New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 633 - Protection of Individuals Receiving Services in Facilities and Services Operated and/or Certified by OPWDD
Section 633.19 - Confidentiality and protective measures regarding the human immunodeficiency virus (HIV) infection (see glossary) and acquired immune deficiency syndrome (AIDS-see glossary) for a person admitted for service for any party proposed for admission
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 633.19
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Principles of compliance.
(1) It
is the policy of OPWDD that any information about anyone applying for services
or admitted and receiving services, is to be held in confidence. Any
information obtained or to be disclosed is to be done so with the understanding
that the information is confidential and is to be maintained exclusively for
the purposes of program planning and the provision of competent and humane care
to that individual. While the requirements of this section address the
particular issues of access to person-specific HIV and AIDS information, it is
the intent of OPWDD that no such information is to be discussed casually or
capriciously. Such person-specific information should only be judiciously
disclosed in accordance with law for the purposes of increasing the
understanding of other care-givers about a person's needs and then only
care-givers who have or will have responsibilities in addressing that person's
needs.
(2) Each agency/facility and
sponsoring agency for a family care home and its employees, volunteers, and
contract agents and family care providers shall ensure the confidentiality of
information in the possession of such agency/facility or sponsoring agency
concerning whether that person admitted for service or anyone proposed for
admission has been the subject of an HIV-related test (see glossary); or has
HIV infection (see glossary), HIV-related illness (see glossary), or AIDS; or
any information indicating a person's possible exposure to HIV.
(3) No one shall have access to HIV-related
information (see glossary) unless he or she has access to clinical records in
the ordinary course of business, has been trained in matters of confidentiality
and related issues, and access to the HIV-related information is reasonably
necessary under the following circumstances:
(i) To provide for the appropriate care and
treatment of a person as described in his or her program plan except when the
sole purpose of accessing the information is to monitor or limit behaviors that
could result in significant risk (see glossary) contacts; and the program
planning team, in consultation with the person, has determined that he or she
exhibits the capacity and willingness to manage his or her behaviors so that
the monitoring or limitations are not necessary.
(ii) In connection with an investigation of
an alleged violation of a person's rights, including discrimination or
abuse.
(iii) To fulfill a specific
statutory duty.
(iv) In connection
with a review of the quality of care rendered by an agency/facility or a family
care provider.
(v) To determine
eligibility for services or reimbursement of services by OPWDD or the medical
assistance program (Medicaid).
(4) Each agency/facility or sponsoring agency
shall protect the confidentiality of HIV-related information, whether in the
form of records or computer data, which is maintained by or is transferred to
authorized parties as defined by paragraph (2) of this subdivision. Employees,
volunteers and family care providers shall be informed of and provided with the
following written requirements:
(i)
HIV-related information shall not be examined, removed or copied by any person
unless authorized under paragraph (3) of this subdivision, 10 NYCRR Part 63, or
article 27-F of the Public Health Law.
(ii) HIV-related information shall not be
disclosed to or discussed with any party unless such party is authorized to
access such information pursuant to article 27-F of the Public Health Law, 10
NYCRR 63.5 or paragraph (2) of this subdivision, and there is a need to do
so.
(iii) The use of markers on the
face of clinical files, lists posted on walls, or other codes or displays for
the sole purpose of identifying persons with HIV infection is
prohibited.
(iv) All disclosures,
oral or written, except as identified in subparagraph (v) of this paragraph,
shall be accompanied by this statement:
"This information has been disclosed to you from confidential records which are protected by State law. State law prohibits you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law. A general authorization for the release of medical or other information is not sufficient authorization for further disclosure. Any unauthorized further disclosure in violation of State law may result in a fine or jail sentence or both."
(v) All disclosures, oral or
written, shall be noted in the clinical record except:
(a) Only initial disclosures to insurance
institutions must be noted.
(b)
Notation is not required for disclosure to agents or health care providers (see
glossary) or health care facilities (see glossary) if:
(1) the agent or health care provider is
authorized to access medical or clinical records;
(2) the health care facility or health care
provider is authorized to obtain the HIV-related information; and
(3) the agent or health care provider
provides general or specific health care to the protected individual, or
maintains or processes medical records for billing or reimbursement.
(c) Notation is not required for
persons engaged in quality assurance, program monitoring or evaluation, nor for
governmental agents acting pursuant to contract or law.
(d) Confidential HIV-related information may
be noted in a certificate of death, autopsy report or related documents
prepared pursuant to Public Health Law, article 41 or other laws relating to
documentation of cause of death.
(e) A protected person shall be informed of
disclosures of HIV information upon request of that person.
(f) Confidential HIV-related information
shall not be disclosable pursuant to Public Officers Law, article 6 (the
Freedom of Information Law).
(vi) Violation of these confidentiality
provisions may lead to disciplinary action, including suspension or dismissal
from employment, and civil or criminal liability.
(5) Each agency/facility and sponsoring
agency shall implement and enforce a program that will prevent the transmission
of HIV infection, should a caregiver be exposed to the virus. Such a program
shall include requiring sound and appropriate health care practices in the care
of all persons, including:
(i) training for
persons being served, staff, volunteers, and family care providers, on the use
of protective equipment, preventive practices, and circumstances that
constitute significant risk exposure;
(ii) appropriate training, counseling, and
supervision of persons regarding behaviors which pose a risk for HIV
transmission. Contact notification, when appropriate, shall be conducted in
accordance with Public Health Law, section
2782(4) and
10 NYCRR 63.7;
(iii) training, counseling, and supervision
of persons who may be in high risk sexual or other contact situations with
others;
(iv) the use of accepted
protective practices to prevent skin and mucous membrane exposure to blood,
other body fluids, or other significant risk body substances (see
glossary);
(v) the use of accepted
preventive practices while handling instruments or equipment that may cause
puncture injuries; and
(vi) the
provision, as appropriate, of personal protective equipment which is of
appropriate quality and quantity.
(6) Each agency/facility and sponsoring
agency shall implement and enforce a program for the management of anyone who
is exposed to blood, other body fluids or other significant risk body
substances. Such program shall include:
(i) a
system for voluntarily reporting all exposures thought to represent a
circumstance for significant risk;
(ii) availability of services for evaluating
the circumstances of a reported exposure and providing appropriate follow-up of
anyone who has been exposed, which includes:
(a) medical and epidemiological assessment of
anyone who is the source of the exposure, where that source is known and
available;
(b) if epidemiologically
indicated, HIV counseling and testing of the source as permitted under article
27-F of the Public Health Law. Where the HIV status is not known to anyone who
has been exposed, disclosure can be made only with the express written consent
of the source or pursuant to court order; and
(c) appropriate medical follow-up of anyone
who has been exposed;
(iii) assurances for protection of
confidentiality for those involved in reported exposures.
(7) Each agency/facility or sponsoring agency
shall ensure that no person being served or anyone proposed for services is
discriminated against, abused or otherwise treated adversely because of his or
her status as one who is the subject of an HIV-related test, or who is thought
to be, or who is, HIV infected. Discrimination includes, but is not limited to,
the denial of appropriate services, isolation or quarantine, or the restriction
of rights as set forth in this Part, solely because the person or other party
has or is thought to have HIV infection.
(b) Standards of certification.
(1) The agency/facility or sponsoring agency
has written policies/procedures for maintaining the confidentiality of
HIV-related information.
(2) OPWDD
shall verify that the agency/facility or sponsoring agency has implemented a
mechanism and/or procedures for the prevention of the transmission of HIV
infection and for the management of anyone thought to be exposed under
significant risk circumstances.
(3)
OPWDD shall verify that the agency/facility or sponsoring agency has not
engaged in any instances of discrimination against persons who have or are
thought to have an HIV-related illness.
(4) OPWDD shall verify that employees,
volunteers and family care providers are aware of the requirements regarding
the confidentiality of HIV-related information and are knowledgeable regarding:
(i) procedures to prevent the transmission of
an HIV-related illness; and
(ii)
procedures to manage persons or others who are exposed to blood, other body
fluids or other significant risk body substances.
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