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Title: Section 405.7 - Patients' rights

Effective Date

12/31/2013

405.7 Patients' rights. The hospital shall ensure that all patients including inpatients, outpatients and emergency service patients, are afforded their rights as set forth in subdivision (b) of this section. The hospital's responsibility for assuring patients' rights includes both providing patients with a copy of these rights as set forth in subdivision (c) of this section and providing assistance to patients to understand and exercise these rights. Each general hospital patient who has been removed but not discharged from a hospital for the mentally ill operated or licensed under the Mental Hygiene Law shall maintain his or her status and rights as a patient pursuant to article 9 of the State Mental Hygiene Law and 14 NYCRR part 527 (Rights of Patients).

(a) Procedural requirements. In order to assure that patients are made aware of, understand and can exercise their rights, the hospital shall meet the following requirements:

(1) each patient or the patient representative shall be given a copy of their rights as set forth in subdivision (c) of this section at the time of admission;

(2) for outpatients and emergency service patients, copies of these rights shall be provided to each patient or his/her representative;

(3) a copy of these rights shall also be posted in clearly viewed areas of the hospital, at readable heights, including the admitting office, patient floors and outpatient department and the emergency service waiting areas;

(4) inservice training shall be provided to all patient care staff to assure their knowledge and understanding of patients' rights requirements;

(5) the hospital shall communicate effectively to each inpatient or patient representative after admission an explanation of those rights and provide information on how these rights can be exercised. Patients shall be offered a choice at admission to have or to decline an in-person explanation of these rights. The hospital shall maintain documentation of such communication;

(6) the hospital shall make available designated staff to answer questions regarding patients' rights for outpatients and emergency service patients. Patients shall be notified of the availability of these services; and

(7) the hospital shall develop a Language Assistance Program to ensure meaningful access to the hospital’s services and reasonable accommodation for all patients who require language assistance. Program requirements shall include:

(i) the designation of a Language Assistance Coordinator who shall report to the hospital administration and who shall provide oversight for the provision of language assistance services;

(ii) policies and procedures that assure timely identification and ongoing access for patients in need of language assistance services;

(iii) the development of materials that will be made available for patients and potential patients that summarize the process and method to access free language assistance services;

(iv) ongoing education and training for administrative, clinical and other employees with direct patient care contact regarding the importance of culturally and linguistically competent service delivery and how to access the hospital’s language assistance services on behalf of patients;

(v) signage, as designated by the Department of Health, regarding the availability of free language assistance services in public entry locations and other public locations;

(vi) identification of language of preference and language needs of each patient upon initial visit to the hospital;

(vii) documentation in the medical record of the patient’s language of preference, language needs, and the acceptance or refusal of language assistance services;

(viii) a provision that family members, friends, or non-hospital personnel may not act as interpreters, unless:

(a) the patient agrees to their use;

(b) free interpreter services have been offered by the hospital and refused; and

(c) issues of age, competency, confidentiality, or conflicts of interest are taken into account. Any individual acting as an interpreter should be 16 years of age or older; individuals younger than 16 years of age should only be used in emergent circumstances and their use documented in the medical record.

(ix) management of a resource of skilled interpreters and persons skilled in communicating with vision and/or hearing impaired individuals;

(a) interpreters and persons skilled in communicating with vision and/or hearing impaired individuals shall be available to patients in the inpatient and outpatient setting within 20 minutes and to patients in the emergency service within 10 minutes of a request to the hospital administration by the patient, the patient’s family or representative or the provider of medical care. The Commissioner of Health may approve time limited alternatives to the provisions of this subparagraph regarding interpreters and persons skilled in communicating with vision and/or hearing impaired individuals for patients of rural hospitals; which:

(1) demonstrate that they have taken and are continuing to take all reasonable steps to fulfill these requirements but are not able to fulfill such requirements immediately for reasons beyond the hospital’s control; and

(2) have developed and implemented effective interim plans addressing the communications needs of individuals in the hospital service area.

(x) an annual needs assessment utilizing demographic information available from the United State Bureau of the Census, hospital administrative data, school system data, or other sources, that will identify limited English speaking groups comprising more than one percent of the total hospital service area population. Translations/transcriptions of significant hospital forms and instructions shall be regularly available for the languages identified by the needs assessment; and

(xi) reasonable accommodation for a family member or patient’s representative to be present to assist with the communication assistance needs for patients with mental and developmental disabilities.

(b) Hospital responsibilities. The hospital shall afford to each patient the right to:

(1) exercise these rights regardless of the patient's language or impairment of hearing or vision. Skilled interpreters shall be provided to assist patients in using these rights;

(2) treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, age, or source of payment;

(3) considerate and respectful care in a clean and safe environment;

(4) receive emergency medical care as indicated by the patient's medical condition upon arrival at the hospital;

(5) limit the use of physical restraints to those patient restraints authorized in writing by a physician after a personal examination of the patient, for a specified and limited period of time to protect the patient from injury to himself or to others. In an emergency, the restraint may be applied only by or under the supervision of and at the direction of a registered professional nurse who shall set forth in writing the circumstances requiring the use of restraints. In such emergencies, a physician shall be immediately summoned and pending the arrival of the physician, the patient shall be kept under continuous supervision as warranted by the patient's physical condition and emotional state. At frequent intervals while restraints are in use the patient's physical needs, comfort and safety shall be monitored. An assessment of the patient's condition shall be made at least once every 30 minutes or at more frequent intervals if directed by a physician;

(6) the name of the medical staff member who has the responsibility for coordinating his/her care and the right to discuss with his/her practitioner the type of care being rendered;

(7) the name, position and function of any person providing treatment to the patient;

(8) obtain from the responsible medical staff member complete current information concerning his/her diagnosis, treatment and prognosis in terms the patient can be reasonably expected to understand. The patient shall be advised of any change in health status, including harm or injury, the cause for the change and the recommended course of treatment. The information shall be made available to an appropriate person on the patient's behalf and documented in the patient's medical record, if the patient is not competent to receive such information;

(9) receive information necessary to give informed consent prior to the start of any nonemergency procedure or treatment or both. An informed consent shall include, as a minimum, the specific procedure or treatment or both, the reasons for it, the reasonably foreseeable risks and benefits involved, and the alternatives for care or treatment, if any, as a reasonable practitioner under similar circumstances would disclose. Documented evidence of such informed consent shall be included in the patient's medical record;

(10) refuse treatment to the extent permitted by law and to be informed of the reasonably forseeable consequences of such refusal;

(11) receive from the responsible medical staff or designated hospital representatives information necessary to give informed consent prior to the withholding of medical care and treatment;

(12) privacy consistent with the provision of appropriate care to the patient;

(13) confidentiality of all information and records pertaining the the patient's treatment, except as otherwise provided by law;

(14) a response by the hospital, in a reasonable manner, to the patient's request for services customarily rendered by the hospital consistent with the patient's treatment;

(15) be informed by the responsible medical staff member or appropriate hospital staff of the patient's continuing health care requirements following discharge, and before any transfer to another facility, all relevant information about the need for and all reasonable alternatives to such a transfer;

(16) prior to discharge, receive an appropriate written discharge plan and a written description of the patient discharge review process available to the patient under Federal or State law;

(17) the identity of any hospital personnel including students that the hospital has authorized to participate in the patient's treatment and the right to refuse treatment, examination and/or observation by any personnel;

(18) refuse to participate in research and human experimentation in accordance with Federal and State law;

(19) examine and receive an explanation of his/her bill, regardless of source of payment;

(20) be informed of the hospital rules and regulations that apply to a patient's conduct;

(21) be admitted to a nonsmoking area;

(22) register complaints and recommend changes in policies and services to the facility's staff, the governing authority and the New York State Department of Health without fear of reprisal;

(23) express complaints about the care and services provided and to have the hospital investigate such complaints. The hospital shall provide the patient or his/her designee with a written response if requested by the patient indicating the findings of the investigation. The hospital shall notify the patient or his/her designee that if the patient is not satisfied with the hospital's oral or written response, the patient may complain to the New York State Department of Health's Office of Health Systems Management. The hospital shall provide the telephone number of the local area office of the Health Department to the patient;

(24) obtain access to his /her medical record pursuant to the provisions of Part 50 of this Title. The hospital may impose reasonable charges for all copies of medical records provided to patients, not to exceed costs incurred by the hospital. A patient shall not be denied a copy of his/her medical record solely because of inability to pay; and

(25) receive supportive services to meet the changing care needs of the patient and the patient's family/representative provided by qualified individuals who collectively have expertise in assessing the special needs of hospital patients and their families.

(c) Patient's Bill of Rights. For purposes of subdivision (a) of this section, the hospital shall utilize the following Patients' Bill of Rights:

Patients' Bill of Rights

As a patient in a hospital in New York State, you have the right, consistent with law, to:

(1) Understand and use these rights. If for any reason you do not understand or you need help, the hospital must provide assistance, including an interpreter.

(2) Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation, age, or source of payment.

(3) Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.

(4) Receive emergency care if you need it.

(5) Be informed of the name and position of the doctor who will be in charge of your care in the hospital.

(6) Know the names, positions, and functions of any hospital staff involved in your care and refuse their treatment, examination or observation.

(7) A no smoking room.

(8) Receive complete information about your diagnosis, treatment and prognosis.

(9) Receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.

(10) Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet "Do Not Resuscitate Orders - A Guide for Patients and Families."

(11) Refuse treatment and be told what effect this may have on your health.

(12) Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation.

(13) Privacy while in the hospital and confidentiality of all information and records regarding your care.

(14) Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge.

(15) Review your medical record without charge and obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay.

(16) Receive an itemized bill and explanation of all charges.

(17) Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital's response, you can complain to the New York State Health Department. The hospital must provide you with the Health Department telephone number.

(18) Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors.

(19) Make known your wishes in regard to anatomical gifts. You may document your wishes in your health care proxy or on a donor card, available from the hospital.

(d) Each hospital shall be required to post in a conspicuous place and provide a pediatric patient's parent or other medical decision maker with a copy of a Parent's Bill of Rights advising that, at a minimum and subject to laws and regulations governing confidentiality, that in connection with every hospital admission or emergency room visit:

(1) The hospital must ask each patient or the patient's representative for the name of his or her primary care provider, if known, and shall document such information in the patient's medical record.

(2) The hospital may admit pediatric patients only to the extent consistent with their ability to provide qualified staff, space and size appropriate equipment necessary for the unique needs of pediatric patients.

(3) To the extent possible given the patient's health and safety, the hospital shall allow at least one parent/guardian to remain with the patient at all times.

(4) All test results completed during the patient's admission or emergency room visit will be reviewed by a physician, physician assistant or nurse practitioner who is familiar with the patient's presenting condition.

(5) Patients may not be discharged from the hospital or the emergency room until any tests that could reasonably be expected to yield "critical value" results – results that suggest a life-threatening or otherwise significant condition such that it requires immediate medical attention – are reviewed by a physician, physician assistant (PA) and/or nurse practitioner (NP) and are communicated to the patient, his or her parents or other decision-makers, as appropriate.

(6) Patients may not be discharged until they receive a written discharge plan, which will also be verbally communicated to patients, their parents or other medical decision-makers, which will identify critical value results of laboratory or other diagnostic tests ordered during the patient's stay and identify any other tests that have not yet been concluded.

(7) The communication of critical value results and the discussion of the discharge plan must be accomplished in a manner that reasonably assures that the patient, their parents or other medical decision makers understand the health information provided in order to make appropriate health decisions.

(8) Hospitals shall provide all lab results to the patient's primary care provider, if known.

(9) A patient, his or her parent or other medical decision maker has the right to request information about the diagnosis, possible diagnoses that were considered and complications that could develop as well as information about any contact that was made with the patient's primary care provider.

(10) On discharge, the hospital must provide a patient, his or her parent or other medical decision maker a phone number that the patient, his or her parent or other medical decision maker could call for advice in the event that complications or questions arise.

Volume

VOLUME C (Title 10)

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