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

Current through Register Vol. 46, No. 28, July 10, 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.