New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter A - Medical Facilities-minimum Standards › Article 2 - Hospitals › Part 405 - Hospitals-Minimum Standards › Section 405.7 - Patients' rights

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