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Title: Section 404.8 - Policies and Procedures

Effective Date


Section 404.8 Policies and Procedures

An integrated services provider shall have written policies, procedures, and methods governing the provision of services to patients, including a description of each service provided. These policies, procedures, and methods shall be reviewed annually and revised as necessary. They shall address, at a minimum, the following:

(a) admission criteria;

(b) evaluations and treatment plans;

(c) screening for substance use disorder, mental health, and/or physical health issues;

(d) the provision of medical services, including screening and referral for associated physical or behavioral health conditions;

(e) how to ensure prompt follow-up action on patients with abnormal test results or physical findings;

(f) identification of specific support and ancillary providers, where appropriate, and methods for coordinating such service delivery;

(g) appropriate transfer and referral procedures to and from other services;

(h) discharge criteria;

(i) procedures for handling patient emergencies and identification of available off-hour emergency services seven days per week, 24 hours per day, including, but not limited to, detoxification, withdrawal and acute psychiatric services;

(j) how to ensure that staff are prepared to care for emergencies in accordance with the services provided at the host site, and necessary emergency equipment is maintained in working order;

(k) the continuity of care, including regular participation of all integrated care services staff in case conferences, in-service training and staff meetings;

(l) the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations;

(m) for providers providing primary care, policies and procedures for investigating, controlling and preventing infections in the host site. The policies and procedures shall include those for:

(1) isolating patients with communicable or infectious diseases or patients suspected of having such diseases;

(2) training all personnel rendering care to such patients in the employment of standard infection control techniques;

(3) obtaining periodic reports of health care associated infections (health care associated infections shall include an increased incidence or outbreak of disease due to biological, chemical or radioactive agents or their toxic products occurring in patients or persons working in the host site); and

(4) reporting immediately to the department, in a manner specified by the commissioner, the presence of health care associated infections
;and to the city, county or district health officer where the host site is located, the presence of any communicable disease as defined in section 2.1 of Title 10 NYCRR (State Sanitary Code);

(n) public health education and screening with regard to tuberculosis, sexually transmitted diseases, hepatitis, and HIV/AIDS prevention and harm reduction; and

(o) the requirement of the mandatory offer of HIV testing in accordance with section 2781-a of Article 27-F of the Public Health Law.


VOLUME C (Title 10)