In September 2019, the U.S. Department of Health & Human Services, Office of Inspector General (“OIG”) published a “Data Brief” regarding State oversight of Ambulatory Surgery Centers (“ASCs”).   The Data Brief focused on the responsibility of the States to survey those ASCs: (1) that are not accredited by third party accreditation agencies (“Non-Deemed Status ASCs”); and (2) about which serious complaints are received, regardless of whether the ASC is accredited.

Although the purpose of the Data Brief is to summarize State compliance with their survey obligations, the findings illuminate issues for ASCs to consider, including the following:

  • The category of the Conditions of Coverage (“CfC”) with the most deficiencies between FY 2013 – FY 2017 was Infection Control with Infection Control findings being approximately one-fifth of all deficiencies. In other words, States cited more than half (55%) of all Non-Deemed Status ASCs with one or more Infection Control deficiencies.
  • The categories with the most deficiencies after Infection Control were: Pharmaceutical Services, Environment, Patient Rights and Patient Admission, Assessment and Discharge.
  • 77% of Non-Deemed Status ASCs had at least one deficiency during survey and 25% had serious deficiencies.
  • Between FY 2013 – FY 2017, there were a fairly limited number of complaints nationwide, with complaints regarding less than 4% of ASCs. Nevertheless, accredited ASCs should keep in mind that they may be surveyed by the States for complaints in the same manner as Non-Deemed Status ASCs.

A complete copy of the Data Brief can be found out at:

Click Here to download the Legal Alert.

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Should you have any questions regarding the above, please contact the Garfunkel Wild attorney with whom you regularly work. For information regarding surveys and, in particular, compliance with Infection Control CfCs, please join us at Garfunkel Wild’s ASC and HealthCare Management Symposium. For additional information, visit our website at or call 516-393-2294


On September 4, 2019, DOH published a Notice of Proposed Rulemaking that implements a New York Court of Appeal’s ruling striking down the so called “soft cap” limitations and affirming the “hard cap” limitations on executive compensation. In particular, a covered provider is prohibited from compensating a covered executive in an amount greater than $199,000 per year using solely State Funds, unless a waiver is obtained.  []

In October, 2018 Garfunkel Wild, P.C. issued a Client Alert of the decision of the New York Court of Appeals striking down the “soft cap” and affirming the “hard cap” limitations on executive compensation under NYS regulations that implemented Executive Order # 38 (“EO 38”). [See prior GW Alert –]. Specifically, the Court upheld the regulations on covered providers, such as hospitals licensed under Article 28 of the Public Health Law, which imposed limits on administrative expenses and executive compensation to the extent funded by “State Funds” – the so-called “hard cap”.  This applied to funds in the State budget for State funded program services, e.g., Cystic Fibrosis Program, Early Intervention Program or “state-authorized payments”, which include funds that are distributed by or disbursed upon a New York State agency’s approval, e.g., Medicaid payments.  However, the Court invalidated the regulations which placed limitations  on the covered provider’s use of non-State Funds in funding executive compensation, e.g., private funds, payments from commercial payors, etc. – the so-called “soft cap”.


The soft cap prohibited executive compensation in excess of $199,000 from State Funds and non-State Funds unless (i) the compensation was within the 75th percentile of comparable providers and (ii) the compensation was approved by the provider’s governing board, including at least two independent directors.  The proposed regulations delete the soft cap prohibition and these comparability data and governing board approval requirements.

The hard cap continues to apply to “covered executives” (generally defined as a compensated director, trustee, managing partner or officer, or key employee), whose salary and benefits, in whole or in part, is considered administrative expenses and exceeds $199,000 during the reporting period. If there are more than 10 key employees who meet this definition, the covered provider need only report the highest compensated top 10 key employees

Covered providers that are subject to the hard cap are required to obtain a waiver in order to compensate their covered executives in an amount greater than $199,000. It is our understanding that few, if any covered providers, have used the waiver process.  Given the proposed change in the regulations, this waiver process may be more prevalent and an agency’s timely processing of waiver applications may be an issue.  Presumably, if a covered provider has sufficient non-State Funds to fund executive compensation, a waiver will not be necessary. However, the covered provider must have sufficient controls in place to document that non-State Funds are sufficient to fund executive compensation.

Of course, covered providers are still required to submit an EO 38 Disclosure Form for each covered reporting year.

Lastly, although the proposed regulations eliminate the use of and approval by the governing board of data to show that executive compensation was within the 75th percentile of comparable providers, we recommend the continued use of comparability data and governing board approval by charitable organizations in meeting their obligations under the Internal Revenue Code for executive compensation and by other covered providers to support a waiver application.

We look forward to comments that will be submitted by interested parties in response to the proposed regulations and to the Department’s responses to such comments.

Click Here to download the Legal Alert.

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If you have any questions about this alert, please contact the Garfunkel Wild attorney with whom you regularly work.


Partner/Directors Karen Rodgers and Scott Higgins facilitated the transfer of 28 skilled nursing facilities with a combined value in excess of $450 million located in 8 states with an associated financing of over $240 million.


Thirty-Four Garfunkel Wild attorneys were selected by their peers for inclusion in 2019 New York Metro Super Lawyers, and 2019 New York Metro Rising Stars.

Super Lawyers and Rising Stars recognize attorneys who exhibit excellence in the practice of law rated by a high-degree of peer recognition and professional achievement.

The following Garfunkel Wild attorneys were named 2019 New York Metro Super Lawyers:

  • Jeffry Adest – Health Care Law
  • Suzanne M. Avena – Environmental Law
  • Greg E. Bloom – Health Care Law
  • Andrew E. Blustein – Health Care Law
  • Roy W. Breitenbach – Business Litigation Law
  • Jeffrey S. Brown – Health Care Law
  • Barry B. Cepelewicz, M.D., Esq. – Health Care Law
  • Kevin G. Donoghue – General Litigation
  • Judith A. Eisen – Health Care Law
  • Peter M. Hoffman – Health Care Law
  • Michael J. Keane – Business Litigation Law
  • Stacey P. Klein – Health Care Law
  • Eve Green Koopersmith – Elder Law
  • Lauren M. Levine – General Litigation
  • Sean P. Leyden – Real Estate Law
  • Doris L. Martin – Estate Planning & Probate
  • John G. Martin – White Collar Crime
  • Lourdes Martinez – Health Care Law
  • Fredrick I. Miller – Health Care Law
  • Marianne Monroy – Employment & Labor Law
  • Salvatore Puccio – Employment Litigation
  • Leonard M. Rosenberg – General Litigation
  • Debra A. Silverman –  Health Care Law
  • Christina Van Vort –   Health Care Law
  • Justin M. Vogel – Business Litigation
  • Burton S. Weston –     Bankruptcy Law
  • Robert Andrew Wild – Health Care Law
  • Hayden S. Wool – Health Care Law
  • Andrew L. Zwerling – General Litigation

The following Garfunkel Wild attorneys were named 2019 New York Metro Rising Stars:

  • Carmen E. Jule – Health Care Law
  • Michael (Mickey) Keane, Jr. – Business Litigation Law
  • Jessica F. Sonpal – Health Care Law
  • Dayna B. Tann – General Litigation
  • Cynthia M. Thomas – Business & Corporate



On September 9, 2019, the Department of Health and Human Services, Office of Civil Rights (“OCR”) announced that Bayfront Health – St. Petersburg, a 480-bed Florida hospital (the “Hospital”), paid $85,000 to settle an investigation regarding the Hospital’s failure to provide one patient with timely access to her medical records.   In its press release, the OCR emphasized that this settlement is consistent with its Patient Access Initiative, which was announced earlier this year.  As part of this initiative, OCR is committed to vigorously enforcing the rights of patients to receive their medical records promptly and without being overcharged.

The investigation that prompted this settlement was initiated when a patient complained to the OCR on August 14, 2018 that the Hospital had not provided her complete copies of her baby’s fetal monitoring strips even though the patient had started making written requests for the information as early as October 18, 2017. After the OCR initiated in an investigation, the patient was finally provided a copy of the requested records on February 17, 2019.

To date, the majority of HIPAA settlements that have been reported have stemmed from unauthorized access to or disclosure of Protected Health Information. This most recent settlement is a reminder that Covered Entities, and, if applicable, their Business Associates need to comply with all facets of HIPAA, including requirements for patient access to information.   In particular, Covered Entities should be reviewing their patient access policies and confirming with their Health Information Management (“HIM”) Departments and Release of Information (“ROI”) vendors, if applicable, that HIPAA requirements for patient access, including limitations on charges, are being followed.

Click Here to download the Legal Alert.

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If you have any questions about this alert, please contact the Garfunkel Wild attorney with whom you regularly work.