Provider Requirements – N.Y. Comp. Codes R. & Regs. tit. 14, § 815.4

Requirements for Providers of Chemical Dependency Services

The law protects the rights of patients seeking chemical dependency services by establishing requirements for service providers currently certified, licensed, operated, or funded by Office of Alcoholism and Substance Abuse Services (OASAS).  The law requires that the provider:

1.    Ensure certain level of patient care:

a.    Develop standards governing staff to ensure protection of patient rights and communication of these rights, responsibilities and standards to patients, while making every effort to accommodate patients’ language barriers and disabilities

b.    In addition to developing the policy, the provider must also make every effort to actually accommodate and ensure effective communication with those who have language barriers and/or disabilities.

c.    Develop policies and procedures to help patients follow their treatment/recovery plans, including expectations and standards for patient behavior and participation in their own treatment. These policies and procedures should identify incremental interventions that assist patients in responding positively to treatment. These interventions should be incorporated into each patient’s specific treatment plan and documented in the patient's record. 

d.    Establish a procedure for implementing quality improvements in response to patient concerns and complaints and to changes in regulatory requirements. This procedure must be reviewed at least every two years, and the provider must maintain documentation of all such reviews.

e.    Establish a policy for patient discharge (in accordance with 815.7), and record and review discharge decisions and appeal results as party of provider’s quality review process

f.     Develop policies and procedures for hiring and training all custodians (director, operator, employee or volunteer of facility) to ensure that they are away of all their obligations and the rights of the patients

2.    Keep the patient notified of his/her rights and responsibilities:

a.    Post copies of a statement stating patient rights (as stated in 815.5), patient responsibilities (as stated in 815.6), and the provider’s policy for addressing patient concerns and grievances.

b.    Provide the patients, upon admission, copies of the provider services, the provider’s policy relating to the rights and responsibilities of both patient and provider, and the consequences of failing to meet treatment goals.  The patient has to acknowledge that he or she has received and understood the documents in writing, and this attestation has to be added to the patient’s record.  The provider is also required to provide patients with the actual text of this part of the title, and inform the patient that they will be provided with the requisite documents if they wish to express a grievance, and that

c.    Retain in the patient’s records the patient’s attestation that he/she received and understood a written copy of the following documents given to him/her upon admission: provider services, policy relating to the rights and responsibilities of the patient and the provider, and the consequences of failing to meet the treatment/recovery plan goals or other provider rules and requirements.

3.    Maintain confidentiality of patient’s records:

a.    Comply with Federal confidentiality regulations (including HIPAA and 42 CFR part 2), and assure each patient at the time of admission that federal and state laws protect the confidentiality of all records and that information is only released in accordance with the law.

b.    Ensure that the patient is fully aware of who is receiving the information disclosed in compliance with federal and state law by making each release form as specific as possible.

c.    Maintain a policy that implements an end date to all release of confidential information forms.

d.    Give the patient copies of his or her records, upon request and in accordance with applicable law, within 15 calendar days of a request.

e.    Submit reports or information to criminal justice entities regarding any patient only after receiving a request and executing a proper consent, and that such reports be limited to information about the patient that is sufficient to satisfy the request, comply with applicable law, and not contain any recommendation for legal action or consequence.

4.    Be aware of and uphold patient rights:

a.    Understand that patient’s rights as a resident of state of New York and as a citizen of the US are not forfeited because of participation in a chemical dependency service

b.    Understand that participation in a chemical dependence service is voluntary and that no provider must force or coerce any person to enter or remain in the service, and let the patients know that they are entitled to leave the service at any time.

c.    Adhere to N.Y. Mental Hygiene § 22.09 when providing emergency services for incapacitated persons.

d.    Use a sliding scale to evaluate a patient’s ability to pay

e.    Treat minors in accordance with N.Y. Mental Hygiene § 22.11

f.     Ensure that patients at inpatient and residential facilities can correspond, call and have opportunities to meet with visitors, and that their correspondence with public officials, attorneys, religious officials is unrestricted and unmonitored.

g.    Store, ship or dispose of patient’s personal property as per his/her wishes

h.    Not advertise or solicit patients in false or misleading ways

i.      Not add any admission criteria not required by regulation, and provide those not admitted with information about alternative options and referrals

Full text of law - (a) The facility or provider agency as governing authority shall establish policies and procedures to protect patient rights. Such policies and procedures shall be consistent with the requirements of the facility’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 disabilities 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, as 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 this Title 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 his or her treatment/recovery plan. Such policies and procedures shall specify standards and expectations for patient conduct, to achieve goals consistent with the plan, and consequences for failing to meet goals, including conduct which may result in discharge. Policies and procedures shall, at a minimum, address patient behavior with timely and appropriate incremental interventions 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.

(6) 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 policy relating to the rights and responsibilities of the patient and the provider, and the consequences of failing to meet the treatment/recovery plan goals or 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 and ensure effective communication with patient language differences and/or disabilities, taking into account the individual's ability to read, in accord 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 a chemical dependence service.

(e) The provider shall comply with the Federal confidentiality regulations at 42 Code of Federal Regulations 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 chemical dependence 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 a chemical dependence service 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 anonymous support-group services available to patients but shall not compel attendance. A patient’s failure to complete treatment required by 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 chemical dependence 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, such as residency, and/or citizenship status. Applicants not admitted to the facility or provider agency shall be given information concerning other service providers which can more appropriately meet the needs of the individual and, if clinically necessary, a referral 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 strictly adhere 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 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 his/her 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 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 which is a representative payee for a patient pursuant to designation by a governmental entity or which 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 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, his/her 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 established.

(r) Providers shall develop policies and procedures for the release of records consistent with 42 Code of Federal Regulations part 2 and other statutes and regulations of the Justice Center.