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 405.3 - Administration

Current through Register Vol. 46, No. 28, July 10, 2024
The hospital shall be managed effectively and efficiently
						in accordance with hospital bylaws and policies and procedures. The daily
						management and operational affairs of the hospital shall be the responsibility
						of the chief executive officer.
(a)
					 The chief executive officer shall be responsible for the development,
					 submission and implementation of all plans to correct operational deficiencies
					 identified by regulatory agencies on a timely basis and shall report to the
					 governing body progress in developing and carrying out plans of
					 correction.
(b)
Personnel.
The chief executive officer develops and implements
						personnel policies and practices with regard to at least the following:
(1) the employment of personnel, without
					 regard to sex, race, creed, sexual orientation, disability, or national origin,
					 whose qualifications are commensurate with anticipated job
					 responsibilities;
(2) the
					 identification of all hospital personnel, including students and volunteers,
					 through the use of identification name tags which are clearly visible and are
					 worn at all times;
(3) the
					 orientation of all new employees to the hospital and to hospital and personnel
					 policies;
(4) the development and
					 implementation of a written plan for inservice training, including orientation
					 and training for the governing body;
(5) effective July 1, 1989, the provision, at
					 all times, of intravenous services, phlebotomy services, messenger services,
					 transporter services, nurse aides, housekeeping services and other ancillary
					 support services in a manner sufficient to meet patient care needs and to
					 prevent adverse impact on the delivery of medical and nursing care;
(6) the maintenance of an accurate, current,
					 and complete personnel record for each hospital employee;
(7) the verification of all applicable
					 current licensure/certification;
(8) a periodic performance evaluation, based
					 on a written job description, of each employee;
(9) the provision of employee health
					 services, in consultation with the medical staff; and
(10) the provision for a physical examination
					 and recorded medical history for all personnel including all employees, members
					 of the medical staff, contract staff, students and volunteers, whose activities
					 are such that a health impairment would pose a potential risk to patients. The
					 examination shall be of sufficient scope to ensure that no person shall assume
					 his/her duties unless he/she is free from a health impairment which is of
					 potential risk to the patient or which might interfere with the performance of
					 his/her duties, including the habituation or addiction to depressants,
					 stimulants, narcotics, alcohol or other drugs or substances which may alter the
					 individual's behavior. The hospital is required to provide such examination
					 without cost for all employees who are required to have such examination. For
					 personnel whose activities are such that a health impairment would neither pose
					 a risk to patients nor interfere with the performance of his/her duties, the
					 hospital shall conduct a health status assessment in order to determine that
					 the health and well-being of patients are not jeopardized by the condition of
					 such individuals. The hospital shall require the following of all personnel,
					 with the exception of those physicians who are practicing medicine from a
					 remote location as a condition of employment or affiliation:
(i) a certificate of immunization against
					 rubella which means:
(a) a document prepared
					 by a physician, physician's assistant, specialist's assistant, nurse
					 practitioner, licensed midwife or a laboratory possessing a laboratory permit
					 issued pursuant to Part 58 of this Title, demonstrating serologic evidence of
					 rubella antibodies; or
(b) a
					 document indicating one dose of live virus rubella vaccine was administered on
					 or after the age of 12 months, showing the product administered and the date of
					 administration, and prepared by the health practitioner who administered the
					 immunization; or
(c) a copy of a
					 document described in clause (
a
) or (
b
) of
					 this subparagraph which comes from a previous employer or the school which the
					 employee attended as a student; and
(ii) a certificate of immunization against
					 measles for all personnel born on or after January 1, 1957 which means:
(a) a document prepared by a physician,
					 physician's assistant, specialist's assistant, nurse practitioner, licensed
					 midwife or a laboratory possessing a laboratory permit issued pursuant to Part
					 58 of this Title, demonstrating serologic evidence of measles antibodies;
					 or
(b) a document indicating two
					 doses of live virus measles vaccine were administered on or after the age of 12
					 months and the second dose administered more than 30 days after the first dose
					 but after 15 months of age showing the product administered and the date of
					 administration, and prepared by the health practitioner who administered the
					 immunization; or
(c) a document,
					 indicating a diagnosis of the employee as having had measles disease prepared
					 by the physician, physician's assistant/specialist's assistant, licensed
					 midwife or nurse practitioner who diagnosed the employee's measles;
					 or
(d) a copy of a document
					 described in clause (
a
), (
b
) or
					 (
c
) of this subparagraph which comes from a previous employer
					 or the school which the employee attended as a student;
(iii) if any licensed physician, physician's
					 assistant, specialist's assistant, licensed midwife or nurse practitioner
					 certifies that immunization with measles and/or rubella vaccine may be
					 detrimental to the employee's health, the requirements of subparagraph (i)
					 and/or (ii) of this paragraph relating to measles and/or rubella immunization
					 shall be inapplicable until such immunization is found no longer to be
					 detrimental to such employee's health. The nature and duration of the medical
					 exemption must be stated in the employee's employment medical record and must
					 be in accordance with generally accepted medical standards, (see, for example,
					 the recommendations of the American Academy of Pediatrics and the Immunization
					 Practices Advisory Committee of the U.S. Department of Health and Human
					 Services);
(iv) for all personnel
					 prior to employment or affiliation, except for personnel with no clinical or
					 patient contact responsibilities who are located in a building or site with no
					 patient care services, an initial individual tuberculosis (TB) risk assessment,
					 symptom evaluation, and TB test (either tuberculin skin test or Food and Drug
					 Administration (FDA) approved blood assay for the detection of latent
					 tuberculosis infection), and annual assessments thereafter. Positive findings
					 shall require appropriate clinical follow-up . The medical staff shall develop
					 and implement policies regarding positive findings, including procedures for
					 facilitating and documenting treatment for latent TB infection where indicated.
					 Annual TB assessment shall include education, individual risk assessment, and
					 follow-up tests as indicated.
(v)
					 documentation of vaccination against influenza, or wearing of a surgical or
					 procedure mask during the influenza season, for personnel who have not received
					 the influenza vaccine for the current influenza season, pursuant to section
					 2.59 of this Title.
(vi) documentation of COVID-19 vaccination or
					 a valid medical exemption to such vaccination, pursuant to section
					 2.61 of this Title, in accordance
					 with applicable privacy laws, and making such documentation immediately
					 available upon request by the Department, as well as any reasonable
					 accommodation addressing such exemption.
(11) the reassessment of the health status of
					 all personnel as frequently as necessary, but no less than annually, to ensure
					 that personnel are free from health impairments which pose potential risk to
					 patients or personnel or which may interfere with the performance of
					 duties;
(12) the provision for
					 emergency health care for all personnel;
(13) the maintenance of medical records for
					 all personnel including the dates, extent and results of all health assessments
					 and physical examinations; the results of laboratory tests and X-ray reports;
					 and records of immunizations, illnesses or injuries;
(14) the requirement that all personnel
					 report immediately to their supervisor any signs or symptoms of personal
					 illness. All personnel making such report shall be referred to an appropriate
					 health care professional for assessment of the potential risk to patients and
					 personnel. Based on this assessment, the hospital shall authorize appropriate
					 measures to be taken, including but not limited to removal, reassignment or
					 return to duty;
(15) the safety and
					 protection of all personnel and advice to personnel concerning the nature of
					 toxic substances which they may encounter in the workplace in the course of
					 their employment or affiliation, in accordance with article 28 of the New York
					 State Labor Law; and
(16) a policy
					 that no hospital employee or member of a hospital medical staff shall be
					 required by the hospital or a member of the hospital staff to participate in an
					 induced termination of pregnancy who has informed the hospital of his or her
					 decision not to participate in such act or acts;