Part 763 - Certified Home Health Agencies, Long Term Home Health Care Programs and AIDS Home Care Programs Minimum Standards

Effective Date: 
Wednesday, December 12, 2018
Doc Status: 
Complete
Statutory Authority: 
Public Health Law Sec. 3612 and Social Services Law, Sec. 367-M

Section 763.1 - General

Section 763.1 General. This Part establishes minimum requirements and operating standards for certified home health agencies, long term home health care programs and AIDS home care programs. For the purposes of this Part, these entities shall be referred to as "agency" unless the regulation specifies otherwise.
 

Effective Date: 
Wednesday, March 23, 1994
Doc Status: 
Complete

Section 763.2 - Patients' rights

763.2 Patients' rights.

(a) The governing authority shall develop and implement written policies and procedures regarding the rights of the patient. These rights, policies and procedures shall afford each patient the right to:

(1) be informed of these rights, and the right to exercise such rights, in writing prior to the initiation of care, as evidenced by written documentation in the clinical record;

(2) be given a statement of the services available from the agency and related charges;

(3) be advised before care is initiated of the extent to which payment for agency services may be expected from any third party payors and the extent to which payment may be required from the patient.

(i) The agency shall advise the patient of any changes in information provided under this paragraph or paragraph (2) of this subdivision as soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change.

(ii) All information required by this paragraph shall be provided to the patient both verbally and in writing;

(4) be informed of all treatments prescribed, when and how services will be provided, and the name and functions of any person and affiliated agency providing care and services;

(5) participate in the planning of his or her care and be advised in advance if any changes to the plan of care are warranted;

(6) refuse care and treatment after being fully informed of and understanding the consequences of such actions;

(7) submit patient complaints about care and services provided or not provided and complaints concerning lack of respect for property by anyone furnishing services on behalf of the agency, to be informed of the procedure for filing such complaints, and to have such complaints investigated by the agency in accordance with the provisions of paragraph (8) of subdivision (a) of section 763.11 of this Part;

(8) voice complaints and recommend changes in policies and services to agency personnel, the New York State Department of Health or any outside representative of the patient's choice. The expression of such complaints by the patient or his/her designee shall be free from restraint, interference, coercion, discrimination or reprisal;

(9) be treated with consideration, respect and full recognition of his or her dignity and individuality;

(10) privacy, including confidential treatment of patient records, and refusal of their release to any individual outside the agency except in the case of the patient's transfer to a health care facility, or as required by law or third-party payment contract;

(11) be advised in writing of the availability of the Department of Health toll-free hotline, the telephone number, the hours of its operation and that the purpose of the hotline is to receive complaints or answer questions about home care agencies; and

(12) refuse consent to advanced tasks performed by an advanced home health aide, in which case the agency shall provide for the performance of such tasks by a registered professional nurse.

(b) The governing authority shall make all personnel providing patient care services on behalf of the agency aware of the rights of patients and the responsibility of personnel to protect and promote the exercise of such rights.

(c) If a patient lacks capacity to exercise these rights, the rights shall be exercised by an individual, guardian or entity legally authorized to represent the patient.

Effective Date: 
Wednesday, December 12, 2018
Doc Status: 
Complete

Section 763.3 - Patient care

763.3 Patient care.

(a) The governing authority shall ensure that a comprehensive array of services is available and provided as needed.

(1) For a certified home health care agency, such services shall include, as a minimum, the following services which are of a preventive, therapeutic, rehabilitative, health guidance and/or supportive nature to persons at home: nursing services; home health aide services; medical supplies, equipment and appliances suitable for use in the home; and at least one additional service which may include, but not be limited to, the provision of physical therapy, occupational therapy, speech/language pathology, nutritional services and social work services.

(2) For a long term home health care program or AIDS home care program, such services shall include as a minimum: nursing services; home health aide services; medical supplies, equipment and appliances; physical therapy; occupational therapy; respiratory therapy; speech-language pathology; audiology; medical social work; nutritional services; personal care; homemaker and housekeeper services.

(b) An agency shall provide at least one of the services identified in paragraph (1) of subdivision (a) of this section directly, while any other services may be provided directly or by contract arrangement. For purposes of this Part, the direct provision of services includes the provision by employees compensated by the agency or individuals under contract with the agency, but does not include the provision of services through contract arrangements with other agencies or facilities.

(c) The agency shall assist the patient with obtaining, from other facilities, agencies or individuals, any of the services in subdivision (a) of this section that are not provided by the agency and which are needed by the patient.

(d) An agency must ensure the availability 24 hours a day, seven days a week of:

(1) professional telephone consultation for patients or caregivers; and

(2) part time, intermittent nursing and home health aide visits in the home as the needs of the patient dictate. If personal care or homemaker services are provided by the agency, such services must also be available on a part time, intermittent basis, 24 hours a day, seven days a week.

(e) If the agency is providing only personal care services to a patient, such services shall be provided in accordance with the regulations in this Article applicable to licensed home care services agencies.
 

Effective Date: 
Wednesday, May 15, 2013
Doc Status: 
Complete

Section 763.4 Policies and procedures of service delivery

763.4 Policies and procedures of service delivery. The agency shall ensure that:

(a) written policies and procedures, consistent with current professional standards of practice, are developed and implemented for each service and are reviewed and revised as necessary;

(b) protocols are developed for each professional discipline to indicate when that service should be included in the patient assessment;

(c) any nursing or therapeutic services, procedures or treatments, not previously carried out in the home by that agency, are first reviewed by the professional advisory committee before being provided regularly. If a patient needs such service, procedure or treatment, it may be provided prior to review by the professional advisory committee, if:

(1) medical consultation has been obtained regarding safety and appropriateness; and

(2) personnel have been trained to provide that specific service, procedure or treatment;

(d) professional personnel are fully informed of, and encouraged to refer patients to, other health and social community resources which may be needed to maintain patients in the home;

(e) policies and procedures for the storage, cleaning and disinfection of medical supplies, equipment and appliances are established;

(f) persons providing care in the home display proper and current identification, including name, title and current photograph of care provider and name of agency providing the service. Such identification shall be returned to the agency upon termination of employment;

(g) supervisory personnel are employed by the agency to assure quality of patient care services. Such supervision shall include:

(1) ongoing review of cases and delegation of assignments;

(2) in-home visits to direct, demonstrate and evaluate the delivery of patient care;

(3) provision of clinical consultation; and

(4) professional guidance on agency policies and procedures; and

(h) all personnel delivering care in patient homes are adequately supervised. The department shall consider the following factors as evidence of adequate supervision:

(1) supervision of nursing personnel is conducted by a supervising community health nurse;

(2) personnel regularly provide services at the frequencies specified in the patient's plan of care, and in accordance with the policies and procedures of their respective services;

(3) personnel are assigned to the care of patients in accordance with their licensure, as appropriate, and their training, orientation and demonstrated skills;

(4) clinical records are kept complete, and changes in patient condition, adverse reactions, and problems with informal supports or home environment are charted promptly and reported to supervisory personnel;

(5) plans of care are revised as needed by the patient, and changes are reported to the authorized practitioner and other personnel providing care to the patient;

(6) supervision of a home health aide or personal care aide is conducted by a registered professional nurse or licensed practical nurse or by a therapist if the aide carries out simple procedures as an extension of physical therapy, occupational therapy or speech/language pathology;

(7) in-home supervision, by professional personnel, of home health aides and personal care aides takes place:

(i) to demonstrate to and instruct the aide in the treatments or services to be provided, with successful re-demonstration by the aide during the initial service visit, or where there is a change in personnel providing care, if the aide does not have documented training and experience in performing the tasks prescribed in the plan of care;

(ii) where any of the changes in paragraph (4) of this subdivision occur, to evaluate the change and initiate any revision in the plan of care which may be needed; and

(iii) to instruct the aide as to the observations and written reports to be made to the supervising community health nurse or therapist;

(8) direct supervision of an advanced home health aide is conducted by a registered professional nurse who:

(i) provides training, guidance, direction and oversight, and evaluation related to the performance of advanced tasks by the advanced home health aide;

(ii) assigns advanced tasks to be performed by the advanced home health aide after completing a nursing assessment to determine the patient’s current health status and care needs;

(iii) provides case specific training to the advanced home health aide to verify and ensure the advanced home health aide can safely and competently perform the advanced tasks for the patient;

(iv) provides written, patient specific instructions for performing advanced tasks, including the criteria for identifying, reporting, and responding to problems, errors or complications;

(v) conducts a comprehensive medication review including evaluation of the patient’s current medication use, and prescribed drug regimen and identifies and resolves any discrepancies prior to assigning the advanced home health aide to administer medications;

(vi) determines direct supervision of the advanced home health aide based on the complexity of advanced tasks, the skill and experience of the advanced home health aide assigned to perform the advanced tasks, and the health status of the patient for whom the advanced tasks are being performed;

(vii) while on duty is continuously available to communicate with the advanced home health aide by phone or other means;

(viii) conducts home visits or arranges for another qualified registered professional nurse whenever necessary to protect the health and safety of the patient;

(ix) performs an initial and ongoing assessments of the patient’s needs; and

(x) conducts a home visit at least every two weeks and more frequently as determined by the registered professional nurse, to observe, evaluate, and oversee services provided by the advanced home health aide;  

(9) a process is in place to document the limitation or revocation of the assignment of advanced tasks by an advanced home health aide when deemed appropriate by a supervising registered professional nurse and to ensure that such information is available to other registered professional nurses that may supervise such aide; and

(10) any failure by a supervising registered professional nurse to comply with the requirements of paragraph eight of this subdivision shall be reported to the department.

 

Effective Date: 
Wednesday, December 12, 2018
Doc Status: 
Complete

Section 763.5 - Patient referral, admission and discharge

763.5 Patient referral, admission and discharge. The governing authority shall ensure that decisions regarding patient referral, admission and discharge are made based on the patient's assessed needs and the agency's ability to meet those needs in a manner that protects and promotes the patient's health and safety and does not jeopardize the safety of personnel. Such decisions shall reflect a commitment to providing authorized practitioner ordered care and services while honoring the patient's expressed needs and choices to the extent practicable and shall be made in accordance with the provisions of this section. For the purposes of this Part, authorized practitioner shall refer to a doctor of medicine, a doctor of osteopathy, a doctor of podiatry or any other practitioner authorized under Federal and State law and applicable rules and regulations to provide medical care and services to the patient.

(a) The initial patient visit shall be made within 24 hours of receipt and acceptance of a community referral or return home from institutional placement unless:

(1) the patient's authorized practitioner orders otherwise; or

(2) there is written documentation that the patient or family refuses such a visit.

(b) A patient shall be admitted to the agency after an assessment, using a form prescribed or approved by the department, is performed during the initial patient visit, which indicates that the patient's health and supportive needs can be met safely and adequately at home and that the patient's condition requires the services of the agency.

(1) In determining whether a prospective patient's health and supportive needs can be met safely at home, the agency shall consider for admission a prospective patient who meets at least one of the following criteria: is self-directing; is able to call for help; can be left alone; or has informal supports or other community supports who are willing, able and available to provide care and support for the patient in addition to the services being provided by the agency. For purposes of this section:

(i) A self-directing patient means an individual who is capable of making choices about his/her clinical care and activities of daily living, understanding the impact of the choice and assuming responsibility for the results of the choice, or has informal supports willing and able to provide advise and/or direction on behalf of the patient, if needed, in accordance with State law;

(ii) A patient who is able to call for help means an individual who is physically, mentally and cognitively capable of initiating effective communication to individuals outside the immediate presence of the patient who can provide timely assistance to the patient;

(iii) A patient who can be left alone means an individual who, based on his/her physical, mental and cognitive capability, does not require the continuous presence of another individual to meet his/her minimal ongoing health and safety requirements; and

(iv) Informal supports or other community supports means friends, relatives or associates of the patient, whether compensated or not, unaffiliated with the agency, who are able, available and willing to provide needed care, support and other services to the patient during the periods agency personnel are not present. Such supports may include personnel of an adult care facility in which the patient resides.

(2) The agency shall not be required to admit a patient:

(i) who does not meet any of the criteria of paragraph (1) of this subdivision;

(ii) when conditions are known to exist in or around the home that would imminently threaten the safety of personnel, including but not limited to:

(a) actual or likely physical assault which the individual threatening such assault has the ability to carry out;

(b) presence of weapons, criminal activity or contraband material which creates in personnel a reasonable concern for personal safety; or

(c) continuing severe verbal threats which the individual making the threats has the ability to carry out and which create in personnel a reasonable concern for personal safety;

(iii) when the agency has valid reason to believe that agency personnel will be subjected to continuing and severe verbal abuse which will jeopardize the agency's ability to secure sufficient personnel resources or to provide care that meets the needs of the patient; or

(iv) who, based on previous experience with the delivery of care from the agency, is known to repeatedly refuse to comply with a plan of care or others interfere with the patient's ability to comply with a plan of care agreed upon, as appropriate, by: the patient; the patient's family; any legally designated patient representative; the patient's physician; agency personnel and/or any case management entity, and such non-compliance will: (a) lead to an immediate deterioration in the patient's condition serious enough so that home care will no longer be safe and appropriate; or

(b) make the attainment of reasonable therapeutic goals impossible.

(3) The assessment shall be conducted by a registered professional nurse, except in those instances where physical therapy or speech/language pathology is the sole service prescribed by the patient's physician and the agency elects to have the therapist conduct the assessment.

(c) At the time a determination is made to deny a patient admission based on the criteria listed in paragraph (2) of subdivision (b) of this section, the agency shall determine whether the patient appears to be eligible for services from the local Protective Services for Adults program in accordance with the criteria set forth in subdivision (b) of section 457.1 of 18 NYCRR.

(1) If the patient appears to be eligible for such services, the agency shall make a referral to the appropriate local Protective Services for Adults program. Such referral shall indicate the patient's ongoing care needs and the reason for the decision not to admit.

(2) If the local Protective Services for Adults program accepts the referral, takes action to address the problems preventing admission and notifies the agency that such problems have been resolved, the agency shall reassess the patient to determine whether admission has become appropriate or remains inappropriate.

(d) Any patient who is assessed or reassessed as inappropriate for agency services shall be assisted by the agency, in collaboration with the discharge planner, the local Social Service Department and other case management entity, as appropriate, with obtaining the services of an alternate provider, if needed, and the patient's authorized practitioner shall be so notified. If alternate services are not immediately available, and the local Protective Services for Adults program, the Office of Mental Retardation and Developmental Disabilities, the Office of Mental Health or other official agency requests that home care services be provided on an interim basis, the agency may provide home care services which address minimally essential patient health and safety needs for a period of time agreed upon by the agency and the requesting entity, provided that the patient and family or informal supports, as appropriate, have been fully informed of the agency's intent to transfer the patient to an alternate service, when available, and have been consulted in the development of an interim plan of care.

(e) Services which the agency provides shall be available to all persons without regard to age, race, color, creed, sex, national origin, disability, service need intensity, location of patient's residence in the service area, or source of payment.

(f) Services shall not be diminished or discontinued solely because of the change in the patient's source of payment or the patient's inability to pay for care.

(g) A discharge plan shall be initiated prior to agency discharge to assure a timely, safe and appropriate transition for the patient.

(h) A patient may be discharged by the agency only after consultation, as appropriate, with the patient's authorized practitioner, the patient, the patient's family or informal supports, any legally designated patient representative and any other professional personnel including any other case management entity involved in the plan of care. If the agency determines that the patient's health care needs can no longer be met safely at home due to the circumstances specified in paragraphs (4) and (5) of this subdivision, the agency must continue to provide home health services only to the extent necessary to address minimally essential patient health and safety needs until such time as an alternative placement becomes available and such placement is made or the patient or the patient's legal representative, who has the authority to make health care decisions on behalf of the patient, makes an informed choice to refuse such placement. As appropriate, the patient and family or informal supports, any legally designated patient representative and any other professional personnel including any case management entity involved, shall be fully informed of the agency's intent to discharge the patient to an alternate service, when available, and shall be consulted in the development of an interim plan of care. Discharge shall be appropriate when:

(1) therapeutic goals have been attained and the patient can function independently or with other types of community support services;

(2) conditions in the home imminently threaten the safety of the personnel providing services or jeopardize the agency's ability to provide care as described in subparagraphs (ii) and (iii) of paragraph (2) of subdivision (b) of this section;

(3) all agency services are terminated by the patient; (4) the patient, the patient's family, informal supports or any legally designated patient representative is non-compliant or interferes with the implementation of the patient's plan of care and the scope and effect of such non-compliance or interference:

(i) has led to or will lead to an immediate deterioration in the patient's condition serious enough that home care will no longer be safe and appropriate; or

(ii) has made attainment of reasonable therapeutic goals at home impossible; and

(iii) the likely outcome of such non-compliance or interference has been explained to the patient, or the patient's legally designated patient representative, family or informal supports, and any case management entity, as appropriate, and the patient continues to refuse to comply with, or others continue to interfere with the implementation of, the plan of care; or

(5) the availability of home health services or community support services is no longer sufficient to meet the patient's changing care needs and to assure the patient's health and safety at home and the patient requires the services of a health care institution or an alternate health care provider. An agency may determine that the patient's health care needs can no longer be met safely at home by the agency if none of the criteria or circumstances of paragraph (1) of subdivision (b) of this section apply any longer to the patient.

(i) If a patient is to be discharged in accordance with subdivision (h) of this section, and the agency believes there will continue to be a substantial risk to the patient's health and safety subsequent to discharge, a referral shall be made to the appropriate local Protective Services for Adults program or other official agency, as appropriate, at the time the discharge determination is made.

(1) If the local Protective Services for Adults program or other official agency to which the patient has been referred accepts the referral, takes action to address adequately the problems leading to the discharge determination and notifies the home care agency that such problems have been resolved, the agency shall reassess the patient.

(2) After reassessment, the home care agency shall determine whether action to discharge the patient should be discontinued or the discharged patient should be readmitted.
 

Effective Date: 
Wednesday, March 23, 1994
Doc Status: 
Complete

Section 763.6 - Patient assessment and plan of care

763.6 Patient assessment and plan of care.

(a) A comprehensive interdisciplinary patient assessment shall be completed, involving, as appropriate, a representative of each service needed, the patient, the patient's family or legally designated representative and patient's authorized practitioner. Such assessment shall address, at a minimum, the medical, social, mental health and environmental needs of the patient.

(b) A plan of care shall be developed within 10 days of admission to the agency and approved by the patient based on the comprehensive interdisciplinary patient assessment. The plan shall designate a professional person employed by the agency to be responsible for coordinating care which includes but is not limited to:

(1) coordination of all services provided directly or by contract to the patient by the agency, informal supports and other community resources to carry out the agency's plan of care;

(2) cooperation with other health, social and community organizations providing or coordinating care;

(3) consultation with the patient's authorized practitioner, the local social services representative and discharge planner, if applicable. If an authorized practitioner has referred a patient under a plan of care that cannot be completed until after an evaluation visit, the authorized practitioner shall be consulted to approve additions or modifications to the original plan; and

(4) responsibility for maintaining current clinical records, conducting case reviews and completing required patient-specific records and reports, as appropriate.

(c) The plan of care shall cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, need for palliative care, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items.

(d) Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration of such services.

(e) The plan of care shall be reviewed as frequently as required by changing patient conditions but at least every 60 days.

(1) Each review shall be documented in the clinical record; and

(2) Agency professional personnel shall promptly alert the patient's authorized practitioner to any significant changes in the patient's condition that indicate a need to alter the plan of care.
 

Effective Date: 
Wednesday, May 15, 2013
Doc Status: 
Complete

Section 763.7 - Clinical records

763.7 Clinical records.

(a) The agency shall maintain a confidential clinical record for each patient admitted to care or accepted for service to include:

(1) identifying patient data;

(2) source of patient referral, including, where applicable, name and type of institution from which discharged, discharge summary and plan of care and date of discharge;

(3) medical orders and nursing diagnoses to include all diagnoses, medications, treatments, prognoses, and need for palliative care. Such orders shall be:

(i) signed by the authorized practitioner within 12 months after admission to the agency, or prior to billing, whichever is sooner;

(ii) signed by the authorized practitioner within 12 months after issuance of any change in medical orders or prior to billing, whichever is sooner, to include all written and oral changes and changes made by telephone by such practitioner; and

(iii) renewed by the authorized practitioner as frequently as indicated by the patient's condition but at least every 60 days;

(4) the comprehensive interdisciplinary patient assessment;

(5) the individualized plan of care;

(6) signed and dated progress notes, following each patient contact by each professional person providing care, which shall include a summary of patient status and response to plan of care and, if applicable, contacts with family, informal supports and other community resources, and a brief summary of care provided at the termination of each service;

(7) observations and reports made to the registered professional nurse, licensed practical nurse or supervising therapist by the advanced home health aide, home health aide or personal care aide, including activity sheets;

(8) documentation of accidents and incidents;

(9) documentation of the patient's receipt of information regarding his/her rights; and

(10) a discharge summary, completed by appropriate personnel when the patient is discharged from the agency, including but not limited to:

(i) documentation of discharge planning preparation;

(ii) notification to the patient's authorized practitioner;

(iii) reasons for discharge and date of discharge;

(iv) summary of care given and patient's progress;

(v) patient status upon discharge including a description of any remaining needs for patient care and supportive services;

(vi) patient or family ability to self-manage in relation to any remaining problems; and

(vii) recommendations and referral for any follow-up care, if needed.

(b) In addition to meeting the clinical record requirements of subdivision (a) of this section, clinical records for long term home health care programs and AIDS home care programs shall include an evaluation of the medical, mental health, social and environmental needs of the patient, on forms prescribed by the Commissioner, which shows that the patient is medically eligible for placement in a hospital or residential health care facility were this program not available.

(c) Each patient's clinical records shall be be kept securely for not less than six years after discharge from the agency and made available to the department upon request. In the case of minors, records are to be kept for not less than six years after discharge, or three years after they reach majority (18 years), whichever is the longer period.

(d) Each agency shall maintain written policies and procedures which:

(1) safeguard clinical records against loss or unauthorized access; and

(2) govern use, removal and release of information.

(e)(1) For agency patients who require placement in a nursing home or health-related facility, the SCREEN as contained in section 400.12 and the Hospital/Community PRI as contained in section 400.13 of this Title shall, as appropriate, be completed by personnel qualified and trained in accordance with section 86-2.30 and section 400.12 of this Title.

(2) Each agency shall have a sufficient number of trained, qualified and approved assessors and screeners to meet H/C PRI and SCREEN requirements and to attest to the accuracy of such patient review forms.

(3) The Commissioner may waive the requirements of this subdivision or any part thereof for recognized demonstration projects to effect the development of additional knowledge and experience in different types of assessments for long term care patients.

Effective Date: 
Wednesday, December 12, 2018
Doc Status: 
Complete

Section 763.8 Reserved

Section 763.9 Reserved

Section 763.10 Reserved

Section 763.11 - Governing authority

763.11 Governing authority. (a) The governing authority of the agency shall be responsible for the management, operation and evaluation of the agency and shall:

(1) ensure compliance of the agency with the applicable federal, state and local statutes, rules and regulations;

(2) ensure adequate personnel resources to:

(i) effectively conduct administrative functions of the agency; and

(ii) provide care in the home, based on the needs of the persons served as specified in the plan of care;

(3) adopt the agency's budget, control assets and funds, and provide for annual fiscal audits;

(4) prohibit personnel paid directly by the agency from being reimbursed by any party other than the agency for services provided by the agency;

(5) prohibit the splitting or sharing of fees between a referral agency, facility, individual or other home care services agency and the agency;

(6) adopt and amend policies regarding management and operation of the agency and the provision of patient care services;

(7) enter into agreements and contracts, where applicable, to provide agency services or to assure services needed by the agency;

(8) ensure the development and implementation of a patient complaint procedure to include:

(i) documentation of receipt, investigation and resolution of any complaint, including maintenance of a complaint log indicating the dates of receipt and resolution of all complaints received by the agency;

(ii) review of each complaint, with a written response to all written complaints or oral complaints, if requested by the individual making the oral complaint, to be provided within 15 days of receipt of such complaint:

(a) describing the complaint investigation findings and the decisions rendered to date by the agency; and

(b) advising the complainant of the right to appeal the outcome of the agency's complaint investigation and the appeal procedure to be followed;

(iii) an appeals process with review by a member or committee of the governing authority within 30 days of receipt of the appeal; and

(iv) notification to the patient or his or her designee that if the patient is not satisfied by the agency's response, the patient may complain to the Department of Health's Office of Health Systems Management;

(9) provide an office facility or facilities equipped and sufficient in size to permit efficient conduct of business, including access to patient records by all personnel providing care and prompt telephone contact to and from patients, referral agencies or facilities, and other home care services agencies;

(10) ensure the development of a written emergency plan which is current and includes procedures to be followed to assure health care needs of patients continue to be met in emergencies which interfere with delivery of services and orientation of all employees to their responsibilities in carrying out such a plan;

(11) for certified home health agencies only, ensure the provision of charity care in each fiscal year of the agency in an amount no less than two percent (2%) of the total operating costs of the agency in that fiscal year for not-for-profit and for-profit agencies and agencies operated by public benefit corporations and three and one-third percent (3-1/3%) of total operating costs of the agency for public agencies. Charity care is care provided at no charge or reduced charge for the services the agency is certified to provide to patients who are unable to pay full charges, are not eligible for covered benefits under title XVIII or XIX of the Social Security Act, are not covered by private insurance, and whose household income is less than two hundred percent (200%) of the federal poverty level. Adjustments to the required percentages of charity care may be made by the department upon recommendation of the appropriate health systems agency to reflect significant county variations from the state average with respect to the proportion of indigent and medically uninsured persons to the total population; and

(12) ensure continuous quality improvement initiatives, by establishing and maintaining a coordinated quality assessment and assurance program which integrates the review activities of all home care services provided by the agency to enhance the quality of care and treatment. Quality improvement shall be the responsibility of all personnel, at every level, at all times. Supervisory personnel alone cannot ensure quality of care and services. Such quality must be part of each individual's approach to his or her daily responsibilities.

(13) appoint a group of professional personnel, which includes one or more physicians, registered professional nurses, and representatives of the professional therapeutic services provided by the agency to perform the activities required in subparagraph (ii) of this paragraph. The findings and recommendations of this group shall be integrated into the agency's quality assessment and assurance program described in paragraph 12 of this subdivision. (i) At least one member of the group shall be neither an owner nor an employee compensated by the agency.

(ii) The group of professional personnel shall participate in the annual evaluation of the agency's program and shall meet at least quarterly to:

(a) review policies pertaining to the delivery of the health care and services provided by the agency and, when revisions are indicated, recommend such policies to the governing authority for adoption;

(b) make recommendations to the governing authority on professional issues, including the adequacy and appropriateness of services based on an assessment of health care resources in the community, patients' needs, available reimbursement mechanisms and availability of qualified personnel;

(c) assist the agency in maintaining liaison with other health care providers in the community;and

(d) review a sample of both active and closed clinical records to determine whether established policies are followed in furnishing services directly or under arrangement; and

(14) ensure that, at least annually, an overall evaluation of the agency's program is conducted.

(i) Such evaluation shall be conducted by all of the following:

(a) the group of professional personnel (or a committee thereof) as described in paragraph (13) of this subdivision;

(b) agency personnel; and

(c) consumers or other professional persons outside the agency working in conjunction with consumers.

(ii) Such evaluation shall include but not be limited to:

(a) an overall policy and administrative review to include the extent to which the agency:

(1) meets service area needs, including underserved geographic areas;

(2) meets the needs of special populations, including persons with intense service needs; mentally, cognitively or physically disabled persons, and financially indigent persons; and

(3) coordinates patient care services with services provided by other community agencies and organizations; and

(b) a review of the results and outcomes of the clinical record review as specified in clause (d) of subparagraph (ii) of paragraph (13) of this subdivision.

(b) To assist the governing authority with executing the responsibilities specified in subdivision (a) of this section, the governing authority shall:

(1) appoint an administrator responsible for the day-to-day management of the agency.

(i) The administrator, who may also be the supervising physician or registered nurse, as specified in paragraph (2) of this subdivision, shall be responsible for the organization and direction of the agency's ongoing functions through, but not limited to:

(a) implementation of an effective budgeting and accounting system;

(b) determination of the number and types of personnel needed to meet the agency's responsibilities and recruitment of qualified personnel;

(c) ensuring a planned orientation of new personnel and provision for appropriate, regularly scheduled in-service education related to personnel responsibilities;

(d) ensuring an annual evaluation of personnel performance;

(e) maintenance of ongoing liaison among the governing authority, the group of professional personnel appointed as specified in paragraph (13) of subdivision (a) of this section, and agency personnel; and

(f) ensuring availability of public information concerning the health care services which the agency provides, the geographic area in which these services are made available, the charges for the various types of services and the payment sources which may be available to pay for such services;

(ii) For long term home health care programs or AIDS home care programs, administrative responsibilities may be assumed by the administrator of the sponsoring certified home health agency, hospital or nursing home;

(2) employ a director of patient services on a full time or part time basis who is responsible for clinical direction and supervision of patient care services. This person, or a qualified alternate, shall be available at all times during operating hours and shall participate in all activities relevant to the professional services furnished, including development of qualifications and the assignment of personnel; and

(3) delineate in writing the organizational lines of responsibility and accountability of the administrator, the supervising community health nurse or physician, the group of professional personnel appointed as specified in paragraph 13 of subdivision (a) of this section, other committees and agency personnel.

(c) Except when a management contract has been approved pursuant to this section, the governing authority may not delegate its responsibility for the operation of the agency to another organization, a parent or subsidiary corporation or through a managing authority contract. An improper delegation may be found to exist where the governing authority no longer retains authority over the operation and management of the agency, including but not limited to such areas as: (1) authority to hire or fire the administrator;

(2) authority for the maintenance and control of the books and records;

(3) authority over the disposition of assets and the incurring of liabilities on behalf of the agency; or

(4) authority over the adoption and enforcement of policies regarding the operation of the agency.

(d) If the governing authority enters into a management contract, the requirements of this subdivision shall be met.

(1) For the purpose of this section, a management contract is an agreement between an agency's governing authority and a managing authority for the purpose of managing the day-to-day operation of the agency of any portion thereof.

(2) Management contracts shall be effective only with the prior written consent of the Commissioner, and shall include the following:

(i) a description of the proposed roles of the governing authority and managing authority during the period of the proposed management contract. The description shall clearly reflect retention by the governing authority of ongoing responsibility for statutory and regulatory compliance;

(ii) a provision that clearly recognizes that the responsibilities of the agency's governing authority are in no way obviated by entering into the management contract, and that any powers not specifically delegated to the managing authority through the provisions of the contract remain with the governing authority;

(iii) a clear acknowledgement of the authority of the Commissioner to void the contract pursuant to paragraph (9) of this subdivision;

(iv) a plan for assuring maintenance of the fiscal stability, the level of service provided and the quality of care rendered by the agency during the term of the management contract;

(v) an acknowledgement that the costs of the contract are subject to all applicable provisions of Part 86 of this Title;

(vi) a requirement that the reports described in paragraph (10) of this subdivision will be provided to the department and to the governing authority annually for the term of the management contract;

(vii) an express representation that any management contract approved by the Commissioner is the sole agreement between the managing authority and the governing authority for the purpose of managing the day-to-day operation of the agency or any portion thereof, and that any amendments or revisions to the management contract shall be effective only with the prior written consent of the Commissioner; and

(viii) a provision that includes the terms of paragraph (8) of this subdivision.

(3) No management contract shall be approved if the governing authority does not retain sufficient authority and control to discharge its responsibility as the certified operator. The following elements of control shall not be delegated to a managing authority;

(i) direct independent authority to hire or fire the administrator;

(ii) independent control of the books and records;

(iii) authority over the disposition of assets and the authority to incur on behalf of the agency liabilities not normally associated with the day-to-day operation of an agency; and

(iv) independent adoption of policies affecting the delivery of health care services.

(4) In addition to a proposed written contract complying with the provisions of paragraph (2) of this subdivision, a governing authority seeking to enter into a management contract shall submit to the department, at least 60 days prior to the intended effective date, unless a shorter period is approved by the Commissioner due to extraordinary circumstances, the following:

(i) documentation indicating that the proposed managing authority holds all necessary approvals to do business in New York State;

(ii) documentation of the goals and objectives of the management contract, including a mechanism for periodic evaluation of the effectiveness of the arrangement in meeting these goals and objectives;

(iii) evidence of the managing authority's financial stability.

(iv) information necessary to determine that the character and competence of the proposed managing authority, and its principals, officers and directors, are satisfactory, including evidence that all agencies or health care facilities managed or operated, in or outside of New York State, have provided a high level of care; and

(v) evidence that it is financially feasible for the agency to enter into the proposed management contract, recognizing that the costs of the contract are subject to all applicable provisions of Part 86 of this Title.

(5) During the period between an agency's submission of a request for approval of a management contract and disposition of that request, an agency may not enter into any arrangement for management contract services other than a written interim consultative agreement with the proposed managing authority. Any interim agreement shall reflect consistency with the provisions of this section, and shall be submitted to the department no later than five days after its effective date. (6) The term of a management contract shall be limited to three years and may be renewed only when authorized by the Commissioner, provided compliance with this section and the following provisions can be demonstrated:

(i) that the goals and objectives of the contract have been met within specified timeframes;

(ii) that the quality of care provided by the agency during the term of the contract has been maintained or has improved; and

(iii) that the reporting requirements contained in paragraph (10) of this subdivision have been met.

(7) Any application for renewal shall be submitted at least 90 days prior to the expiration of the existing contract.

(8) An agency's governing authority shall, within the terms of the contract, retain the authority to discharge the managing authority and its employees from their positions at the agency with or without cause on not more than 90 days' notice. In such event, the agency shall notify the department in writing at the time the managing authority is notified. The agency's governing authority shall provide a plan for the operation of the agency subsequent to the discharge, to be submitted with the notification to the department.

(9) A management contract shall terminate and be deemed cancelled, without financial penalty to the governing authority, not more than 60 days after notification to the parties by the department of a determination that the management of the agency is so deficient that the health and safety of patients would be threatened by continuation of the contract.

(10) Each managing authority shall submit annual reports to the department and the governing authority providing measurements of agency performance in the following areas:

(i) financial operations, including a balance sheet, any change in financial position, and a statement of revenues and expenses sufficient to determine liquidity, working capital, net operating margin and age, extent and type of payables and receivables;

(ii) personnel; and

(iii) services delivered.

(e) Franchise agreements. (1) For purposes of this subdivision, a franchise agreement means a contract or agreement between an agency's governing authority (franchisee) and a franchisor by which:

(i) the governing authority is granted the right to engage in the business of offering home care services under a marketing plan or system developed in substantial part by a franchisor, and the governing authority is required to pay, directly or indirectly, a franchise fee; or

(ii) the governing authority is granted the right to engage in the business of offering home care services associated substantially with the franchisor's trademark, service mark, trade name, logotype, advertising, or other commercial symbol designating the franchisor or its affiliate, and the governing authority is required to pay, directly or indirectly, a franchise fee.

(2) A governing authority may enter into a franchise agreement if the requirements of this subdivision are met. A franchise agreement which has been approved by the department prior to the effective date of this subdivision need not be amended further in order to meet the specific requirements of this subdivision. A franchise agreement entered into on or after the effective date of this subdivision shall be effective only with the prior written consent of the Commissioner. A governing authority seeking to enter into a franchise agreement shall submit to the department a copy of the proposed agreement complying with the provisions of this section at least 60 days prior to the intended effective date, unless a shorter period is approved by the Commissioner due to extraordinary circumstances. The department shall review proposals expeditiously and shall notify the governing authority of any changes that must be made. Such agreements shall include the following:

(i) a description of the proposed roles of the governing authority and franchisor during the period of the proposed agreement. The description shall reflect clearly the governing authority's ongoing responsibility for the operation and management of the agency and for compliance with all statutory and regulatory requirements;

(ii) a provision which recognizes clearly that the responsibilities of the agency's governing authority are in no way lessened by entering into the agreement and that the governing authority has full legal authority over the operation and management of the agency, and that the governing authority retains the right and authority to independently adopt, amend and implement policies and procedures regarding the operation of the agency in order to ensure the provision of quality home care services and that the agency is operated in compliance with all applicable statutes and regulations; (iii) a provision which recognizes that the policies, standards, procedures, manuals and other documents developed by the franchisor which relate to the operating standards, policies and procedures for the agency shall be available for inspection and copying by the department in accordance with the department's statutory and regulatory authority. Such documents, when received by the department, shall be subject to the relevant provisions of the Freedom of Information Law including, if applicable, provisions relating to excepting from disclosure documents which are trade secrets or are maintained for the regulation of commercial enterprise which if disclosed would cause substantial injury to the competitive position of the subject enterprise.

(iv) an express representation that any franchise agreement approved by the Commissioner is the sole franchise agreement between the franchisor and the governing authority for the agency, or any portion thereof, relating to the geographic service area that is covered by the franchise agreement.

(3) A franchise agreement shall not be approved if the governing authority does not retain sufficient authority and control to discharge its responsibilities as the agency operator. The following elements of control shall not be delegated to a franchisor:

(i) authority to hire of fire agency personnel;

(ii) control of the agency's books and records;

(iii) authority over the disposition of assets or the authority to incur liabilities on behalf of the agency; and

(iv) sole authority for the independent adoption of policies and procedures affecting the delivery of health care services. Although the governing authority may agree to adopt and utilize policies and procedures developed by the franchisor, the governing authority must retain authority to independently adopt, amend and implement policies and procedures regarding the operation of the agency in order to ensure the provision of quality home care services and that the agency is operated in compliance with all applicable statutes and regulations.

(4) An agreement which contains elements of both a franchise agreement and a management contract shall be subject to the applicable provisions of this subdivision and subdivisions (c) and (d) of this section. (f) Health Provider Network Access and Reporting Requirements. The governing authority of an agency shall obtain from the Department’s Health Provider Network (HPN), HPN accounts for each agency it operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven-day a week contacts for emergency communication and alerts, must be designated by each agency in the HPN Communications Directory. A policy defining the agency’s HPN coverage consistent with the agency’s hours of operation shall be created and reviewed by the agency no less than annually. Maintenance of each agency’s HPN accounts shall consist of, but not be limited to, the following: (1) sufficient designation of the facility’s HPN coordinator(s) to allow for HPN individual user application; (2) designation by the governing authority of an agency of sufficient staff users of the HPN accounts to ensure rapid response to requests for information by the State and/or local Department of Health; (3) adherence to the requirements of the HPN user contract; and (4) current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis.

Effective Date: 
Wednesday, November 2, 2005
Doc Status: 
Complete

Section 763.12 - Contracts

763.12 Contracts.

(a) The governing authority may enter into contracts with individuals, organizations, agencies or facilities, when necessary, to provide or obtain those services required by patients. Such contracts shall specify:

(1) the contracting parties' agreements, including, but not limited to:

(i) the services to be provided;

(ii) the manner in which services will be supervised and evaluated;

(iii) charges, reimbursement and other financial arrangements; and

(iv) any provisions made for indemnification between the agency and the contract provider;

(2) that contracted personnel meet the personnel requirements as set forth in section 763.13 of this Part, which can be verified by written documented evidence and examined by the agency and the department on request;

(3) that services provided to the patient by contract shall be in accordance with the plan of care developed by the agency in consultation with all providers of care, as appropriate, and that the contracting party agrees to abide by the patient care policies established by the agency;

(4) that nurses or therapists providing care and services under individual contract with the agency or as personnel of another contracted agency maintain liaison to assure that care planning and service delivery provided by such individuals is coordinated, supervised and integrated effectively into the patient services responsibilities required by this Part;

(5) that the agency to which the patient is admitted retains ultimate responsibility for coordination and provision of patient care;

(6) that the contracting party agrees to permit any personnel providing patient care to participate in patient care conferences upon request of the agency;

(7) that the contracting party submits patient clinical record entries, progress notes, visit schedules and periodic patient evaluations to the agency as frequently and promptly as necessary but at least within 12 calendar days of each visit to reflect:

(i) the current condition and progress of the patient; and

(ii) effective reporting and coordination of patient care between the agency and contract personnel; and

(8) the following terms and conditions: "Notwithstanding any other provisions in this contract, the agency remains responsible for:

(i) ensuring that any service provided pursuant to this contract complies with all pertinent provisions of Federal, State and local statutes, rules and regulations;

(ii) planning, coordinating and ensuring the quality of all services provided; and

(iii) ensuring adherence to the plan of care established for patients."

(b) The agency shall retain sole authority for the admission and discharge of patients. (c) A certified home health agency shall provide to a sub-contracting licensed home care services agency all information to allow such licensed home care services agency to meet the financial and statistical reporting requirements of section 766.12(c)(1) of this Part.
 

Effective Date: 
Wednesday, June 4, 2008
Doc Status: 
Complete

Section 763.13 - Personnel

763.13 Personnel. The agency shall ensure for all personnel:

(a) the development and implementation of written personnel policies and procedures, which are reviewed and revised as necessary;

(b) (1) that qualifications as specified in section 700.2 of this Title are met; (i) that the information required by Public Health Law section 3613(3)(a)-(f) has been entered into the home care services worker registry in accordance with Part 403 of this Title; and (ii) a criminal history record check to the extent required by section 400.23 and Part 402 of this Title.

(c) that the health status of all new personnel is assessed prior to assuming patient care duties. The assessment 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 agency shall require the following of all personnel prior to assuming patient care duties:

(1) a certificate of immunization against rubella which means:

(i) 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

(ii) a document indicating one dose of live virus rublella vaccine was administered on or after the age of twelve months, showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization, or

(iii) a copy of the document described in subparagraph (i) or (ii) of this paragraph which comes from a previous employer or the school which the individual attended as a student; and

(2) a certificate of immunization against measles for all personnel born on or after January 1, 1957, which means:

(i) 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

(ii) a document indicating two doses of live virus measles vaccine were administered with the first dose administered on or after the age of 12 months and the second dose administered more than 30 days after the first does 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

(iii) a document, indicating a diagnosis of the person as having had measles disease prepared by the physician, physician's assistant/specialist's assistant, licensed midwife or nurse practitioner who diagnosed the person's measles; or

(iv) a copy of the document described in subparagraph (i), (ii) or (iii) of this paragraph which comes from a previous employer or the school which the person attended as a student;

(3) 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 person's health, the requirements of paragraphs (1) and (2) of this subdivision relating to measles and/or rubella immunization shall be inapplicable until such immunization is found no longer to be detrimental to such person's health. The nature and duration of the medical exemption must be stated in the individual's personnel record and must be in accordance with generally accepted medical standards (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); and

(4) either tuberculin skin test or Food and Drug Administration (FDA) approved blood assay for the detection of latent tuberculosis infection, prior to assuming patient care duties and no less than every year thereafter for negative findings. Positive findings shall require appropriate clinical follow-up but no repeat tuberculin skin test or blood assay. The agency shall develop and implement policies regarding follow-up of positive test results;

(5) 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.

(d) that the health status of all personnel be reassessed 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;

(e) that a record of all tests, examinations, health assessments and immunizations required by this section is maintained for all personnel who have direct patient contact;

(f) that personal identification is produced by each applicant for employment and verified by the agency prior to hiring of an applicant by the agency;

(g) that prior to patient contact, employment histories from previous employers, if applicable, and recommendations from other persons unrelated to the applicant if not previously employed, are verified;

(h) that personnel records include, as appropriate, records of professional licenses and registrations; verifications of employment history and qualifications for the duties assigned; signed and dated applications for employment; records of physical examinations and health status assessments; performance evaluations; dates of employment, resignations, dismissals, and other pertinent data, provided that all documentation and information pertaining to an employee's medical condition or health status, including such records of physical examinations and health status assessments shall be maintained separate and apart from the non-medical personnel record information and shall be afforded the same confidential treatment given patient medical records under section 763.7 of this Part;

(i) that time and payment records are maintained for all personnel;

(j) that there is a current written job description for each position which delineates responsibilities and any specific education, licensure and experience requirements;

(k) that an annual assessment of the performance and effectiveness of each person is conducted and documented in writing, including at least one home visit to observe performance if the person provides services in the home; and

(l) that all personnel receive orientation to the policies and procedures of the agency operation, inservice education necessary to perform his/her responsibilities and continuing programs for development and support. At a minimum:

(1) home health aides shall participate in 12 hours of inservice education per year;

(2) personal care aides shall participate in six hours of inservice education per year; and

(3) advanced home health aides must participate in 18 hours of in-service education per year, which must include medication management, infection control, and injection safety, and which must be directly supervised by a registered professional nurse.

(m)(1) that a program is implemented for the prevention of personnel or patients/clients becoming exposed to significant risk body substances which could put them at significant risk of HIV or other blood-borne pathogen infection as defined in sections 63.1 and 63.9 of this Title. Such a program shall include:

(i) use of scientifically accepted protective barriers during job-related activities which involve, or may involve, exposure to significant risk body substances. Such preventive action shall be taken by personnel with each patient/client and shall constitute an essential element for the prevention of bi-directional spread of HIV or other blood-borne pathogen;

(ii) use of scientifically accepted preventive practices during job-related activities which involve the use of contaminated instruments or equipment which may cause puncture injuries;

(iii) training at the time of employment and yearly personnel development programs on the use of protective equipment, preventive practices, and circumstances which represent a significant risk for all personnel whose job-related tasks involve, or may involve, exposure to significant risk body substances;

(iv) provision of personal protective equipment for personnel which is appropriate to the tasks being performed;

(v) a system for monitoring preventive programs to assure compliance and safety.

(2) that policies and procedures are implemented and enforced for the counseling, support and health care management of individuals who are exposed to significant risk body substances under circumstances which constitute significant risk of transmitting or contracting HIV or other blood-borne pathogen infection. They shall include:

(i) a system for reporting to a designated individual in the agency exposure thought to be a circumstance which constitutes significant risk of transmitting or contracting HIV or other blood-borne pathogen infection.

(ii) evaluation of the circumstances of a reported exposure and services for providing follow-up of the exposed individual which includes:

(a) medical and epidemiological assessment of the individual who is the source of the exposure, where that individual is known and available;

(b) if indicated epidemiologically, HIV or other blood-borne pathogen counseling and voluntary testing of the source individual. Disclosure of the HIV status of the source individual can be made with the express written consent of the protected individual, or a person authorized pursuant to law to consent to health care for the protected individual if such person lacks capacity to consent, or pursuant to court order, if the HIV status is not known to the exposed individual;

(c) appropriate medical follow-up of the exposed individual;

(iii) ensuring protection of confidentiality for those involved in reported exposures.

Effective Date: 
Wednesday, December 12, 2018
Doc Status: 
Complete

Section 763.14 - Records and reports

763.14 Records and reports.

(a) The governing authority shall ensure that:

(1) copies of the following current records are retained on file at the principal administrative office of the agency within its approved geographic service area:

(i) the certificate of incorporation and any amendments thereto, the partnership agreement and the certificate of doing business under an assumed name, if applicable;

(ii) the operating certificate;

(iii) all contracts and other agreements pertaining to the operation of the agency;

(iv) rules and bylaws of the governing authority and/or other authority, if applicable;

(v) operating policies and procedures and relevant determinations and interpretations;

(vi) a patient roster;

(vii) a listing of all personnel;

(viii) copies of all notices and documents required to be filed with the Securities and Exchange Commission; and

(ix) any other licenses, permits and certificates required by law for the operation of the agency;

(2) copies of the documents required under subparagraphs (1)(v), (vi) and (vii) of this subdivision are retained at each branch office of the agency. The listing of personnel and patients should be specific to each branch office;

(3) the following reports and records are retained by the agency and copies are furnished to the department immediately upon request:

(i) minutes of the meetings of the governing authority and the committees thereof which shall be retained for three years from the date of the meeting;

(ii) records of all financial transactions which shall be retained eight years from the date of the transaction;

(iii) personnel records, which shall be retained six years from the date of termination or resignation;

(iv) records of grievances, complaints and appeals, which shall be retained three years from resolution;

(v) all records related to patient care and services; and

(vi) other such records and reports as may be required by the department.

(4) all records required by paragraph (3) of this subdivision to be retained are maintained in hard copy or electronic form. If electronic storage is maintained, such records shall:

(i) be secure from unwarranted access;

(ii) have confidentiality protected, when appropriate; and

(iii) be immediately available to the agency and the department in hard copy format upon request.

(b) The agency shall furnish annually to the department a copy of:

(1) the listing of charges for all services offered;

(2) statistical summaries of all services provided, including patient specific information and discharge summary data;

(3) if a for-profit corporation, a list of the directors, officers and principal shareholders and the number and percent of the total issued and outstanding shares of the corporation held by each, duly certified by the secretary of the corporation as to completeness and accuracy;

(4) if a not-for-profit corporation, a list of corporate members, directors and officers; and

(5) other such records and reports as may be required by the department.
 

Effective Date: 
Wednesday, March 23, 1994
Doc Status: 
Complete