Frequently Referenced Regulations Regulations

• 405.3 Administration405.3 Administration• 405.4 Medical Staff405.4 Medical Staff

405.3 Administration405.3 Administration

(b) Personnel(b) Personnel: : Identification/name tagsIdentification/name tags Training/inservicesTraining/inservices Verification of applicable Verification of applicable

licenses/certificationslicenses/certifications Health requirementsHealth requirements

Employee Health RequirementsEmployee Health RequirementsNYCRR 405.3NYCRR 405.3

Health AssessmentHealth Assessment• Pre-employmentPre-employment• Ensure the employee is free from any conditions Ensure the employee is free from any conditions which could pose a potential risk to patients orwhich could pose a potential risk to patients or interfere in the performance of his/her dutiesinterfere in the performance of his/her duties

Annual reassessmentAnnual reassessment• May be a self assessmentMay be a self assessment

Employee Health RequirementsEmployee Health RequirementsNYCRR 405.3NYCRR 405.3

Documented evidence of immunizations or Documented evidence of immunizations or proof of immunity for:proof of immunity for:

• RubellaRubella• Measles for personnel born after January 1, 1957Measles for personnel born after January 1, 1957

Employee Health RequirementsEmployee Health RequirementsNYCRR 405.3NYCRR 405.3

Tuberculin testingTuberculin testing• Pre-employment andPre-employment and• Annually thereafter for negative resultsAnnually thereafter for negative results• The medical staff must develop and implement The medical staff must develop and implement

policies regarding positive outcomes.policies regarding positive outcomes.

Reporting RequirementsReporting Requirements

405.3(e)405.3(e)

Speaks to the hospital’s reporting requirement Speaks to the hospital’s reporting requirement to the Office of Professional Medical Conductto the Office of Professional Medical Conduct

Reporting requirementsReporting requirements(continued)(continued)

If the hospital has:

• Denied• Suspended• Restricted• Terminated, or • Curtailed a physician’s training, employment, association or professional privileges for the following reasons:

Alleged mental or physical impairment, incompetence, malpractice, misconduct or endangerment of patient safety or welfare;

Voluntary or involuntary resignation or withdrawal of association or of privileges with the hospital to avoid the imposition of disciplinary measures;

The receipt of information concerning a conviction of a misdemeanor or felony.

Reporting requirements(continued)

*A Report is Required Within Thirty (30) Days of the Occurrence*

405.4 Medical Staff405.4 Medical Staff

405.4 (a) Medical Staff accountability405.4 (a) Medical Staff accountability

(2) medical staff must establish mechanism to (2) medical staff must establish mechanism to monitor on-going performancemonitor on-going performance

(3) medical staff must review and if applicable (3) medical staff must review and if applicable recommend limitation or suspension of recommend limitation or suspension of privilegesprivileges

405.4 Medical Staff405.4 Medical Staff

405.4 (b) Organization405.4 (b) Organization (4) speaks to the responsibility of the medical staff to review (4) speaks to the responsibility of the medical staff to review

credentials of medical staff candidates and make credentials of medical staff candidates and make recommendations to the governing body. Periodic recommendations to the governing body. Periodic reappraisals done on at least, a biennial basis.reappraisals done on at least, a biennial basis.

(5) appointment/re-appointment process in accordance with (5) appointment/re-appointment process in accordance with review procedures of the hospital's quality assurance review procedures of the hospital's quality assurance committeecommittee

Site Contents

•Birth, Death, Marriage & Divorce Records•Health Insurance Programs•Employment Opportunities•Forms•Community, Family & Minority Health•Health Care Professionals & Patient Safety•Hospitals, Nursing Homes & Other Health Care Facilities•Diseases & Conditions•Health & Safety in the Home, Workplace & Outdoors•Healthy Lifestyles & Prevention•Laws & Regulations•Statistics & Data•Meetings & Training•Grants/Funding Opportunities•Permits, Licenses & Certification•Health Information Technology (Health IT)•Press Releases & Reports•Freedom of Information Law•Webcasts•Related Sites

Current Issues

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Dear Administrator LettersDear Administrator Letters

Public WebsitePublic Website• http://www.health.state.ny.us/professionals/http://www.health.state.ny.us/professionals/

hospital_administrator/letters/ceo.htmhospital_administrator/letters/ceo.htm• Health Commerce SystemHealth Commerce System

Questions?Questions?

Kathleen EricsenKathleen Ericsen

(518) 402-1003(518) 402-1003

[email protected]@health.state.ny.us