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Title: Section 751.5 - Operating policies and procedures

Effective Date


751.5 Operating policies and procedures. The operator shall ensure:

(a) the development and implementation of policies and procedures written in accordance with prevailing standards of professional practice which include but are not limited to:

(1) the provision of service(s) without regard to age, race, color, sexual orientation, marital status, religion, sex, national origin or sponsor;

(2) provisions for communicating with patients who exhibit a communication barrier;

(3) a method for promptly handling patient complaints;

(4) the provision for continuing care by the same health care practitioner, when ever possible;

(5) ensuring prompt follow-up action on patients with abnormal test results or physical findings;

(6) the referral to a health-care facility or health-care practitioner for service(s) not available at the center;

(7) the prompt transfer of a copy of the pertinent parts of the medical record and other information, with the patient's written consent, when the patient is referred to another health-care facility or health-care practitioner;

(8) the identification, assessment, and appropriate treatment or referral of individuals who are suspected to be human trafficking victims, as that term is defined in section 483-aa of the Social Services Law and used in Article 10-D of the Social Services Law; training in the recognition of indicators of a human trafficking victim and the responsibilities of such personnel in dealing with persons suspected as human trafficking victims, the reporting of individuals who are suspected to be human trafficking victims and are under eighteen years old as abused or maltreated children if required under Title 6 of Article 6 of the Social Services Law; and the posting of the human trafficking hotline poster issued by the National Human Trafficking Resources Center, or a variation of such poster created by the Office of Temporary and Disability Assistance (OTDA) consistent with section 483-ff of the Social Services Law, whichever OTDA makes available on its website, in conspicuous locations near primary public entrances and where other posters and notices are posted;

(9) the identification, assessment, reporting and referral of cases of suspected child abuse or maltreatment and identification and treatment of victims of domestic violence;

(10) the identification, of patients' medically related personal and social problems which may interfere with the patients' treatment, recovery or rehabilitation;

(11) the establishment and implementation, in consultation with a qualified social worker, of a plan, consistent with available community and center resources, to provide or arrange for the provision of social work, psychological and health educational services that may be necessary to meet the treatment goals of its patients;

(12) if social work services are provided onsite by the center, the service must be under the direction of a qualified social worker and must be provided in accordance with all applicable requirements set forth in section 752.1 of this Title;

(13) the designation of a member of the center staff to be specifically assigned to implement policies and procedures for the coordination of the services of the center with the services of community health facilities and programs and community social agencies;

(14) the operation, maintenance and security of the center;

(15) ensuring that emergency equipment and staff prepared to care for emergencies are provided in accordance with the services provided at the center, and equipment is maintained in working condition;

(16) the granting of access to his/her health-care records to a patient or other qualified person in accordance with the provisions of section 18 of the Public Health Law and Subpart 50-3 of this Title; and

(17) if prenatal services are provided onsite, the center must ensure that the pregnant woman is provided HIV counseling and that voluntary HIV testing is recommended. Counseling and/or testing, if accepted, shall be provided pursuant to Public Health Law Article 27-F. Information regarding the woman's HIV counseling and HIV status must be transferred as part of her medical history to the delivering facility. Women with positive test results shall be referred to the necessary health and social services within a clinically appropriate time.

(b) the center's policies and procedures are available to all center personnel; and

(c) that the center's policies and procedures are reviewed at least annually and revised as necessary.


VOLUME E (Title 10)