The New York State Department of Health (NYSDOH) has issued a proposed regulation to change the general hospital recertification review period of medical staff credentials, including dentists, from biannually to triennially.  The complete State Register notice filed today is below.

Department of Health

PROPOSED RULE MAKING

NO HEARING(S) SCHEDULED

General Hospital Medical Staff Recertification

I.D. No. HLT-10-25-00003-P

PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:

Proposed Action: This is a consensus rule making to amend section 405.6 of Title 10 NYCRR.

Statutory authority: Public Health Law, section 2803

Subject: General Hospital Medical Staff Recertification.

Purpose: Changes the period general hospitals must periodically review the credentials of medical staff from biannually to triennially.

Text of proposed rule: Subparagraph (vi) of paragraph (7) of subdivision (b) of Section 405.6 is amended to read as follows:

(b) The activities of the quality assurance committee shall involve all patient care services and shall include, as a minimum:

* * *

(7) the committee shall oversee and coordinate the following:

* * *

(vi) a [biennial] triennial review of credentials, physical and mental capacity and competence in delivering health care services of all clinical staff who are employed or associated with the hospital which for physicians, dentists and podiatrists shall include a comprehensive review of the information maintained in accordance with subparagraph (v);

Text of proposed rule and any required statements and analyses may be obtained from: Katherine Ceroalo, DOH, Bureau of Program Counsel, Reg. Affairs Unit, Room 2438, ESP Tower Building, Albany, NY 12237, (518) 473-7488, email: regsqna@health.ny.gov

Data, views or arguments may be submitted to: Same as above.

Public comment will be received until: 60 days after publication of this notice.

Consensus Rule Making Determination

Statutory Authority: Section 2803 of the Public Health Law (PHL) authorizes the promulgation of such regulations as may be necessary to implement the purposes and provisions of PHL Article 28, including the establishment of minimum standards governing the operation of health care facilities, including hospitals.

Basis: On May 1, 2024, the physician credentialing review requirements in section 405.4(b)(4) and section 405.6(b)(7)(i) were changed from biennial to triennial.  The amendments to section 405.4(b)(4) and section 405.6(b)(7)(i) lengthened the requirement for general hospitals to review the credentials of medical staff from every two years to every three years in order to reduce administrative burdens and provide consistency with revisions by The Joint Commission to its credentialing and privileging standards applied to its Advanced Diagnostic Imaging, Ambulatory Surgical Center, Critical Access Hospital, and Hospital accreditation programs.  This regulation makes a conforming amendment to section 405.6(b)(7)(vi), again changing a biennial credentialing review requirement to triennial.  Under section 405.6(b)(7)(vi), as amended, general hospital quality assurance committees must oversee and coordinate a triennial review, not a biennial review.  This consensus regulation corrects a drafting error in the regulation that was published and effective on May 1, 2024, to ensure the requirements are consistent throughout the regulation.  No person is likely to object to this consensus rulemaking, because it simply corrects the regulation to make it consistent throughout, and the Department did not receive any public comments in opposition to the original rulemaking amending the requirements for physician credentialing review from biennial to triennial.

Job Impact Statement

No Job Impact Statement is required pursuant to section 201a(2)(a) of the State Administrative Procedure Act.  It is apparent, from the nature of the proposed amendment, that it will not have a substantial adverse impact on jobs and employment opportunities.