Inspections
The New York State Department of Health licenses hospitals and hospital extension clinics. The Department also conducts inspections of the quality of care, monitors incidents, and investigates complaints.
Through inspections the Department determines if the hospital has satisfied regulatory requirements and provided medical care in accordance with acceptable standards of practice. The Department informs the hospital of the results of all inspections conducted. When the Department determines the hospital violated a regulation, the Department issues a statement of deficiencies to the hospital. The facility then must correct the deficient practice. The Department monitors the effectiveness of the hospitals' corrective actions.
When inspection results indicate that the hospital's regulatory noncompliance contributed to serious negative outcomes, the Department initiates enforcement actions. These typically result in the assessment of monetary fines, or the implementation of specific sanctions.
Additionally, for certain types of inspections, the Department also informs other agencies, including: Centers for Medicare & Medicaid, NYS Office of Mental Health, and Office of Alcoholism and Substance Abuse Services.
A diversity of inspections are performed, covering various activities, including: inspections of care, reviews of medical records, addition/deletion of beds, changes in services provided, and focused and follow-up surveys.
Complaints
The New York State Department of Health is responsible for investigating complaints issued against hospitals in New York State.
The Department conducts an investigation on every complaint it receives. The more serious complaints require Department investigators to conduct interviews, review medical records and other facility documentation, and perform other activities onsite at the Hospital.
Some complaints contain more than one allegation. The Department investigates every allegation related to each complaint a part of a single investigation. When an investigation determines that an alleged incident did occur, the allegation is substantiated.
The complaint investigation will determine whether a facility has failed to meet state requirements. For cases in which an allegation is substantiated, or when the Department determines the Hospital violated a regulation, the Department issues a statement of deficiencies to the Hospital. The facility then must correct the deficient practice, and usually submit a plan of correction that is acceptable to the Department.
The Department also informs complainants of the results of complaint investigations, and assists the public in the resolution of problems.
The Complaint Information shows the number of complaint investigations completed in the reporting period, the number of those that resulted in citations (a statement of deficiencies) being issued and the regulatory areas cited for the specific cases.
Understanding the Complaints Summary Section
The reporting period for the results listed is shown first.
Total Complaints Received per 10,000 patient days: The number of complaints received in the reporting period, divided by the total number of patient days (number of individual patients multiplied by their respective lengths of stay in the hospital). Figures are given for both the specific hospitals, and for all hospitals statewide.
Number Reviewed Resulting in Citations: The number of complaint investigations completed in which the Department determined that the hospital violated a regulation, and issued a statement of deficiencies. The total is given for both the specific hospitals, and for all hospitals statewide.
Percentage of Allegations Made that were Substantiated: The percentage of the allegations made that, following an investigation, the Department determined were valid. The percentage is given for both the specific hospitals, and for all hospitals statewide.
Hospital Citations
A diversity of inspections are performed, covering various activities, including: inspections of care, reviews of medical records, addition/deletion of beds, changes in services provided, and focused and follow-up surveys.
The Department informs the hospital of the results of all inspections conducted. When the Department determines the hospital violated a regulation, the Department issues a statement of deficiencies to the hospital. The facility then must correct the deficient practice, and usually submit a plan of correction that is acceptable to the Department.
Understanding the Citations Summary Section
The reporting period for the results listed is shown first.
Statement of Deficiencies issuance date: The date on which the written report, which included the Statement of Deficiencies for the citations displayed, was sent to the hospital.
Plan of Correction Approval Date: The date the Department accepted the hospital's Plan of Correction for all deficiencies cited for this inspection/survey (when applicable).
Regulatory Citation: The numerical identifier of the Section of the New York State Codes, Rules and Regulations that was cited.
Deficiency Categories: The title of the Section of the New York State Codes, Rules and Regulations that was cited. This indicates the Category of Hospital service delivery for which a deficiency has been found. The categories are described in the Deficiency Categories section of this site.
Hospital Enforcement
Section 12 of the Public Health Law allows the Department of Health to assess fines against Hospitals that have been cited for noncompliance with state regulations that resulted in harm to patients, represents substandard quality of care, or placed patients at immediate risk for harm.
The maximum fine allowed under law is $10,000 per violation. The Enforcement Summary Section presents a history of fines assessed against each Hospital, since January 1, 2002.
Understanding the Enforcement Summary Section
Stipulation and Order Date: The date the Stipulation and Order was signed.
Stipulation and Order Number: The document log number for the Stipulation and Order.
Fine Assessed: The total amount of the fine assessed against the facility.
Statement of Deficiencies Issuance Date: The date of the issuance of the statement of deficiencies, for the inspection/survey for which the Stipulation and Order was issued. (In some instances, an indication that the Stipulation and Order was based on more than one report is indicated.)
Description of Case: A brief synopsis of the statement(s) of deficiencies, that are the basis of the Stipulation and Order.