Accreditation as Equivalent: Deemed Status

(A) If a hospital is currently accredited by the Joint Commission, AOA, or another accrediting body approved by CMS and the Commissioner, the Commissioner may deem the hospital to meet all the requirements of the Conditions of Participation except any requirement promulgated by regulation by the Secretary of Health and Human Services pursuant to 42 U.S.C. § 1395x(e)(9) which the Secretary, after consulting with the Joint Commission, AOA or another accrediting body approved by CMS and the Commissioner, identifies as being more stringent or more precise than the requirements for accreditation; and except the requirements for utilization review specified in 105 CMR 130.200; and with respect to psychiatric hospitals subject to licensure. (B) Each accredited hospital which desires to obtain deemed status shall release to the Commissioner a copy of the hospital’s current accreditation letter and the accrediting agency’s explanation of its survey findings. The hospital shall also sign a Department consent form indicating it: (1) Agrees to permit Department observers at the summation conferences scheduled at the completion of an accreditation; and (2) Agrees upon request to release to the Commissioner any other accreditation information requested.