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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
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
•Emergency Preparedness & Response•METRIX•Marriage Equality Act•Medical Indemnity Fund•Smokers' Quit Line - 1-866-NY-QUITS•Obesity Prevention•Influenza (Flu)•Controlled Substance Information•EMS/EMT•Accredited Office-Based Surgery Practices•American Recovery and Reinvestment Act•Prevention Agenda Toward the Healthiest State•Prevention Quality Indicators•Environmental Public Health Tracking•Medicaid•Child Health Plus•Family Health Plus•2% Across the Board Reduction•EPIC for Seniors•Prescription Drug Prices•Immunization•Lead Poisoning Prevention•HIV/AIDS•Doctor Profile•Physician / Physician Assistant - Board Actions•Hospital Profile•Nursing Home Profile•Home Health and Hospice Profile•Long-Term Care•Organ and Tissue Donation•Wadsworth Center Laboratories
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