New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 815 - Patient Rights
Section 815.4 - Provider requirements

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 815.4

Current through Register Vol. 46, No. 12, March 20, 2024

(a) The facility or provider agency as program governing authority shall establish policies and procedures to protect patient rights. Such policies and procedures shall be consistent with the requirements of the program's operating certificate, including, but not limited to:

(1) standards governing staff conduct to ensure the protection of patient rights and to ensure the communication of such standards, rights and responsibilities to patients. When communicating, providers shall make every effort to accommodate patient differences in language and language abilities in accordance with applicable law.

(2) Copies of a statement of the rights and responsibilities of patients shall be posted prominently and conspicuously throughout the provider's facility. This statement, at a minimum, shall include the requirements of sections 815.5 and 815.6 of this Part. Such postings shall also include contact information for the toll-free hotline to the Vulnerable Persons' Central Register, the provider's director, the Commissioner, the Office patient advocate, and the Office toll-free telephone number.

(3) The postings shall include the policy and procedures for addressing patient concerns or grievances with the provider and/or the Office. Such policy shall include, at a minimum, the following rights:
(i) to question a policy, voice a concern or grievance with the provider or the Office;

(ii) to receive a timely response and/or resolution;

(iii) to not suffer adverse consequences or retaliation as a result; and

(iv) to communicate with the provider's director, medical director, board of directors, other responsible staff and the Commissioner.

(4) A copy of this Part, and any other Part of Title 14 that is applicable to the provider, shall be provided to a patient upon request.

(5) The provider shall develop policies and procedures to help patients follow their treatment/recovery plan. Such policies and procedures shall specify standards and expectations for patient conduct, including conduct that may result in discharge, achievement of goals consistent with the plan, and procedures for reevaluating and revising the treatment plan when goals are not met.

(6) Provider policies and procedures shall, at a minimum, address patient conduct with timely incremental interventions that are strength-based, person-centered and trauma-informed and designed to assist patients in responding positively to treatment. Such incremental interventions shall be incorporated and delivered consistent with the patient's treatment/recovery plan; be time-limited, and documented in the patient's record. When a patient poses an imminent threat to others, immediate discharge may be warranted consistent with other provisions of this Part.

(7) The provider shall establish a policy and procedure for implementing quality improvements with respect to patient concerns and complaints, changes in regulatory requirements, or other factors, and shall review such policies no less frequently than once every two years. Documentation shall be kept of all such reviews.

(b) Upon admission, each patient shall be given a written copy of provider services, including onsite and referral service, and the policy relating to the rights and responsibilities of the patient and the provider, and other provider rules and requirements. The patient shall acknowledge in writing the provision and understanding of these documents, and such attestation shall be kept in the patient's record. Patients shall be informed that if they wish to express a concern or grievance, they will be provided documents to initiate such grievance and resolution process upon request.

(c) The provider shall make every effort to accommodate patient differences in language and language abilities and ensure effective communication in accordance with applicable law.

(d) A patient's rights as a citizen of the United States or as a resident of the State of New York shall not be forfeited or abridged because of such patient's participation in addiction services as defined in Part 800 of this Title.

(e) The provider shall comply with the federal confidentiality regulations at 42 Code of Federal Regulations (CFR) Part 2, the Health Insurance Portability and Accountability Act ("HIPAA"), the Public Health Law, and all other applicable law. At the time of admission, the provider shall inform each patient that federal and state law protects the confidentiality of all records of identity, diagnosis, prognosis, or treatment in connection with a person's attendance, participation, or receipt of addiction services. Such information shall be released only in accordance with applicable provisions of federal and state law.

(f) The provider shall establish a policy and procedure for patient discharge pursuant to section 815.7 of this Part. Discharge decisions and appeal results shall be recorded, reviewed and incorporated into the provider's quality review and improvement process.

(g) Participation in addiction services is voluntary and no provider shall force or coerce any person to enter or remain in any service. All patients shall be informed prior to admission that their participation is voluntary and that they are entitled to terminate their participation at any time. Providers may make mutual help or support-group services available to patients but shall not compel attendance. A patient's inability to complete treatment required by a judicial or child welfare mandate may have legal consequences to the patient under the terms of such mandate but, nevertheless, treatment remains voluntary.

(h) The delivery and receipt of emergency substance use disorder services for incapacitated persons shall be governed by Mental Hygiene Law section 22.09.

(i) When admitting a patient to a facility or provider agency, the provider shall not add admission criteria not required by regulation, including, but not limited to, residency, specific identification requirements and/or citizenship status. Applicants not admitted to the program shall be given information concerning other service providers which can more appropriately meet the needs of the patient and, if clinically necessary, a referral and connection shall be made on the patient's behalf.

(j) Office funded service providers must use a sliding scale when evaluating a self-pay patient that considers the patient's ability to pay. Admission to an Office funded provider agency may not be conditioned upon a patient's ability or inability to pay.

(k) Providers shall adhere strictly to the Confidentiality requirements of 42 CFR Part 2, and shall make each release form signed by a patient as specific as possible so as to ensure that clients are fully aware of who is receiving the information. Additionally, providers shall have a policy that ensures an end date to all release of confidential information forms. Copies of records shall be given to a patient or former patient upon request, in accordance with applicable law, regulations, and the program's procedures, within fifteen (15) calendar days of a request.

(l) The provider shall admit and treat minors in accordance with the requirements of Mental Hygiene Law section 22.11.

(m) The provider shall establish guidelines to ensure that patients at inpatient and residential facilities may correspond, have reasonable access to telephones, and have regularly scheduled opportunities to meet with visitors consistent with treatment needs. Patient correspondence addressed to, or from, the Office, public officials, attorneys, and clergy shall be unrestricted and shall be forwarded promptly without being opened or read by provider staff.

(n) The provider director or their designee may take temporary custody of a patient's personal property with the patient's written permission. Personal property retained by the provider shall, at the patient's direction, be returned to the patient when the patient leaves the service, sent to an address designated by the patient at the patient's expense, or donated to the provider. All property left by a patient will be disposed of as abandoned property within thirty (30) days, or in accordance with applicable law. Any interest on money received and held for a patient shall be the property of the individual patient and shall not accrue for the benefit of the provider or for the general welfare of all patients in a facility. A provider who serves as a representative payee for a patient pursuant to designation by a governmental entity or assumes management responsibility over the funds of a patient shall maintain such funds in a fiduciary capacity to the patient.

(o) The provider may submit reports or information to criminal justice entities regarding any patient only after receiving a request and executing a proper consent. Such reports shall be limited to only treatment or clinical information about the patient that is sufficient to satisfy the request, consistent with applicable law, and shall not contain any recommendation or suggestion of any legal action or consequence, such as: court intervention; remand; custody; violation; or incarceration.

(p) Providers shall not offer or accept payment, benefit, or other consideration in any form, in exchange for the referral of any person as a potential patient for substance use disorder service s and shall not advertise, or otherwise solicit patients, in false, deceptive or misleading ways.

(q) Providers shall develop and implement policies and procedures consistent with the requirements for hiring and training all custodians, as such term is defined in Part 836 of this Title. Such procedures shall include, but not be limited to, receipt of signed attestations that such custodian has been notified of, and understands, their obligations pursuant to chapter 501 of the Laws of 2012 and Justice Center regulations and that such custodian shall abide by the Code of Conduct for custodians as established by the Justice Center for the Protection of People with Special Needs; and provider's obligation to cooperate with any investigation of a custodian regarding a reportable or significant incident by the Justice Center as an agent of the Office.

(r) Providers shall develop and implement policies and procedures to ensure the provision of culturally appropriate and affirming services for patients, including but not limited to, sexual orientation and gender identity or expression.

(s) Providers shall develop and implement policies and procedures to ensure access to approved medications for substance use disorder treatment as follows and in accordance with guidance issued by the Office:

(1) Medication for Addiction Treatment (MAT) for Substance Use Disorder:
(i) Providers shall maintain a patient with substance use disorder on approved medication, including those federal Food and Drug Administration (FDA) approved medications to treat substance use disorder, if deemed clinically appropriate and in collaboration with the patient's existing provider, and with the patient's consent, in accordance with federal and state rules and guidance issued by the Office. Such contact with the existing program or practitioner prescribing such medications shall be documented in the patient record.

(ii) To facilitate access to full opioid agonist medication for patients who are maintained on such medication at the time of admission or who choose to start such medication during admission, providers shall develop a formal agreement with at least one Opioid Treatment Program (OTP) certified by the Office to facilitate patient access to full opioid agonist medication, if clinically appropriate. Such agreements shall address the program and the OTPs responsibilities to facilitate patient access to such medication in accordance with guidance issued by the Office.

(iii) Providers shall provide FDA approved medications to treat substance use disorder to an existing patient or prospective patient seeking admission to an Office certified program in accordance with all federal and state rules and guidance issued by the Office.

(iv) Providers shall provide education to an existing patient or prospective patient with substance use disorder about FDA approved medications for the treatment of substance use disorder if the patient is not already taking such medications, including the benefits and risks. The program shall document such discussion and the outcome of such discussion, including a patient's preference for or refusal of medication, in the patients record.

(v) Providers shall ensure that the patient's discharge plan includes an appointment with a treatment provider or program that can continue the medication post-discharge.

(2) Overdose Prevention Education.
(i) Providers shall offer overdose prevention education and naloxone education and training to a patient, prospective patient, and/or their significant other(s), in accordance with guidance issued by the Office.

(ii) Providers shall offer a naloxone kit or prescription to patients, prospective patients, and/or their significant other(s), in accordance with guidance issued by the Office.

(t) Providers shall document all formal agreements with Opioid Treatment Programs to facilitate patient access to opioid full agonist medication, where appropriate, and consistent with state and federal rules and guidance issued by the Office.

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