Current through Register Vol. 46, No. 39, September 25, 2024
The hospital shall ensure that all patients including
inpatients, outpatients and emergency service patients, are afforded their
rights as set forth in subdivision (b) of this section. The hospital's
responsibility for assuring patients' rights includes both providing patients
with a copy of these rights as set forth in subdivision (c) of this section and
providing assistance to patients to understand and exercise these rights. Each
general hospital patient who has been removed but not discharged from a
hospital for the mentally ill operated or licensed under the Mental Hygiene Law
shall maintain his or her status and rights as a patient pursuant to article 9
of the State Mental Hygiene Law and 14 NYCRR Part 527 (Rights of
Patients).
(a)
Procedural
requirements.
In order to assure that patients are made aware of,
understand and can exercise their rights, the hospital shall meet the following
requirements:
(1) each patient or the
patient representative shall be given a copy of their rights as set forth in
subdivision (c) of this section at the time of admission;
(2) for outpatients and emergency service
patients, copies of these rights shall be provided to each patient or his/her
representative;
(3) a copy of these
rights shall also be posted in clearly viewed areas of the hospital, at
readable heights, including the admitting office, patient floors and outpatient
department and the emergency service waiting areas;
(4) inservice training shall be provided to
all patient care staff to assure their knowledge and understanding of patients'
rights requirements;
(5) the
hospital shall communicate effectively to each inpatient or patient
representative after admission an explanation of those rights and provide
information on how these rights can be exercised. Patients shall be offered a
choice at admission to have or to decline an in-person explanation of these
rights. The hospital shall maintain documentation of such
communication;
(6) the hospital
shall make available designated staff to answer questions regarding patients'
rights for outpatients and emergency service patients. Patients shall be
notified of the availability of these services; and
(7) the hospital shall develop a language
assistance program to ensure meaningful access to the hospital's services and
reasonable accommodation for all patients who require language assistance.
Program requirements shall include:
(i) the
designation of a language assistance coordinator who shall report to the
hospital administration and who shall provide oversight for the provision of
language assistance services;
(ii)
policies and procedures that assure timely identification and ongoing access
for patients in need of language assistance services;
(iii) the development of materials that will
be made available for patients and potential patients that summarize the
process and method to access free language assistance services;
(iv) ongoing education and training for
administrative, clinical and other employees with direct patient care contact
regarding the importance of culturally and linguistically competent service
delivery and how to access the hospital's language assistance services on
behalf of patients;
(v) signage, as
designated by the Department of Health, regarding the availability of free
language assistance services in public entry locations and other public
locations;
(vi) identification of
language of preference and language needs of each patient upon initial visit to
the hospital;
(vii) documentation
in the medical record of the patient's language of preference, language needs,
and the acceptance or refusal of language assistance services;
(viii) a provision that family members,
friends, or non-hospital personnel may not act as interpreters, unless:
(a) the patient agrees to their
use;
(b) free interpreter services
have been offered by the hospital and refused; and
(c) issues of age, competency,
confidentiality, or conflicts of interest are taken into account. Any
individual acting as an interpreter should be 16 years of age or older;
individuals younger than 16 years of age should only be used in emergent
circumstances and their use documented in the medical record;
(ix) management of a resource of
skilled interpreters and persons skilled in communicating with vision and/or
hearing-impaired individuals;
(a)
interpreters and persons skilled in communicating with vision and/or
hearing-impaired individuals shall be available to patients in the inpatient
and outpatient setting within 20 minutes and to patients in the emergency
service within 10 minutes of a request to the hospital administration by the
patient, the patient's family or representative or the provider of medical
care. The Commissioner of Health may approve time limited alternatives to the
provisions of this subparagraph regarding interpreters and persons skilled in
communicating with vision and/or hearing-impaired individuals for patients of
rural hospitals; which:
(1) demonstrate that
they have taken and are continuing to take all reasonable steps to fulfill
these requirements but are not able to fulfill such requirements immediately
for reasons beyond the hospital's control; and
(2) have developed and implemented effective
interim plans addressing the communications needs of individuals in the
hospital service area;
(x) an annual needs assessment utilizing
demographic information available from the United States Bureau of the Census,
hospital administrative data, school system data, or other sources, that will
identify limited English-speaking groups comprising more than one percent of
the total hospital service area population. Translations/transcriptions of
significant hospital forms and instructions shall be regularly available for
the languages identified by the needs assessment; and
(xi) reasonable accommodation for a family
member or patient's representative to be present to assist with the
communication assistance needs for patients with mental and developmental
disabilities.
(b)
Hospital responsibilities.
The hospital shall afford to each patient the right
to:
(1) exercise these rights
regardless of the patient's language or impairment of hearing or vision.
Skilled interpreters shall be provided to assist patients in using these
rights;
(2) treatment without
discrimination as to race, color, religion, sex, gender identity, national
origin, disability, sexual orientation, age, or source of payment;
(3) considerate and respectful care in a
clean and safe environment;
(4)
receive emergency medical care as indicated by the patient's medical condition
upon arrival at the hospital;
(5)
limit the use of physical restraints to those patient restraints authorized in
writing by a physician after a personal examination of the patient, for a
specified and limited period of time to protect the patient from injury to
himself or to others. In an emergency, the restraint may be applied only by or
under the supervision of and at the direction of a registered professional
nurse who shall set forth in writing the circumstances requiring the use of
restraints. In such emergencies, a physician shall be immediately summoned and
pending the arrival of the physician, the patient shall be kept under
continuous supervision as warranted by the patient's physical condition and
emotional state. At frequent intervals while restraints are in use the
patient's physical needs, comfort and safety shall be monitored. An assessment
of the patient's condition shall be made at least once every 30 minutes or at
more frequent intervals if directed by a physician;
(6) the name of the medical staff member who
has the responsibility for coordinating his/her care and the right to discuss
with his/her practitioner the type of care being rendered;
(7) the name, position and function of any
person providing treatment to the patient;
(8) obtain from the responsible medical staff
member complete current information concerning his/her diagnosis, treatment and
prognosis in terms the patient can be reasonably expected to understand. The
patient shall be advised of any change in health status, including harm or
injury, the cause for the change and the recommended course of treatment. The
information shall be made available to an appropriate person on the patient's
behalf and documented in the patient's medical record, if the patient is not
competent to receive such information;
(9) receive information necessary to give
informed consent prior to the start of any nonemergency procedure or treatment
or both. An informed consent shall include, as a minimum, the specific
procedure or treatment or both, the reasons for it, the reasonably foreseeable
risks and benefits involved, and the alternatives for care or treatment, if
any, as a reasonable practitioner under similar circumstances would disclose.
Documented evidence of such informed consent shall be included in the patient's
medical record;
(10) refuse
treatment to the extent permitted by law and to be informed of the reasonably
foreseeable consequences of such refusal;
(11) receive from the responsible medical
staff or designated hospital representatives information necessary to give
informed consent prior to the withholding of medical care and
treatment;
(12) privacy consistent
with the provision of appropriate care to the patient;
(13) confidentiality of all information and
records pertaining to the patient's treatment, except as otherwise provided by
law;
(14) a response by the
hospital, in a reasonable manner, to the patient's request for services
customarily rendered by the hospital consistent with the patient's
treatment;
(15) be informed by the
responsible medical staff member or appropriate hospital staff of the patient's
continuing health care requirements following discharge, and before any
transfer to another facility, all relevant information about the need for and
all reasonable alternatives to such a transfer;
(16) prior to discharge, receive an
appropriate written discharge plan and a written description of the patient
discharge review process available to the patient under Federal or State
law;
(17) the identity of any
hospital personnel including students that the hospital has authorized to
participate in the patient's treatment and the right to refuse treatment,
examination and/or observation by any personnel;
(18) refuse to participate in research and
human experimentation in accordance with Federal and State law;
(19) examine and receive an explanation of
his/her bill, regardless of source of payment;
(20) be informed of the hospital rules and
regulations that apply to a patient's conduct;
(21) be admitted to a nonsmoking
area;
(22) register complaints and
recommend changes in policies and services to the facility's staff, the
governing authority and the New York State Department of Health without fear of
reprisal;
(23) express complaints
about the care and services provided and to have the hospital investigate such
complaints. The hospital shall provide the patient or his/her designee with a
written response if requested by the patient indicating the findings of the
investigation. The hospital shall notify the patient or his/her designee that
if the patient is not satisfied with the hospital's oral or written response,
the patient may complain to the New York State Department of Health's Office of
Health Systems Management. The hospital shall provide the telephone number of
the local area office of the Health Department to the patient;
(24) obtain access to his/her medical record
pursuant to the provisions of Part 50 of this Title. The hospital may impose
reasonable charges for all copies of medical records provided to patients, not
to exceed costs incurred by the hospital. A patient shall not be denied a copy
of his/her medical record solely because of inability to pay; and
(25) receive supportive services to meet the
changing care needs of the patient and the patient's family/representative
provided by qualified individuals who collectively have expertise in assessing
the special needs of hospital patients and their families.
(c)
Patients' Bill of Rights.
For purposes of subdivision (a) of this section, the
hospital shall utilize the following Patients' Bill of Rights:
Patients' Bill of
Rights
As a patient in a hospital in New York State, you have
the right, consistent with law, to:
(1) Understand and use these rights. If for
any reason you do not understand or you need help, the hospital must provide
assistance, including an interpreter.
(2) Receive treatment without discrimination
as to race, color, religion, sex, gender identity, national origin, disability,
sexual orientation, age, or source of payment.
(3) Receive considerate and respectful care
in a clean and safe environment free of unnecessary restraints.
(4) Receive emergency care if you need
it.
(5) Be informed of the name and
position of the doctor who will be in charge of your care in the
hospital.
(6) Know the names,
positions, and functions of any hospital staff involved in your care and refuse
their treatment, examination or observation.
(7) Identify a caregiver who will be included
in your discharge planning and sharing of post-discharge care information or
instruction.
(8) Receive complete
information about your diagnosis, treatment and prognosis.
(9) Receive all the information that you need
to give informed consent for any proposed procedure or treatment. This
information shall include the possible risks and benefits of the procedure or
treatment.
(10) Receive all the
information you need to give informed consent for an order not to resuscitate.
You also have the right to designate an individual to give this consent for you
if you are too ill to do so. If you would like additional information, please
ask for a copy of the pamphlet Deciding about Health Care-A Guide for
Patients and Families.
(11) Refuse treatment and be told what effect
this may have on your health.
(12)
Refuse to take part in research. In deciding whether or not to participate, you
have the right to a full explanation.
(13) Privacy while in the hospital and
confidentiality of all information and records regarding your care.
(14) Participate in all decisions about your
treatment and discharge from the hospital. The hospital must provide you with a
written discharge plan and written description of how you can appeal your
discharge.
(15) Review your medical
record without charge and obtain a copy of your medical record for which the
hospital can charge a reasonable fee. You cannot be denied a copy solely
because you cannot afford to pay.
(16) Receive an itemized bill and explanation
of all charges.
(17) View a list of
the hospital's standard charges for items and services and the health plans the
hospital participates with.
(18)
Challenge an unexpected bill through the independent dispute resolution
process.
(19) Complain without fear
of reprisals about the care and services you are receiving and to have the
hospital respond to you and if you request it, a written response. If you are
not satisfied with the hospital's response, you can complain to the New York
State Health Department. The hospital must provide you with the Health
Department telephone number.
(20)
Authorize those family members and other adults who will be given priority to
visit consistent with your ability to receive visitors.
(21) Make known your wishes in regard to
anatomical gifts. Persons 16 years of age or older may document their consent
to donate their organs, eyes and/or tissues, upon their death, by enrolling in
the NYS Donate Life Registry or by documenting their authorization for organ
and/or tissue donation in writing in a number of ways (such as health care
proxy, will, donor card, or other signed paper). The health care proxy is
available from the hospital.
(d) Each hospital shall be required to post
in a conspicuous place and provide a pediatric patient's parent or other
medical decision maker with a copy of a Parent's Bill of Rights advising that,
at a minimum and subject to laws and regulations governing confidentiality,
that in connection with every hospital admission or emergency room visit:
(1) The hospital must ask each patient or the
patient's representative for the name of his or her primary care provider, if
known, and shall document such information in the patient's medical
record.
(2) The hospital may admit
pediatric patients only to the extent consistent with their ability to provide
qualified staff, space and size appropriate equipment necessary for the unique
needs of pediatric patients.
(3) To
the extent possible given the patient's health and safety, the hospital shall
allow at least one parent/guardian to remain with the patient at all
times.
(4) All test results
completed during the patient's admission or emergency room visit will be
reviewed by a physician, physician assistant or nurse practitioner who is
familiar with the patient's presenting condition.
(5) Patients may not be discharged from the
hospital or the emergency room until any tests that could reasonably be
expected to yield "critical value" results - results that suggest a
life-threatening or otherwise significant condition such that it requires
immediate medical attention - are reviewed by a physician, physician assistant
(PA) and/or nurse practitioner (NP) and are communicated to the patient, his or
her parents or other decision-makers, as appropriate.
(6) Patients may not be discharged until they
receive a written discharge plan, which will also be verbally communicated to
patients, their parents or other medical decision-makers, which will identify
critical value results of laboratory or other diagnostic tests ordered during
the patient's stay and identify any other tests that have not yet been
concluded.
(7) The communication of
critical value results and the discussion of the discharge plan must be
accomplished in a manner that reasonably assures that the patient, their
parents or other medical decision makers understand the health information
provided in order to make appropriate health decisions.
(8) Hospitals shall provide all lab results
to the patient's primary care provider, if known.
(9) A patient, his or her parent or other
medical decision maker has the right to request information about the
diagnosis, possible diagnoses that were considered and complications that could
develop as well as information about any contact that was made with the
patient's primary care provider.
(10) On discharge, the hospital must provide
a patient, his or her parent or other medical decision maker a phone number
that the patient, his or her parent or other medical decision maker could call
for advice in the event that complications or questions arise.