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

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Frequently Referenced Regulations Administration Administration Medical Staff Medical Staff

405.3 Administration (b) Personnel: Identification/name tags Identification/name tags Training/inservices Training/inservices Verification of applicable licenses/certifications Verification of applicable licenses/certifications Health requirements Health requirements

Employee Health Requirements NYCRR Health Assessment Health Assessment Pre-employmentPre-employment Ensure the employee is free from any conditionsEnsure the employee is free from any conditions which could pose a potential risk to patients or which could pose a potential risk to patients or interfere in the performance of his/her duties interfere in the performance of his/her duties Annual reassessment Annual reassessment May be a self assessmentMay be a self assessment

Employee Health Requirements NYCRR Documented evidence of immunizations or proof of immunity for: Documented evidence of immunizations or proof of immunity for: RubellaRubella Measles for personnel born after January 1, 1957Measles for personnel born after January 1, 1957

Employee Health Requirements NYCRR Tuberculin testing Tuberculin testing Pre-employment andPre-employment and Annually thereafter for negative resultsAnnually thereafter for negative results The medical staff must develop and implement policies regarding positive outcomes.The medical staff must develop and implement policies regarding positive outcomes.

Reporting Requirements 405.3(e) Speaks to the hospital’s reporting requirement to the Office of Professional Medical Conduct

Reporting requirements (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 Staff (a) Medical Staff accountability (a) Medical Staff accountability (2) medical staff must establish mechanism to monitor on-going performance (2) medical staff must establish mechanism to monitor on-going performance (3) medical staff must review and if applicable recommend limitation or suspension of privileges (3) medical staff must review and if applicable recommend limitation or suspension of privileges

405.4 Medical Staff (b) Organization (b) Organization (4) speaks to the responsibility of the medical staff to review credentials of medical staff candidates and make recommendations to the governing body. Periodic reappraisals done on at least, a biennial basis. (4) speaks to the responsibility of the medical staff to review credentials of medical staff candidates and make recommendations to the governing body. Periodic reappraisals done on at least, a biennial basis. (5) appointment/re-appointment process in accordance with review procedures of the hospital's quality assurance committee (5) appointment/re-appointment process in accordance with review procedures of the hospital's quality assurance committee

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Questions? Kathleen Ericsen (518)