N.Y. Comp. Codes R. & Regs. tit. 10 § 404.12

Current through Register Vol. 46, No. 45, November 2, 2024

Section 404.12 - Staffing

(a) Personnel. The governing authority shall ensure the employment of personnel without regard to age, race, color, sexual orientation, religion, sex or national origin. A personnel file shall be maintained for each employee.

(b) Integrated services programs that are providing primary care services shall ensure that:

(1) the health status of each employee is examined prior to the beginning of employment, which is sufficient in scope to ensure that the employee is free from a health impairment which is of potential risk to patients or which may interfere with the performance of his/her duties;

(2) a record of the following tests, procedures and examinations is maintained for all employees:

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

(a) 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 Title 10 of the New York Codes of Rules and Regulations, demonstrating serologic evidence of rubella antibodies;

(b) a document indicating one dose of live virus rubella vaccine was administered on or after the age of 12 months, showing the product administered and the date of administration, and prepared by the health practitioner who administered the immunization; or

(c) a copy of a document described in clause (a) or (b) of this subparagraph which comes from a previous employer or the school which the employee attended as a student; and

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

(b) 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 dose 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

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

(d) a copy of a document described in clause (a), (b) or (c) of this subparagraph which comes from a previous employer or the school which the employee attended as a student;

(iii) if any licensed physician, physician's assistant/specialist's assistant, licensed midwife or nurse practitioner certifies that immunization with measles or rubella vaccine may be detrimental to the employee's health, the requirements of subparagraph (i) and/or (ii) of this paragraph relating to measles and/or rubella immunization shall be inapplicable until such immunization is found no longer to be detrimental to such employee's health. The nature and duration of the medical exemption must be stated in the employee's employment medical record and must be in accordance with generally accepted medical standards, (see, 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

(iv) for all personnel prior to employment or affiliation, except for personnel with no clinical or patient contact responsibilities who are located in a building or site with no patient care services, an initial individual tuberculosis (TB) risk assessment, symptom evaluation, and TB test (either tuberculin skin test or Food and Drug Administration (FDA) approved blood assay for the detection of latent tuberculosis infection), and annual assessments thereafter. Positive findings shall require appropriate clinical follow-up. The medical staff shall develop and implement policies regarding positive findings, including procedures for facilitating and documenting treatment for latent TB infection where indicated. Annual TB assessment shall include education, individual risk assessment, and follow-up tests as indicated;

(v) an annual, or more frequent if necessary, health status reassessment to assure freedom from a health impairment which is a potential risk to the patients or might interfere with the performance of duties; and

(vi) 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 Title 10 of the New York Codes of Rules and Regulations.

(3) each person delivering health care services wears identification indicating his/her name and title.

(c) Medical Director.

(1) Integrated services providers providing primary care services shall have a medical director. The governing authority shall be responsible for appointing a medical director who:

(i) is qualified by training, experience, and administrative ability;

(ii) is a physician licensed by and currently registered with the New York State Education Department;

(iii) develops and recommends to the governing authority policies and procedures governing patient care, medical staff and clinical privileges; and

(iv) is responsible for the supervision of the quality assurance program and reporting to the governing authority.

(2) Integrated services providers providing substance use disorder services, shall have a medical director who, unless such medical director was in place on July 1, 2011:

(i) holds at least one of the following certifications:

(a) a subspecialty board certification in addiction psychiatry from the American Board of Medical Specialties;

(b) an addiction certification from the American Society of Addiction Medicine; or

(c) a certification by the American Board of Addiction Medicine (ABAM); or

(d) a subspecialty board certification in Addiction Medicine from the American Osteopathic Association; and

(ii) possesses a Federal DATA 2000 waiver (buprenorphine-certified).

In lieu of employing a medical director meeting these requirements, the integrated services provider providing substance use disorder services may have a consultation agreement with a full- or part-time physician who meets the requirements of this paragraph.

N.Y. Comp. Codes R. & Regs. Tit. 10 § 404.12

Adopted, New York State Register December 31, 2014/Volume XXXVI, Issue 52, eff. 1/1/2015

Amended New York State Register December 16, 2020/Volume XLII, Issue 50, eff. 12/16/2020