HIV AIDS Resource Guide/HIV-AIDS Resource Guide.iso/STAT/STATE/NY-AD-01.ASC

Text File | 1993-01-14 | 102KB | 2,373 lines

/* NEW YORK ADMINISTRATIVE CODE includes AIDS drug
assistance programs; health facilities for PWAs; adult day
care centers; home care and long term care; organ donor
screening; testing for state employees, inmates, and the
public; confidentiality; emergency chelters for homeless
PWAs; hospices; discrimination; insurance; alcoholism
facilities; needle exchange program; and clinical service
rates. It is presented in four parts. */

PART 83

CONFIDENTIALITY OF HIV AND AIDS RELATED INFORMATION

3.1  Purpose. It is the responsibility and the intent of the
State Department of Civil Service to adopt regulations
pursuant to the HIV and AIDS Related Information Act (Public
Health Law, article 27-F). All officers, employees and
agents of the department shall at all times maintain the
confidentiality of any HIV related information in their
possession, in accordance with the requirements of the
statute and these regulations.



83.2 Definitions. For the purposes of this Part:

(a)  The term department or Department of Civil Service
means the New York State Department of Civil Service.

(b)  The term AIDS means acquired immune deficiency
syndrome, as may be defined from time to time by the centers
for disease control of the United States Public Health
Service.

(c)  The term HIV infection means infection with the human
immunodeficiency virus or any other related virus identified
as a probable causative agent of AIDS.

(d)  The term HIV related illness means any illness that may
result from or may be associated with HIV infection.

(e)  The term HIV related test means any laboratory test or
series of tests for any virus, antibody, antigen or
etiologic agent whatsoever thought to cause or to indicate
the presence of HIV/AIDS.

(f)  The term confidential HIV related information means any
information concerning whether an individual has been the
subject of an HIV related test, or has HIV infection, HIV
related illness or AIDS, or information which identifies or
reasonably would identify an individual as having one or
more of such conditions, including information pertaining to
such individual's contacts.

(g)  The term contact means an identified spouse or sex
partner of the protected individual or a person identified
as having shared hypodermic needles or syringes with the
protected individual.

(h) The term significant risk of transmitting or contracting
HIV infection or significant risk includes the following
circumstances:

(1)  sexual contact which exposes a mucous membrane or
broken skin of  a noninfected individual to blood, semen or
vaginal secretions of an infected individual;

(2)  sharing of needles or other paraphernalia used for
preparing and injecting drugs between infected and
noninfected individuals;

(3)  the gestation, birthing or breast feeding of an infant
when the mother is infected with HIV;

(4)  transfusion or transplantation of blood, organs, or
other tissues obtained from an infected individual to an
uninfected individual, provided that such products have not
tested negatively for antibody or antigen and have not been
rendered noninfective by heat or chemical treatment;

(5)  other circumstances, not identified in paragraphs (1)
through (4) of this subdivision, during which a significant
risk body substance (other than breast milk) of an infected
person contacts mucous membranes (e.g., eyes, nose, mouth)
or nonintact skin (e.g., open wound, dermatitis, abraded
areas) or the vascular system of a non-infected person;

(6)  circumstances that constitute significant risk shall
not include:

(i)  exposure to urine, feces, sputum, nasal secretions,
saliva, sweat, tears or vomitus that does not contain
visible blood;

(ii) human bites where there is no direct blood to blood, or
blood to mucous membrane contact;

(iii)  exposure of intact skin to blood or any other body
substance; and

(iv)  occupational settings where individuals use
scientifically accepted barrier techniques and preventing
practices in circumstances which would otherwise pose a
significant risk.



83.3 Antidiscrimination.  (a)  It is the policy of the
department that the department and its officers, employees
and agents shall not discriminate against any individual by
virtue of his or her being identified as, or suspected of,
having AIDS, HIV infection, or HIV related illness.

(b)  The department will take appropriate steps to make its
officers, employees and agents aware of the department's
policy as set forth in this section. All officers, employees
and agents of the department shall act in a manner
consistent with this policy when performing their official
duties for the department.



83.4 Access to confidential HIV related information.  (a)
Employees or agents of the department are not to have access
to confidential HIV related information maintained by the
department except as part of their official duties.

(b)  Agents of the department may be authorized to have
access to confidential HIV related information maintained by
the department only when reasonably necessary to perform the
specific activities for which they have been designated as
agents of the department.



83.5 Confidentiality.  (a) No person who obtains
confidential HIV related information in the course of
performing his or her duties as an employee or agent of the
department may disclose such information except in
accordance with the provisions of the HIV and AIDS Related
Information Act (Public Health Law, article 27-F) and the
provisions of this Part.

(b)  Any disclosure, except disclosures to employees or
agents of the department where reasonably necessary to carry
out their official duties and to any person to whom
disclosure is mandated by a court of competent jurisdiction,
must be accompanied by the following written statement
prohibiting further disclosure: "This information has been
disclosed to you from confidential records which are
protected by State law. State law prohibits you from making
any further disclosure of this information without the
specific written consent of the person to whom it pertains,
or as otherwise permitted by law. Any unauthorized further
disclosure in violation of State law may result in a fine or
jail sentence or both. A general authorization for the
release of medical or other information is not sufficient
authorization to further disclosure."

(c)  All disclosures, except disclosures to employees and
agents as reasonably necessary to perform their official
duties, are to be appropriately documented in the case
folder of the protected individual, who shall be informed of
such disclosures upon request.

(d)  No flags on case folders, lists on walls, or other
similar displays shall be used to indicate clients with HIV
infection. This shall not be construed to prevent the
existence of specialized caseloads.

(e)  Confidential HIV related information shall not be
disclosed in response to a request under the Freedom of
Information Law (Public Officers Law, article 6) or in
response to a subpoena. A court order issued pursuant to
Public Health Law, section 2785 is required.

(f)  The department will take appropriate steps to make all
employees and agents aware of the provisions of the HIV and
AIDS Related Information Act (PHL, article 27-F) concerning
confidentiality of HIV related information and the
department's rules regarding confidentiality of records. All
authorized employees and agents of the department shall at
all times maintain the confidentiality of any confidential
HIV related information in their possession.



83.6 Records control.  (a)  The department will ensure the
security of files which may contain confidential HIV related
information. All officers, employees and agents of the
department in possession of, or having access to,
confidential HIV related information shall at all times
maintain the security of all records that contain
confidential HIV related information.



83.7 Protection of others at significant risk of infection.
(a)  The department shall implement and enforce a plan for
tile prevention of circumstances which could result in an
employee or individual becoming exposed to blood or body
fluids. Such a plan shall include:

(1)  training for appropriate persons on the use of
protective equipment, preventive practices, and
circumstances that constitute significant risk exposure;

(2)  appropriate training, counseling and supervision of
persons regarding behaviors which pose a risk for HIV
transmission at the work site. Contact notification, when
appropriate, shall be conducted in accordance with Public
Health Law, Section 2782(4) and 10 NYCRR 63.7;

(3)  use of accepted protective practices to prevent skin
and mucous membrane exposure to blood, other body fluids, or
other significant risk body substances, as defined in 10
NYCRR 63.9(b);

(4)  the use of accepted preventive practices while handling
instruments or equipment that may cause puncture injuries;
and

(5)  the provision, as appropriate, of personal protective
equipment which is of appropriate quality and quantity.

(b)  The department shall implement and enforce a plan for
responding to incident to exposure at the employee's work
site to blood, other body fluids or other significant risk
body substances. Such program shall include:

(1)  a system for receiving voluntary reports of all
exposures thought to represent circumstance for significant
risk;

(2)  availability of services for evaluating the
circumstances of such a reported exposure and providing
appropriate follow-up of anyone who has been exposed, which
includes:

(i)  medical and epidemiological assessment of an employee
or individual who is the source of the exposure, where that
source is known, available and agrees to be tested;

(ii) if epidemiologically indicated, HIV counseling and
testing of the source as permitted under article 27-F of the
Public Health Law. Where the HIV status is not known to
anyone who has been exposed, disclosure of the HIV status of
a living person can be made only with the express written
consent of the source or pursuant to court order; and

(iii) appropriate medical follow-up of employees and
individuals who have be exposed; and

(3)  assurances for protection of confidentiality for those
involved in reported exposures.



83.8 Severability. If any provision of this Part or the
application thereof to any person or circumstance is judged
invalid by a court of competent jurisdiction, such judgment
shall not affect or impair the validity of the other
provisions of this Part or the application thereof to other
persons and circumstances.



TITLE 7 CORRECTIONAL SERVICES

PART 7 AIDS CONFIDENTIALITY

Section 7.1  Purpose.  It is the responsibility and the
intent of the Department of Correctional Services (the
department) to adopt regulations to fully comply with the
provisions of Public Health Law, article 27-F. All
department staff should be aware that there are statutory
penalties for the violation of Public Health Law article 27-
F, including criminal misdemeanor penalties and/or civil
penalties up to $5,000 for each violation.

A violation of Public Health Law article 27-F or of this
Part may result in departmental discipline.



7.2  Definitions.  When used in this Part, the following
terms have the following meanings:

(a)  AIDS means acquired immune deficiency syndrome, as may
be defined from time to time by the Centers for Disease
Control of the United States Public Health Service.

(b)  HIV infection means infection with the human
immunodeficiency virus or any other related virus identified
as a probable causative agent of AIDS.

(c)  HIV-related illness means any illness that may result
from or may be associated with HIV infection.

(d)  HIV-related test means any laboratory test or series of
tests for any virus, antibody, antigen or etiologic agent
whatsoever thought to cause or to indicate the presence of
HIV infection.

(e)  Capacity to consent means an individual's ability,
determined without regard to such individual's age, to
understand and appreciate the nature and consequences of a
proposed health care service, treatment or procedure, and to
make an informed decision concerning such service, treatment
or procedure.

(f)  Protected individual means a person who is the subject
of an HW-related test or who has been diagnosed as having
HIV infection, AIDS or HIV-related illness.

(g)  Confidential HIV-related information means any
information, in the possession of a person who provides one
or more health or social services or who obtains the
information pursuant to a release of confidential HIV-
related information, concerning whether an individual has
been the subject of an HIV-related test, or has HIV
infection, HIV-related illness or AIDS, or information which
identifies or reasonably could identify an individual as
having one or more of such conditions, including information
pertaining to such individual's contacts.

(h)  Health or social service means any public or private
care, treatment, clinical laboratory test, counseling or
educational service for adults or children, and acute,
chronic, custodial, residential, outpatient, home or other
health care provided pursuant to the Public Health Law or
the Social Services Law; public assistance or care as
defined in article 1 of the Social Services Law; employment-
related services, housing services, foster care, shelter,
protective services, day care, or preventive services
provided pursuant to the Social Services Law; services for
the mentally disabled as defined in article 1 of the Mental
Hygiene Law; probation services, provided pursuant to
article 12 of the Executive Law; parole services, provided
pursuant to article 12-B of the Executive Law; correctional
services, provided pursuant to the Correction Law; and
detention and rehabilitative services provided pursuant to
article 19-G of the Executive Law.

(i)  Release of confidential HIV-related information means a
written authorization for disclosure of confidential HIV-
related information which is signed by the protected
individual, or if the protected individual lacks capacity to
consent, a person author zed pursuant to law to consent to
health care for the individual. Such release shall be dated
and shall specify to whom disclosure is authorized, the
purpose for such disclosure and the time period during which
the release is to be effective. A general authorization [or
the release of medical or other information shall not be
construed as a release of confidential HIV-related
information, unless such authorization specifically
indicates its dual purpose as a general authorization and an
authorization for the release of confidential HIV-related
information and complies with this definition.

(j)  Contact means an identified spouse or sex partner of
the protected individual or a person identified as having
shared hypodermic needles or syringes with the protected
individual.

(k)  Health care provider means any physician, nurse,
provider of services for he mentally disabled as defined in
article one of the Mental Hygiene Law, or other per on
involved in providing medical, nursing, counseling, or other
health care or mental heath service. As used in this Part,
the term includes but is not limited to, the Deputy Com
missioner/Director of Correctional Medical Standards, the
medical director of a correctional facility, physicians,
dentists and nurses providing patient care, the counselor of
the protected individual, if deemed necessary by tile
treating physician for the provision of counseling services,
and department personnel involved in direct patient care, as
determined by the physician.



7.3  Antidiscrimination.  (a)  It is the policy of the
department that the department and its officers, employees
and agents shall not discriminate against any individual by
virtue of his or her being identified or suspected of being
identified as having AIDS, HIV infection, or HIV-related
illness.

(b)  The policy set forth in subdivision (a) of this section
shall not be construed to prevent differential treatment of
inmates on account of HIV status or current medical
condition, provided that such differential treatment is
necessary in order to provide adequate and appropriate
medical treatment and services for individuals identified,
or suspected of being identified, as having AIDS, HIV
infection or HIV-related illness, or in order to protect the
health and safety of such individuals, where it has been
determined that there is a significant risk to the health
and safety of the individual or another person, by virtue of
the individual's HIV status or medical condition.

(c)  The department shall ensure that its authorized
officers, employees and agents are aware of the department's
policy as set forth in this section. All officers, employees
and agents of the department shall act in a manner
consistent with this policy.



7.4  HIV-related testing.  (a)  Except as noted in
subdivision (b) of this section no physician or other person
authorized pursuant to law may order an HIV-related test
without first obtaining written informed consent.

(1)  Informed consent shall include providing pre-test
counseling to the person to be tested or, if such person
lacks capacity to consent, to the person lawfully authorized
to consent to health care for such person. Pre-test
counseling shall include:

(i)  explanations regarding the nature of HIV infection and
HIV-related illness, an explanation of the HIV-related test,
including a description of the procedure to be followed,
meaning of the test result, and the benefits of taking the
test, including early diagnosis and medical intervention;

(ii) information regarding discrimination problems which
might occur as a result of unauthorized disclosure of HIV-
related information and legal protections prohibiting such
disclosures;

(iii)  information on preventing exposure or transmission of
HIV infection, including behavior which poses a risk of HIV
transmission;

(iv)  an explanation that the test is voluntary, that
consent may be withdrawn a any time and information on the
availability of anonymous HIV testing, including the
location and telephone numbers of anonymous test sites and
that anonymous testing is not available in the facilities;

(v)  written informed consent must be executed on form HS-1.

(b)  Informed consent is not required in the following
situations, but pre- and post-test counseling shall be
offered in situations described in paragraphs (1) and (2) of
this subdivision:

(1)  for court ordered testing pursuant to Civil Practice
Law and Rules, section 3121;

(2)  if otherwise specifically authorized or required by
State or Federal law;

(3)  for testing related to procuring, processing,
distributing or use of a human body or human body part,
including organs, tissues, eyes, bones, arteries, blood,
semen or other body fluids for use in medical research or
therapy, or for transplantation to persons, provided that if
the test results are communicated to the tested person, post-
test counseling is required;

(4)  for research if the testing is performed in a manner by
which the identity of the test subject is not known and may
not be retrieved by the researcher;

(5)  for testing of a deceased person to determine cause of
death or for epidemiological purposes.

(c)  In addition to an explanation of the test result, post-
test counseling or referrals with respect to a positive test
result, shall be provided to the person who consented to the
test. Such post-test counseling and referrals must address:

(1)  coping emotionally with the test results;

(2)  discrimination issues;

(3)  information on the ability to release or revoke the
release of confidential H V-related information;

(4)  information on preventing exposure to or transmission
of HIV infection information on available medical treatment;

(5)  the need to notify contacts to prevent transmission,
including information )n State or county assistance in
voluntary contact notification, if appropriate.

(d)  When a negative HIV-related test result is communicated
to the individual, counseling shall be offered discussing:

(1)  the meaning of and limitation of the test result; and

(2)  the means to remain free of infection and means to
avoid transmitting the virus.

(e)  A physician or other person authorized pursuant to law
to order an HIV-related test shall certify on a laboratory
requisition form that informed consent has been obtained.



7.5  Confidentiality and disclosure.  (a)  It is the policy
of the department that whenever disclosure of confidential
HIV-related information is warranted as defined in
subdivision (b) of this section, such disclosure, whenever
possible, should be made pursuant to the consent of the
protected individual, and all reasonable steps, including
appropriate counseling, should be taken to obtain consent.
Once consent has been obtained, Form HS-2, or any other form
approved by the Department of Health, is to be used as a
release form for disclosure of confidential HIV-related
information. Only Form HS-2, or other Department of Health
approved form, is to be used for this purpose. A general
medical release is not sufficient for the purpose of
disclosing confidential HIV- related information.

(b)  No person who obtains confidential HIV-related
information in the course of his or her employment with the
department or pursuant to a release of confidential HIV-
related information may disclose or be compelled to disclose
such information, except to the following:

(1)  the protected individual or, when the protected
individual lacks capacity to consent, a person authorized by
law to consent to health care for the individual;

(2)  any person to whom disclosure is authorized pursuant to
a release of confidential HIV-related information in
accordance with subdivision (a) of this section;

(3)  a health care provider of the protected individual as
defined in section 7.2 of this Part;

(4)  Deputy Commissioner/Director of Correctional Medical
Standards and  employees within the Division of Health
Services authorized by the Deputy Commission as necessary to
perform their duties and to provide appropriate supervision,
monitoring, administration or provision of treatment and
services offered to the protected individual;

(5)  Assistant Commissioner for Health Services and
employees within the Division of Health Services as
necessary on a need to know basis for providing appropriate
supervision, monitoring, administration or provision of
treatment and services offered to the protected individual;

(6)  superintendent of the facility in which the protected
individual is incarcerated as necessary on a need to know
basis for providing appropriate supervision, monitoring,
administration or provision of treatment and services
offered to the protected individual, including services
associated with possible parole release;

(7)  attorneys for the department or with the Office of the
Attorney General when access is reasonably necessary in the
course of providing legal services and when reasonably
necessary for supervision, monitoring, administration or
provision of services;

(8)  authorized employees of the facility Business Office,
Deputy Superintendent for Administration, Central Office
Budget and Finance, Bureau of Internal Controls, the Deputy
Commissioner of Administration, and the Division of Audit
and Control as necessary to ensure appropriate payment of
medical services or to track expenses associated with HIV-
related care;

(9)  Assistant Commissioner for Population Management as
necessary on a need to know basis for providing appropriate
supervision, monitoring, administration or provision of
treatment and services offered to the protected individual,
including services associated with possible parole release;

(10) institutional parole officer from the facility medical
director by use of the Health Discharge Summary Sheet;

(11) Parole Services Program Specialist by the Deputy
Commissioner/Director of Correctional Medical Standards;

(12) authorized employee of the State Commission of
Correction, as defined by the rules and regulations
promulgated by the State Commission of Correction;

(13) a clinician of the Office of Mental Health upon the
clinician's written request provided that the clinician is
involved in the treatment of the individual, or if facility
medical personnel believes the release of confidential HIV-
related information to the clinician may be beneficial to
the treatment of the individual;

(14) a medical director of a local correctional facility or
the medical director of a Federal correctional facility or
the medical director of the Bureau of Immigration and
Naturalization Services in which the protected individual is
incarcerated or is to be transferred, to the extent that
such medical director is authorized to access such
information with respect to a protected individual;

(15) a funeral director upon taking charge of the remains of
a deceased person when such funeral director has access in
the ordinary course of business to HIV related information
on the death certificate of the deceased individual, as
authorized by Public Health Law, section 2785;

(16) any person not listed above, to whom disclosure is
authorized pursuant to Public Health Law, section 2782.1(a)
through (o) or 2785.

(c)  Confidential HIV-related information of a protected
person may be disclosed to authorized employees or agents of
a governmental agency pursuant to the regulations of the
governmental agency when the person providing health or
social services is regulated, supervised or monitored by the
governmental agency or when the governmental agency
administers the health program or a social service program
and when such employees or agents have access to records in
the ordinary course of business and when access is
reasonably necessary for regulation, supervision,
monitoring, administration or provision of services. Such
authorized employees or agents may include  attorneys
authorized by a governmental agency when access occurs in
the ordinary course of providing legal services and is
reasonably necessary for supervision, monitoring,
administration or provision of services. Such authorized
employees or agents may also include public health officers
as required for conducting epidemiological or surveillance
investigations pursuant to the State Sanitary Code. Such
surveillance or investigational data shall also be disclosed
by the Public Health Officer to the State Department of
Health as required by the State Sanitary Code.

(d)  Confidential HIV-related information of a protected
person may be disclosed to authorized employees or agents of
a provider of health or social services when such provider
is either regulated, supervised or monitored by a
governmental agency or when a governmental agency
administers the provider's health or social service program,
and when such employees or agents have access to records in
the ordinary course of business and when access is
reasonably necessary for regulation, supervision,
monitoring, administration or provision of services. Such
authorized employees or agents may include attorneys
authorized by persons providing health services when access
occurs in the ordinary course of providing legal services
and is reasonably necessary for supervision, monitoring,
administration or provision of services.

(e)  A physician may disclose confidential HIV-related
information pertaining to a protected individual to a
person, known to the physician, authorized pursuant to law
to consent to the health care for a protected individual
when the physician reasonably believes that:

(1)  disclosure is medically necessary in order to provide
timely care and treatment for the protected individual; and

(2)  after appropriate counseling as to the need for such
disclosure, the protected individual will not inform a
person authorized by law to consent to health care; pro
vided, however, that the physician shall not make such
disclosure if, in the judgment of the physician:

(i)  the disclosure would not be in the best interest of the
protected individual; or

(ii) the protected individual is authorized pursuant to law
to consent to such care and treatment.

A physician's decision to disclose pursuant to this
paragraph, and the basis for that decision shall be recorded
in the medical record.

(f)  Written disclosure must be accompanied by a written
statement prohibiting further disclosure. The statement
shall include the following language or substantially
similar language: "This information has been disclosed to
you from confidential records which are protected by State
law. State law prohibits you from making any fur [her
disclosures of this information without the specific written
consent of the person to whom it pertains, or as otherwise
permitted by law. Any unauthorized further disclosure in
violation of State law may result in a fine or jail sentence
or both. A general authorization for the release of medical
or other information is not sufficient authorization for
further disclosure." Form HS-3 is to be used for this
purpose.

(g)  If oral disclosures are necessary, they must be
accompanied or followed as soon as possible, but no later
than 10 days, by the statement required by subdivision (f)
of this section.

(h)  The statement required by subdivisions (f) and (g) of
this section is not required for release to the protected
person or to a person authorized by law to consent to health
care for the individual when the protected individual lacks
capacity, or for releases made by a physician or public
health officer to a contact. For disclosures of confidential
HIV-related information from the patient's medical record to
persons who are permitted to access this information
pursuant to paragraphs (b) (4)-(15) of this section and phy
sicians or nurses or their authorized staff who are
permitted to access this information pursuant to paragraph
(b)(3) of this section, it shall be sufficient for the
statement required by subdivisions (f) and (g) of this
section to appear in the medical record itself.

(i)  No person to whom confidential HIV-related information
has been disclosed shall disclose the information to another
person except as authorized by this Part, provided, however,
that the provisions of this Part shall not apply to the
protected individual or a natural person who is authorized
pursuant to law to consent to health care for the protected
individual.



7.6  Documentation of HIV-related information and
disclosures.  (a)  Confidential HIV-related information
shall be recorded in the inmate's medical record such that
it is readily accessible to provide proper care and
treatment.

(1)  If the protected individual specifically requests, on a
prospective basis, the results of the HIV antibody testing
shall not be placed in the individual's medical record.

(2)  No flags on case folders or charts, lists on walls or
other similar displays shall be used to indicate individuals
with HIV infection. This shall not be construed to prevent
the existence of specialized case loads.

Confidential HIV-related information shall not be disclosed
in response to a request under the Freedom of Information
Law (Public Officers Law, article 6) or in response to a
subpoena.

The department will ensure that all employees and agents
authorized to receive confidential HIV-related information
under these regulations are aware of the provisions of the
HIV and AIDS Related Information Act (Public Health Law,
article 27-F) concerning confidentiality of HIV-related
information and the department's rules regarding
confidentiality of records. All authorized employees and
agents of the department shall at all times maintain the
confidentiality of any confidential HIV-related information
in their possession.

(e)  Confidential HIV-related information shall be noted in
a certificate of death, autopsy report or related documents
prepared pursuant to Public Health Law, article 41 or other
laws relating to documentation of cause of death.

(f)  All disclosures of confidential HIV-related information
must be noted in the in-mate's medical record, except:

(1)  Notation is not required for disclosure to agents or
employees of health facilities or health care providers
authorized under section 7.5(b)(4) or (7) of this Part or
for disclosure to physicians or nurses or their clerks
authorized under section 7.5(b)(3) of this Part.

(g)  The protected person shall be informed of disclosures
of HIV information upon request of the protected person.



7.7  Contact notification.  (a) A physician employed by the
department or rendering professional services at the request
of the department or facility of the department may disclose
HIV-related information, without the protected person's
consent, to a contact or to a public health officer when:

(1)  the physician reasonably believes disclosure is
medically appropriate and a significant risk of infection
exists; and

(2)  the protected person has been counseled to notify
his/her contacts and the physician reasonably believes the
protected person will not inform the contacts.

(b)  The physician must inform the protected person of the
physician's intent to disclose and the physician must comply
with the protected person's choice of whether the physician
or a public health officer will attempt to notify the
contact. All notifications shall be in person except where
circumstances reasonably prevent doing so.

(c)  The identity of the protected person shall not be
disclosed to the contact.

(d)  When a public health officer is requested to notify
contacts, the officer shall meet, when possible, with the
protected party to counsel and verify information prior to
any notification of such person's contacts.

(e)  The person notifying the contact shall provide or make
referrals for the provision of appropriate medical advice
and counseling for coping with the emotional consequences of
learning the information and for changing behavior to
prevent transmission or contraction of HIV infection.

(f)  If a protected person dies and the physician reasonably
believes the protected person had not informed his/her
contacts and reasonably believes disclosure is medically
appropriate and that a significant risk of infection exists,
the physician may notify the contact or request the public
health officer to notify the contact. All such notifications
shall be in person, except where circumstances reasonably
prevent doing so and the identity of the deceased shall not
be disclosed.

(g) A physician shall have no obligation to identify, locate
or notify any contact.



7.8  Records control.  (a)  The Deputy Commissioner/Director
of Correctional Medical Standards shall develop and
implement policies and procedures for persons authorized to
obtain confidential HIV-related information pursuant to
section 7.5(b)(3) through (8) inclusive of this Part to
ensure that records are maintained securely, including
records which are electronically stored, and used for the
purpose intended.

(b)  The Deputy Commissioner/Director of Correctional
Medical Standards shall develop and implement procedures for
handling requests by other parties for confidential HIV-
related information.

(c)  No employee or agent of the department who has access
to confidential HIV related information shall disclose such
information to any other person unless such person also has
access to confidential HIV-related information as described
in section 7.5(b) of this Part.

(d)  Each employee who is given authorized access to the
health records of an identified person that includes
confidential HIV-related information shall:

(1)  be advised in writing by the supervisor that the
employee shall not:

(I)  examine documents or computer data containing such HIV-
related information unless required to do so in the course
of his/her official duties and responsibilities;

(ii)  remove or copy any such documents or computer data
unless he or she is acting within the scope of his or her
assigned duties;

(iii)  discuss the content of any such documents or computer
data with any person unless that person is authorized to
have access to such documents or data.



7.9  Significant risk. (a)  The three factors necessary to
create a significant risk of contracting or transmitting HIV
infection are:

(1)  the presence of a significant risk body substance;

(2)  a circumstance which constitutes significant risk for
transmitting or contracting HIV infection; and

(3)  the presence of an infectious source and a noninfected
person.

(b)  Significant risk body substances are blood, semen,
vaginal secretions, breast milk, tissue and the following
body fluids: cerebrospinal, amniotic, peritoneal, synovial,
pericardial, and pleural.

(c)  Circumstances which constitute significant risk for
transmitting or contracting HIV infection are as follows:

(1)  sexual intercourse (vaginal, anal, oral) which exposes
a noninfected individual to blood, semen or vaginal
secretions of an infected individual;

(2)  sharing of needles and other paraphernalia used for
preparing and injecting drugs between infected and
noninfected individuals;

(3)  the gestation, birthing or breast feeding of an infant
when the mother is infected with HIV;

(4)  transfusion or transplantation of blood, organs, or
other tissues obtained from an infected individual to an
uninfected individual, providing such products have not
tested negatively for antibody or antigen and have not been
rendered noninfective by heat or chemical treatment;

(5)  other circumstances not identified in paragraphs (1)
through (4) of this subdivision during which a significant
risk body substance (other than breast milk) of an infected
individual contacts mucous membranes (e.g., eyes, nose,
mouth), nonintact skin (e.g., open wound, skin with a
dermatitis condition, abraded areas), or the vascular system
of a noninfected person. Such circumstances include, but are
not limited to, needle stick or puncture wound injuries and
direct saturation or permeation of these body surfaces by
the infectious body substance.

(d)  Circumstances that involve significant risk shall not
include:

(1)  exposure to urine, feces, sputum, nasal secretions,
saliva, sweat, tears or vomitus that does not contain blood
that is visible to the naked eye;

(2)  human bites where there is no direct blood to blood, or
blood to mucous membrane contact;

(3)  exposure of intact skin to blood or any other body
substance;

(4)  occupational settings where individuals use
scientifically accepted bar techniques and preventive
practices in circumstances which would otherwise pa
significant risk.



7.10 Training and protection of persons who may be in
contact with the human immunodeficiency virus (HIV).  (a)
The department will seek to protect individuals, in contact
with protected individuals, when such contact creates a
significant risk of contracting or transmitting HIV
infection.

(b)  The following procedures will be adopted to protect
employees:

(c)  Employees will be instructed to use universal
precautions and infection control equipment in accordance
with the Centers for Disease Control in situations where
there is actual or potential contact with significant risk
body substances as defined in section 7.9(b) of this Part.

(2)  Employees shall use generally accepted preventive
practices during job-relate activities which involve the use
of contaminated instruments or equipment which may cause
puncture injuries.

(3)  Employees shall receive education at the time of
employment and appropriate intervals thereafter on the use
of protective equipment, preventive practices, and
circumstances which represent a significant risk for all
employees whose job-related tasks involve, or may involve,
exposure to significant risk body substances.

(c)  Employees may voluntarily report exposures thought to
represent a circumstance for significant risk to facility
health services personnel or the Deputy Commis
sioner/Director of Correctional Medical Standards. The
circumstances of the reported exposure shall be evaluated
and appropriate follow-up of the exposed individual shall be
offered, including the following:

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

(2)  if epidemiologically indicated, HIV counseling and
referral for voluntary testing of the exposed individual. If
the HIV status is not known to the exposed individual,
disclosure can be made with the express written consent of
the protected individual, or pursuant to court order, or a
person authorized by law to consent to health care for the
protected individual if such person lacks capacity to
consent;

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

(4)  assurances for protection of confidentiality for those
involved in reported exposures;

(5)  at any time that testing or other activity is
considered pursuant to this section, both the source
individual and the exposed individual shall, in addition to
any other notices, receive and sign a notice that no one can
be compelled to disclose information concerning an HIV test
or HIV-related illness, nor can anyone be compelled to
submit to an HIV-related test absent a court order or unless
otherwise specifically authorized under State or Federal
law;

(6)  no person may retaliate against any individual by
reason or his or her refusal to submit to testing or to
disclosing confidential HIV-related information.



SUBTITLE E YOUTH

PART 164

AIDS TESTING AND CONFIDENTIALITY OF HIV-RELATED INFORMATION:
REQUIREMENTS REGARDING TESTING, CONFIDENTIALITY AND
PRECAUTIONS CONCERNING THE HUMAN IMMUNODEFICIENCY VIRUS
(HIV) AND ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)



Section 164.1  Background and intent.  (a)  The purpose of
this Part is to establish standards for the proper
disclosure of HIV-related information within facilities op
erated by the Division for Youth, including foster homes.

(b)  The purpose of this Part is to establish standards
which limit the risk of discrimination and harm to a youth's
privacy which unauthorized disclosure of HIV information can
cause.

(c)  The purpose of this Part is to establish standards
which seek to enhance the safety of employees, foster care
parents and youth at facilities or programs operated by the
Division for Youth.



164.2     Legal basis.  (a)  Section 500 of the Executive
Law grants the director of the Division for Youth (director)
the power and responsibility to adopt regulations that are
necessary and proper to implement matters under his or her
jurisdiction, and to set standards of quality and adequacy
of facilities, equipment, personnel, services, records and
programs for the rendition of services for youth.

(b)  Section 2756 of the Public Health Law requires the
director to promulgate regulations which provide safeguards
against discrimination, abuse and other adverse actions
directed toward protected individuals; provide for the
proper disclosure of HIV-related information; protect
individuals in contact with protected individuals when such
contact creates a significant risk of contracting or
transmitting HIV infection and  establish criteria for
determining when it is reasonably necessary for a provider
of a health or  social service or a State agency or a local
government agency to have or use confidential HIV-related
information for supervision, monitoring, investigation or
administration.



164.3     Applicability.  This Part applies to any Division
for Youth operated  residential facility, including foster
homes and group homes.



164.4     Definitions pertaining to this Part.  (a)  HIV
infection means infection with the human immunodeficiency
virus or any other related virus identified as a probable
causative agent of AIDS.

(b)  HIV-related illness means any illness that may result
from or be associated with HIV infection.

(c)  HI V- related test means any laboratory test or series
of tests for any virus, antibody, antigen or etiologic agent
whatsoever thought to cause or to indicate the presence of
HIV infection.

(d)  Capacity to consent means an individual's ability,
determined without regard to   such individual's age, to
understand and appreciate the nature and consequences of a
proposed health care service, treatment of procedure. and to
make an informal decision concerning such service, treatment
or procedure.

(e)  Protected individual means a person who is the subject
of an HIV-related test or who has been diagnosed as having
HIV infection, AIDS or HIV-related illness.

(f)  Confidential HI V-related information means any
information, in the possession of a person who provides one
or more health or social services or who obtains the
information pursuant to a release of confidential HIV-
related information, concerning whether an individual has
been the subject of an HIV-related test, or has HIV
infection, HIV-related illness or AIDS, or information which
identifies or reasonably could identify an individual as
having one or more of such conditions, including information
pertaining to such individual's contacts.

(g)  Health or social services means any public or private
care, treatment, clinical laboratory test, counseling or
educational service for youth, and acute, chronic, custo
dial, residential, outpatient, home or other health care;
public assistance; employment- related services, housing
services, foster care, shelter, protective services, day
care, or preventive services; services for the mentally
disabled; probation services; parole services; correctional
services; and detention and rehabilitative services, all as
defined in section 2750(8) of the Public Health Law.

(h)  Health facility means a hospital as defined in section
2801 of the Public Health Law, blood bank, blood center,
sperm bank, organ or tissue bank, clinical laboratory, or
facility providing care or treatment to persons with a
mental disability.

(i)  Health care provider means any physician, nurse,
provider of services for the mentally disabled or other
person involved in providing medical, nursing, counseling,
or other health care or mental health service including
those associated with, or under contract to, a health
maintenance organization or medical services plan.

(j)  Contact means an identified spouse or sex partner of
the protected individual or a person identified as having
shared hypodermic needles or syringes with the protected
individual.

(k)  Person includes any natural person, partnership,
association, joint venture, trust, public or private
corporation or State or local government agency.

(1)  Division means the New York State Division for Youth.

(m)  Youth means any person between the ages of seven and 21
years (inclusive) who resides in any facility operated by
the Division for Youth, including foster homes and group
homes.

(n)  AIDS means acquired immune deficiency syndrome, as may
be defined from time to time by the Centers for Disease
Control of the United States Public Health Service.



164.5 Prevention of discrimination and abuse.  (a)  No youth
will be subjected to discrimination because that youth is or
is thought to be HIV infected. All youth shall be
appropriately served by programs operated by the division
according to the needs of the youth.

(b)  The division shall provide training and/or training
opportunities to all direct care personnel in facilities,
foster care and group homes, which shall include, at a
minimum:

(1)  initial employee and annual in-service training
regarding the symptoms, use and transmission of HIV and
universal infection control procedures; and

(2)  initial employee training and annual in-service
training regarding legal prohibitions against unauthorized
disclosure of confidential HIV-related information.

(c)  A list of all employees and Division for Youth foster
parents who have had such training shall be maintained by
the division together with a list of those employees and
Division for Youth foster parents authorized to access
confidential HIV-related information. Such lists shall be
updated annually.

(d)  The Division for Youth shall establish and promulgate
policies ensuring:

(1)  maintenance of records containing confidential HIV-
related information in a secure manner, limiting access to
only those individuals permitted access pursuant to section
164.7 of this Part; and

(2)  procedures for handling requests by other parties for
confidential HIV-related information.



164.6     HIV-related testing.  (a) Except as noted in
paragraph (b)(2) of this section, no physician or other
person authorized pursuant to law may order an HIV-related
test without obtaining written informed consent.

(1)  Informed consent shall consist of providing to the
youth to be tested or, if such youth lacks capacity to
consent, as defined in section 164.4(d) of this Part to the
person lawfully authorized to consent to health care for
such person, pretesting counseling that includes:

(i)  explanations regarding the nature of HIV infection and
HIV-related illness, benefits of the test and its results,
an explanation of the HIV-related test and results, the
accuracy of the HIV-related test, the significance and
benefits of the test and its result; and the benefits of
taking the test, including early diagnosis and medical
intervention;

(ii) information regarding discrimination problems which
might occur as a result of unauthorized disclosure of HIV-
related information and legal protections prohibiting such
disclosures;

     (iii)  information on preventing exposure or
transmission of HIV infection, including behavior which
poses a risk of HIV transmission; and

     (iv)  an explanation that the testis voluntary and that
consent may be withdrawn at any time; information on the
availability of anonymous HIV testing, including the
location and telephone numbers of anonymous test sites.

(b)  (1)  Written informed consent must be executed on a
form developed or approved by the Department of Health,
pursuant to that department's regulations found at 10 NYCRR
section 63.4(a).

(2)  Informed consent is not required in the following
situations:

(i)  for court ordered testing pursuant to Civil Practice
Law and Rules, sect n 3121;

(ii) if otherwise authorized or required by State or Federal
law;

(iii)  for testing related to procuring, processing,
distributing or use of human body or human body part,
including organs, tissue, eyes, bones, arteries, blood,
semen or other body fluids for use in medical research or
therapy, or for transplantation to persons, provided that if
the test results are communicated to the tested person, post-
test counseling is required;

(iv)  for research if the testing is performed in a manner
by which the identity of the test subject is not known and
may not be retrieved by the researcher;

(v)  for testing of a deceased to determine cause of death
or for epidemiological purposes.

(c)  Post-testing counseling, and referrals with respect to
a positive or negative test result, shall be provided to the
person who consented to the test. Such post-test counseling
and referrals must address:

(1)  coping emotionally with the test results;

(2)  discrimination issues;

(3)  information on the ability to release or revoke the
release of confidential HIV related information;

(4)  information on preventing exposure to or transmission
of HIV infection and the availability of medical treatment;
and

(5)  the need to notify contacts to prevent transmission,
including information on State or county assistance in
voluntary contact notification, if appropriate.

(d)  A physician or other person authorized pursuant to law
to order an HIV-related test shall certify on a laboratory,
requisition form that informed consent has been obtained.



164.7     Confidentiality and disclosure.  (a)  Access to a
youth's confidential HIV related information shall be
strictly limited. No flags or other markings on charts,
lists on walls, or similar public displays shall be used to
indicate youths' HIV status. Nothing in these regulations
shall be construed to limit or enlarge access to that
portion of a youth's file not containing confidential HIV-
related information.

(b)  No person who obtains confidential HIV-related
information in the course of providing any health or social
service or pursuant to a release of confidential HIV-related
information may disclose or be compelled to disclose such
information, except to the following:

(1)  the protected individual or, when the protected
individual lacks capacity to consent, a person authorized
pursuant to law to consent to health care for the individ
ual;

(2)  any person to whom disclosure is authorized pursuant to
a release of confidential HIV-related information in
accordance with the regulations of the Department of Health
set forth at 10 NYCRR section 63.4(a);

(3)  an agent or employee of a health facility or health
care provider if:

(i)  the agent or employee is authorized to access medical
records;

(ii) the health facility or health care provider itself is
authorized to obtain the HIV-related information; and

(iii)  the agent or employee provides health care to the
protected individual, or maintains or processes medical
records for billing or reimbursement;

(4)  a health care provider or health facility when
knowledge of the HIV-related information is necessary to
provide appropriate care or treatment to the protected youth
or a child of the youth;

(5)  a health facility or health care provider, in relation
to the procurement, processing, distributing or use of a
human body or a human body part, including organs, tissues,
eyes, bones, arteries, blood, semen, or other body fluids,
for use in medical education, research, therapy, or for
transplantation to individuals;

(6)  health facility staff committees, or accreditation or
oversight review organizations authorized to access medical
records, provided that such committees or organizations may
only disclose confidential HIV-related information:

(i)  back to the facility or provider of a health or social
services;

(ii) to carry out the monitoring, evaluation, or service
review for which it was obtained; or

(iii)  to a Federal, State or local government agency for
the purposes of and subject to the conditions provided in
paragraph (19) of this subdivision;

(7)  a Federal, State, county or local health officer when
such disclosure is mandated by Federal or State law;

(8)  authorized agencies as defined by Social Services Law,
section 371 and corporations incorporated or organized to
receive youth for adoption or foster care, in connection
with foster care or adoption of a youth. Such agency shall
be authorized to redisclose such information only pursuant
to the provisions of article 27-F of the Public Health Law
or in accordance with the provisions of section 373-A of the
Social Services Law;

(9)  third-party reimbursers or their agents to the extent
necessary to reimburse health care providers, including
health facilities, for health services, provided that, where
necessary, an otherwise appropriate authorization for such
disclosure has been secured by the provider;

(10) an insurance institution, for other than the purpose
set forth in paragraph (9) of this subdivision, provided the
insurance institution secures a dated and written
authorization that indicates that health care providers,
health facilities, insurance institutions, and other persons
are authorized to disclose information about the protected
individual, the nature of the information to be disclosed,
the purposes for which the information is to be disclosed
and which is signed by:

(i)  the protected individual;

(ii) if the protected individual lacks the capacity to
consent, such other person authorized pursuant to law to
consent for such individual; or

(iii)  if the protected individual is deceased, the
beneficiary or claimant for benefits under an insurance
policy, a health services plan, or an employee welfare
benefit plan as authorized in article 27-F of the Public
Health Law;

(11) any person to whom disclosure is ordered by a court of
competent jurisdiction   r pursuant to section 2785 of the
Public Health Law;

(12) an employee or agent of the Division of Parole,
Division of Probation and Correctional Alternatives, or
Commission of Correction, in accordance with regulations
promulgated by those agencies;

(13) a medical director of a local correctional facility in
accordance with regulations promulgated by the facility
operator. Redisclosure by the medical director is prohibited
except as permitted under Public Health Law, article 27-F
and its implementing regulations;

(14) a physician may disclose the confidential HIV-related
information during contact notification pursuant to Public
Health Law, article 27-F;

(15) a physician may, upon the informed consent of a youth
or, if the youth lacks the capacity to consent, other person
qualified to give consent on behalf of the youth, disclose
confidential HIV-related information to a State, county, or
local health officer for the purpose of reviewing the
medical history of a youth to determine the fitness of the
youth to attend school;

(16) confidential HIV-related information may be disclosed
to a governmental agency or to authorized employees or
agents of a governmental agency when the person providing
health services is regulated by the governmental agency or
when the governmental agency administers a health or social
services program and when such employees or agents have
access to records in the ordinary course of business and
when access is reasonably necessary for supervision,
monitoring, administration or provision of services. Such
authorized employees or agents may include attorneys
authorized by a government agency when access occurs in the
ordinary course of providing legal services and is
reasonably necessary for supervision, monitoring,
administration or provision of services;

(17) confidential HIV-related information may be disclosed
to authorized employees or agents of a person providing
health services when such person is either regulated by a
governmental agency or when a governmental agency
administers a health or social services program, and when
such employees or agents have access to records in the
ordinary course of business and when access is reasonably
necessary for supervision, monitoring, administration or
provision of services and when such employee or agent has
been authorized by the division pursuant to this Part. Such
authorized employees or agents may include attorneys
authorized by persons providing health services when access
occurs in the ordinary course of providing legal services
and is reasonably necessary for supervision, monitoring,
administration or provision of services;

(18) no person to whom confidential HIV-related information
has been disclosed shall disclose the information to another
person except as authorized by this Part; provided, however
that the provisions of this Part shall not apply to the
protected youth or a natural person who is authorized
pursuant to law to consent to health care for the protected
individual;

(19) nothing in this section shall limit a person's or
agency's responsibility or authority to report, investigate,
or redisclose, child protective and adult protective serv
ices information in accordance with title 6 of article 6 and
titles 1 and 2 of article 9-B of the Social Services Law, or
to provide or monitor the provision of child and adult
protective or preventive services;

(20) confidential HIV-related information shall not be
disclosed to a health care provider or health care facility
if the sole purpose of disclosure is infection control when
such provider or facility is regulated under the Public
Health Law and required to implement infection control
procedures pursuant to Department of Health regulations;

(21) confidential HIV information shall not be released
pursuant to a subpoena. A court order pursuant to Public
Health Law, section 2785 is required;

(22) where a youth has obtained personal confidential HIV-
related information from an alternate anonymous testing
site, sexually transmitted disease clinic or the youth's
private physician, the youth may choose not to disclose any
information to the division. However, all youth must be
informed that disclosing such information confidentially
with selected division staff may help him or her to manage
the stress associated with HIV infection and also assist in
planning for appropriate services in the community upon
release. The test results will not be disclosed to any other
person unless the youth, or other person authorized to give
consent, gives prior written consent, pursuant to section
164.6 of this Part or unless disclosed pursuant to paragraph
(23) of this subdivision. Youth must also be informed that
once a positive test result is disclosed, it will be shared
confidentially with a limited number of people directly
involved with the youth's care and planning for care, as set
forth below. These people will be limited to the following:

(i)  the facility's medical staff caring for the youth
(i.e., physician's assistant, nurse, and the supervising
physician of the physician's assistant or primary care
physician serving the youth where the facility lacks other
medical staff);

(ii) the facility director or, as applicable, the youth's
foster parents and the division staff responsible for
supervision of the youth's foster care case; and

(iii)  the director of the division's Bureau of Health and
Recreation Services;

(23)  if, in the judgment of the facility health staff and
facility director or, as applicable, the division staff
responsible for supervision of the youth's foster care case,
the results must be disclosed to additional party(ies),
including the youth's parent(s) or guardian(s), the facility
director or foster care case supervisor shall consult with
the director of the Bureau of Health and Recreation
Services. The director of the bureau must concur with the
facility director or the division staff responsible for
supervision of the youth's foster care case, if the
information is to be disclosed to others not approved by the
youth. In such cases the criterion used for overriding the
youth's objections shall be that further disclosure of the
information is critically important for the youth's physical
or mental well-being, and that such benefit may not
otherwise be obtained. At no time will confidential HIV-
related information be disclosed in violation of Public
Health Law, article 27-F. Any decision or action taken
pursuant to this paragraph and the basis for such decision
or action shall be recorded in the youth's medical file;

(24) where a youth who has acquired HIV-related information
through a division employed physician or physician's
assistant or through a physician maintained to serve
division youth, either on a contract or fee-for-service
basis, the youth must be advised that such information will
be disclosed as set forth in paragraphs (22) and (23) of his
subdivision; and

(25) where such access is necessary in furtherance of the
duties of the Division's Office of Counsel confidential HIV-
related information may be disclosed to the Division's
Office of Counsel and the New York State Attorney General's
office.



164.8     Disclosure and release.  (a)  No confidential HIV-
related information shall be disclosed pursuant to a general
release or subpoena without a Supreme Court order, pursuant
to Public Health Law, section 2785. Disclosure is permitted
for HIV-relate d information pursuant to a specific release
form which has been developed or approved by the Department
of Health. The release must be signed by the protected
individual or if the protected individual lacks capacity to
consent pursuant to section 164.4(d) of this Part, by a
person authorized pursuant to law to consent to health care
for the individual.

(b)  All written disclosures of confidential HIV information
must be accompanied by a statement prohibiting redisclosure.
The statement shall include the following language or
substantially similar language: "This information has been
disclosed to you from confidential records which are
protected by State law. State law prohibits you from making
any further disclosure of this information without the
specific written consent of the person to whom it pertains,
or as otherwise permitted by law. Any unauthorized further
disclosure in violation of State law may result in a fine or
jail sentence or both.  A general authorization for the
release of medical or other information is not sufficient
authorization for further disclosure. Disclosure of
confidential HIV information that occurs as the result of a
general authorization for the release of medical or other
information will be in violation of the State law and may
result in a fine or jail sentence or both."

(c)  If oral disclosures are necessary, they must be
accompanied or followed as soon as possible, but no later
than 10 days, by the statement required in subdivision (b)
of this section. All disclosures, oral or written, shall be
recorded in the youth's official record.

(d)  The statement required by subdivisions (a) and (b) of
this section is not required for release to the protected
person or to his or her legal representative, for releases
made by a physician or public health officer to a contact,
or for releases made by a physician to a person authorized
pursuant to law to consent to the health care of the
protected person when the person has been counseled and the
disclosure is medically necessary pursuant to Public Health
Law, section 2782(4)(e). For disclosure of confidential HIV-
related information from the youth's medical files to
persons who are permitted access pursuant to section
164.7(b)(3)-(4), (6)-(7), (9)-(10) and (16)-(17) of this
Part, it shall be sufficient for the statement required by
subdivisions (b) and (c) of this section to appear in the
youth's medical record.



164.9     Protection of others at significant risk of
infection.  (a)  Staff and youth protection. Since medical
history and examination cannot reliably identify all youth
infected with HIV or other blood-borne pathogens, blood and
body-fluid precautions shall be consistently used for all
youth. This approach, referred to as "universal blood and
body-fluid precautions" or "universal precautions," or
"universal infection control procedures" shall be used
during job-related activities which involve or may involve
exposure to significant risk body substances as defined in
Department of Health regulations at 10 NYCRR section 63.9.

(b)  Facilities and programs, including foster care, shall
abide by any additional administrative guidelines regarding
protective barriers or procedures as may be required by the
division.

(c)  Facility staff and division staff responsible for
supervision of foster care cases will educate youth
regarding behaviors which pose a risk for HIV transmission.

(d)  Each division facility shall:

(1)  implement and enforce a plan for the prevention of
circumstances which could result in another exposed to blood
or body fluids which could put them at risk for HIV
infection, during the provision of services. Such a plan
shall include:

(i)  use of generally accepted protective barriers during
the job-related activities which involve, or may involve.
exposure to blood or body fluids. Such preventive action
shall be taken by the employee with each youth and shall
constitute an essential element for the prevention of bi-
directional spread of HIV;

(ii) use of generally 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 staff
development programs on the use of protective equipment,
preventive practices, and circumstances which represent a
risk for all employees whose job-related tasks involve, or
may involve, exposure to blood or body fluids;

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

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

(2)  implement and enforce a plan for the management of
individuals who are exposed to blood or body fluids. The
plan shall include:

(i)  a system for voluntary reporting of all exposures
thought to represent a circumstance for significant risk;

(ii) availability of services for evaluating the
circumstances of a reported exposure and providing
appropriate follow-up of the exposed individual which in
cludes:

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

(b)  if epidemiologically indicated, HIV counseling and
testing of the source individual as permitted under Public
Health Law, article 27-F. Where the HIV status is not known
to the exposed individual, disclosure can be made only with
the express written consent of the protected individual or
pursuant to a Supreme Court order; and

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

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



164.10    Monitoring.  Employees and agents of the division
responsible for monitoring, inspecting, supervising, and
investigating programs operated by the division shall have
access to confidential HIV information to the extent
necessary to discharge those responsibilities.



SUBTITLE CC DIVISION OF PAROLE

PART 8011

CONFIDENTIALITY OF HIV- AND AIDS-RELATED INFORMATION

Section 8011.1  Purpose.  It is the responsibility and the
intent of the division to adopt regulations pursuant to the
HIV- and AIDS-Related Information Act (Public Health Law,
article 27-F). All officers, employees, and agents of the
division shall at all times maintain the confidentiality of
any HIV-related information in their possession, in
accordance with the requirements of the statute and this
Part.



8011.2  Definitions.  When used in this Part:

(a)  AIDS means acquired immune deficiency syndrome, as may
be defined from time to time by the centers for disease
control (CDC) of the United States Public Health Service.

(b)  HIV infection means infection with the human
immunodeficiency virus or any other related virus identified
as a probable causative agent of AIDS.

(c)  HIV-related illness means any illness that may result
from or may be associated with HIV infection.

(d)  HIV-related test means any laboratory test or series of
tests for any virus, antibody, antigen or etiologic agent
whatsoever thought to cause or to indicate the presence of
AIDS.

(e)  Protected individual means a person who is the subject
of an HIV-related test or who has been diagnosed as having
HIV infection, AIDS or HIV-related illness.

(f)  Confidential HIV- related information means any
information concerning whether an individual has been the
subject of an HIV-related test, or has HIV infection, HIV-
related illness or AIDS, or information which identifies or
reasonably could identify an individual as having one or
more of such conditions, including information pertaining to
such individual's contacts, when such information is in the
possession of a provider of one or more health or social
services or has been obtained pursuant to a release of
confidential HIV-related information. Parole services
provided by the division are health or social services
pursuant to Public Health Law, section 2780(8). When such
information is in the possession of an authorized officer,
employee or agent of the division, the provisions of these
regulations apply regardless of whether the inform as been
obtained by consent, by authorized disclosure pursuant to
the provisions of the HIV and AIDS-Related Information Act
(Public Health Law, article 27-F), or in any other manner,
including from unofficial sources or through unofficial
communications.

(g)  Authorized officer or employee means an officer or
employee of the division who is permitted to have access to
confidential HIV information; such individuals, described
more specifically in section 8011.4 of this Part, are those
officers and employees who, in the performance of their
duties for the division, need to have access to records or
information relating to the care of, treatment of, or
administration or provision of parole services to, protected
individuals.

(h)  Authorized agent means:

(1)  an entity that has contracted with the division to
provide treatment or parole services to parolees, or an
employee of such entity, provided that the entity, or the
employee, needs to know confidential HIV-related information
in order to provide the contracted for service; and

(2)  attorneys providing legal services to the division, its
officers, or employees provided that access occurs in the
ordinary course of providing legal services and is
reasonably necessary for the provision of legal services.

(i)  Need to know means that knowledge of confidential HIV-
related information is reasonably necessary in order to
provide appropriate treatment or parole service to
recipients of such services, or to audit, monitor or
supervise the provision of such services, or to administer
or plan the provision of such services on an individual,
regional or statewide planning basis.

(j)  Treatment or parole services means services provided to
inmates or releasees by officers, employees or agents of the
division pursuant to article 12-B of the Executive Law,
officers or employees of the United States Parole
Commission, or parole officers of another state pursuant to
article 12-B of the Executive Law.

(k)  Release of confidential HIV-related information means a
written authorization for disclosure of confidential HIV-
related information which complies with the requirements of
PHL, section 2780(9). Any such release obtained from a
protected individual by any officer or employee of the
division shall be obtained only by using Department of
Health approved form (see subdivision [r] of this section) -
- Division of Parole form 4136.

(l)  Contact means an identified spouse or sex partner of
the protected individual or a person identified as having
shared hypodermic needles or syringes with the protected
individual.

(m)  Health care provider means any physician, nurse,
provider of services for the mentally disabled as defined in
article one of the Mental Hygiene Law, or other person
involved in providing medical, nursing, counseling or other
health care or mental health service, including those
associated with, or under contract to, a health maintenance
organization or medical services plan. As used in this Part,
the term includes the medical director of a State
correctional facility, and also includes any physician
providing any officer, employee or agent of the division
with a confirmed diagnosis of AIDS, HIV infection or HIV-
related illness.

(n)  Capacity to consent means an individual's ability,
determined without regard to such individual's age, to
understand and appreciate the nature and consequences of a
propose health care service, treatment or procedure, and to
make an informed decision concerning such service,
treatment, or procedure.

(o)  Significant risk of transmitting or contracting HIV
infection or significant risk means the circumstances set
forth in regulations promulgated by the Department of Health
at 10 NYCRR section 63.9. Those provisions are summarized as
follows. The following body fluids and substances are
currently considered to be significant risk body substances:
blood, semen, vaginal secretions, breast milk, tissue,
cerebrospinal fluid, amniotic fluid, peritoneal fluid,
synovial fluid, pericardial fluid, and pleural fluid. The
following circumstances constitute significant risk of
transmitting or contracting HIV infection:

(1)  sexual contact which exposes a mucous membrane or
broken skin to blood, semen or vaginal secretions of an
infected individual;

(2)  sharing of needles or other paraphernalia used for
preparing and injecting drugs between infected and
noninfected individuals;

(3)  the gestation, birthing or breast feeding of an infant
when the mother is infected with HIV;

(4)  transfusion or transplantation of blood, organs, or
other tissues obtained from an infected individual to an
uninfected individual, provided that such products have not
tested negatively for antibody or antigen and have not been
rendered noninfective by heat or chemical treatment; and

(5)  other circumstances, not identified in paragraphs (1)
through (4) of this subdivision, during which a significant
risk body substance (other than breast milk) of an infected
person contacts mucous membranes (e.g., eyes, nose, mouth)
or nonintact skin (e.g., open wound, dermatitis, abraded
areas) or the vascular system of a non-infected person.
[footnote 1: The following do not constitute significant
risk: exposure to urine, feces, sputum, nasal secretions,
saliva, sweat, tears or vomitus that does not contain
visible blood; human bites where there is no direct blood to
blood or blood to mucous membrane contact; exposure of
intact skin to blood or any other body substance.]

(p)  Confirmed diagnosis means confirmation provided by an
authorized laboratory that an individual has AIDS, HIV-
related illness, or HIV infection.

(q)  Universal precautions means the use of scientifically
accepted protective barriers and preventive practices in
circumstances which involve, or may involve, exposure to
significant risk body substances or potentially contaminated
implements which may cause puncture wounds.

(r)  Form 4136 - Authorization for release of confidential
HIV-related information.

Authorization for Release of Confidential HIV* Related
Information

Confidential HIV-Related Information is any information
indicating that a person had an HIV-related test, or has HIV
infection, HIV-related illness, or AIDS, or any information
which could indicate that a person has been potentially
exposed to HIV.

Under New York State Law, except for certain people,
confidential HIV-related information can only be given to
persons you allow to have it by signing a release. You can
ask for a list of people who can be given confidential HIV-
related information without a release form.

If you sign this form, HIV-related information can be given
to the people listed on the form, and for the reasons(s)
listed on the form. You do not have to sign the form, and
you can change your mind at any time.

If you experience discrimination because of release of HIV
related information, you may contact the New York State
Division of Human Rights at [phone] or the New York
City Commission of Human Rights at [phone]. These
agencies are responsible for protecting your rights.

Name of person whose HIV-related information will be
released:

Name and address of person signing this form (of other than
above):

Relationship to person whose HIV information will be
released:

Reason for release of HIV-related information:

Time during which release is authorized:

From:                         To:

My questions about this form have been answered. I know that
I do not have to allow release of HIV-related information,
and that I can change my mind at any time.

Date           Signature

*Human Immunodeficiency Virus that causes AIDS

Division of Parole

Form 4136



8011.3  Antidiscrimination.  (a)  It is the policy of the
division that the division and its officers, employees and
agents shall not discriminate against any individual by
virtue of his or her being identified as, or suspected of,
having AIDS, HIV infection, or HIV-related illness.

(b)  The policy set forth in subdivision (a) of this section
shall not be construed to prevent differential treatment of
inmates or releasees on account of HIV status or current
medical condition, provided that such differential treatment
is necessary in order to provide adequate and appropriate
treatment or parole services for individuals identified as
having AIDS, HIV infection or HIV-related illness.

(c)  The division will take appropriate steps to make its
authorized officers, employees and agents aware of the
division's policy as set forth in this section. All
officers, employees and agents of the division shall act in
a manner consistent with this policy when performing their
official duties for the division.



8011.4  Access to confidential HIV-related information.  The
following employees of the division are considered
authorized employees who may have access to confidential HIV-
related information on a need to know basis, as set forth in
this section.

(a)  Any parole officer assigned to, or any other employee
providing treatment or parole services for, a particular
case, and any parole officer who is covering a case for the
regularly assigned parole officer and who needs access to
the parole file in order to perform whatever duties are
necessary to cover the case, may have access to any con
fidential HIV-related information contained in the parole
file for that case;

(b)  Other staff who make entries in case folders or
electronic records may have access to confidential HIV-
related information, but only to the extent that they
actually make entries relating to the provision of treatment
or parole services;

(c)  The direct line casework supervisor (this will
ordinarily be the senior parole officer, but may be any
other individual performing that function, regardless of
actual title) may have access, on a need to know basis, to
confidential HIV-related information contained in the parole
file for any case for which that direct line supervisor
performs any supervisory duties.

(d)  All supervisors in the direct line of supervision, and
any officer or employee performing a planning, monitoring,
administrative oversight, litigation or casework assistance
function, may have access to any confidential HIV-related
information contained in a particular parole file, provided
that access to the parole file is reasonably necessary in
order to carry out an appropriate supervisory, planning,
monitoring administrative oversight, litigation or casework
assistance function. The direct line of supervision will
ordinarily include the area supervisor, deputy regional
director regional director and the director of operations,
or any other officer or employee designated to perform an
equivalent supervisory function, regardless of actual title.
Access to the parole file, and to any confidential HIV-
related information contained in the file, will be on a need
to know basis.

(e)  Members of the Board of Parole.



8011.5  Confidentiality.  (a)  No authorized officer or
employee or agent of he division who obtains confidential
HIV-related information in the course of performing his or
her duties as an officer, employee or agent of the division
may disclose such information except in accordance with the
provisions of the HIV- and AIDS-Related Information Act
(Public Health Law, article 27-F) and the provisions of
these regulations.

(b)  It is the policy of the division that disclosure of
confidential HIV-related information should, whenever
possible, be made pursuant to the consent of the protected
individual, and all reasonable steps, including appropriate
counseling, should be taken to obtain consent. Once consent
has been obtained, a release form that complies with the
requirements of PHL, article 27-F is to be executed, and
disclosure may then be made in accordance with that release.
Only Department of Health approved form 4138 is to be used
as a release form for disclosure of confidential HIV-related
information. The provisions of this subdivision shall not
apply to disclosures made for the purpose of defending
litigation against the division, its officers or employees.

(c)  In the absence of consent, disclosure may be made only
to the following, and, except for disclosure pursuant to
paragraph (1) of this subdivision, disclosure by parole
officers and senior parole officers may be made only with
the written approval of the area supervisor or designee or a
parole services program specialist, such written approval to
be placed in the parolee's file:

(1)  an authorized officer or employee of the division, as
defined in section 8011.2(g of this Part;

(2)  an authorized agent of the division, as defined in
section 8011.2(h) of this Part, if disclosure is necessary
to permit the agent to carry out his, her or its functions
for the division;

(3)  officers or employees of parole authorities of another
state, or the United States Parole Commission, when such
officers or employees are providing treatment or parole
services pursuant to article 12-B of the Executive Law;

(4)  a health care provider, but only when knowledge of the
HIV-related information is necessary to provide care or
treatment to the protected individual; for purposes of these
regulations, disclosure to the medical director of the
appropriate state correctional facility, or appropriate
medical staff at a Division for Youth facility, is deemed to
be necessary for any parole violator returned to the custody
of the State Department of Correctional Services or the
State Division for Youth;

(5)  the medical director of a local correctional facility
whenever a parole violator is being lodged at that
correctional facility;

(6)  any person to whom disclosure is ordered by a court of
competent jurisdiction; and

(7)  any person not listed in this subdivision, to whom
disclosure is authorized pursuant to PHL, section 2782.1(a)
through (o).

(d)  Any disclosure, except disclosures pursuant to
paragraph (c)(1) of this section, must be accompanied or
followed by a written statement prohibiting further
disclosure. Form 4137, a copy of which appears in
subdivision (i) of this section, is to be used for this
purpose.

(e)  All disclosures, except disclosures pursuant to
paragraph (c)(1) of this section, are to be appropriately
documented in the case folder of the protected individual,
who shall be informed of such disclosures upon request.

(f)  No flags on case folders, lists on walls, or other
similar public displays shall be used to indicate clients
with HIV infection. This shall not be construed to prevent
the existence of specialized caseloads.

(g)  Confidential HIV-related information shall not be
disclosed in response to a request under the Freedom of
Information Law (Public Officers Law, article 6) or in
response to a subpoena. A court order issued pursuant to
Public Health Law, section 2785 is required.

(h)  The division will take appropriate steps to make all
authorized officers, employees and agents aware of the
provisions of the HIV- and AIDS-Related Information Act
(PHL, article 27-F) concerning confidentiality of HIV-
related information and the division's rules regarding
confidentiality of records. All authorized officers,
employees and agents of the division shall at all times
maintain the confidentiality of any confidential HW-related
information in their possession.

(i)  Form 4137-HIV information disclosure form.



NEW YORK STATE

DIVISION OF PAROLE

This information has been disclosed to you from confidential
records which are protected by state law. State law
prohibits you from making any further disclosures of this
information without specific written consent of the person
to whom it pertains, or as otherwise permitted by law. Any
unauthorized further disclosure in violation of state law
may result In a fine or jail sentence or both. A general
authorization for the release of medical or other
information is not sufficient authorization for further
disclosure.

8011.6  Records control.  (a)  The division will ensure the
security of files which may contain confidential HIV-related
information. All officers, employees and agents of the
division in possession of, or having access to, confidential
HIV-related information shall at all times maintain the
security of all records that contain confidential HIV
related information.

(b)  The division will ensure that any secondary reports,
presentations or statistical compilations that include or
refer to confidential HIV-related information will, to the
extent possible, minimize the use of names of, or other
information tending to identify, protected individuals. With
respect to documents that must identify a releasee by name,
the division will ensure that confidential HIV-related
information is included in such a document only if, and to
the extent, necessary.



8011.7  Provision of confidential HIV-related information to
authorized officers and employees of the division.  (a)  The
Department of Correctional Services, an the medical
directors of its correctional facilities, in accordance with
the provisions of Executive Law, section 259-1 and Public
Health Law, section 2782.1(1), may provide  confidential HIV-
related information to the authorized officers and employees
of the division described in section 8011.4 of this Part,
without the consent of the protected individual. Any such
confidential HIV-related information will be subject to the
limitations on disclosure imposed by PHL, article 27-F and
this Part.

(b)  The medical director of a local correctional facility,
in accordance with the  provisions of Public Health Law,
section 2782.1(1), may provide confidential HIV-related
information to the authorized officers and employees of the
division described in Section 8011.4 of this Part, without
the consent of the protected individual. Any such
confidential HIV-related information will be subject to the
limitations on disclosure imposed by PHL, article 27-F and
these regulations.

(c)  The Division for Youth, in accordance with the
provisions of Public Health Law, Section 2782.1(1), may
provide confidential HIV-related information with respect to
juvenile offenders to the authorized officers and employees
of the division described in section 8011.4 of this Part,
without the consent of the protected individual. Any such
confidential HIV-related information will be subject to the
limitations on disclosure imposed by PHL, article 27-F and
these regulations.

(d)  A provider of a health or social service (including but
not limited to those entities that provide treatment or
parole services to releasees, whether by contract with the
division or otherwise) which provides health or social
services to releasees, may provide confidential HIV-related
information to the authorized officers and employees of the
division described in section 8011.4 of this Part, without
the consent of the protected individual. Any such
confidential HIV-related information will be subject to the
limitation on disclosure imposed by PHL, article 27-F and
this Part.



8011.8  Protecting contacts when there is a significant risk
of contracting or transmitting HIV infection.  (a)  The
division will seek to protect individuals in contact with
protected individuals, when such contact creates a
significant risk of contracting or transmitting HIV
infection through the exchange of significant risk body
substances, as defined by the Department of Health and in
section 8011.2(o) of this Part.

(b)  The following procedures will be adopted with respect
to employees:

(1)  Employees will be instructed to use universal
precautions in situations where there is the potential for
exchange of significant risk body substances as defined by
the Department of Health and in section 8011.2(o) of this
Part.

(2)  Appropriate protective clothing and equipment will be
kept at an identified location at each work site.

(3)  Each work site is to develop its own protocol, which is
to be posted in areas accessible to all employees, for
obtaining medical assistance for emergency situations.

(4)  In the event of a work related potential exposure
reported to the division (e.g., a needle stick), an employee
involved in the potential exposure is to be referred to the
employee health service for counseling and appropriate
medical treatment.

(5)  The division will promulgate risk reduction guidelines
specific to the parole context and will ensure that all
employees receive a copy of the guidelines and training with
respect to the guidelines.

The following procedures will be adopted with respect to
members of the public which are potential contacts of
releasees.

(1)  The families and/or individuals with whom a post-
release residence is proposed, of all releasees, will be
provided with information which will enable such individuals
to make informed decisions regarding behavior that may limit
the risk of contracting or transmitting AIDS. Such
information will be made available to the families, or
persons with whom a residence is proposed, of all releasees,
regardless of the division's knowledge of the releasee's HIV
status, and recipients of information will be advised that
information packets are being provided to all families,
regardless of a particular releasee's HIV status. Such
information will consist of literature available to the
division for distribution, whether of a general
informational nature, or specifically tailored to the parole
context.

(2)  All releasees will be counseled to behave in ways that
minimize the risk of contracting or transmitting HIV
infection. Those releasees known to have a confirmed
diagnosis of AIDS, HIV-related illness or HIV infection will
be counseled with a view to encourage them to inform their
families, or persons with whom a residence is proposed, and
any contacts as defined in section 8011.2(1) of this Part,
of their HIV status for the purposes of limiting infection.
A releasee who has told parole staff that b  or she plans to
notify a contact will also be encouraged to execute a
release of confidential HIV-related information permitting
disclosure to contact(s) so that authorized employees of the
division may participate in any discussions with the
protected individual and his or her contacts that may occur
in the course of parole supervision and that may involve
confidential HIV-related information.

(3)  In the event that a releasee known to have a confirmed
diagnosis of AIDS, HIV related illness or HIV infection has
been counseled in accordance with paragraph (2) of this
subdivision, and the releasee refuses to execute a consent
for release of confidential HIV-related information to
contacts, and the parole officer or other employee providing
treatment or parole services has an articulable factual
basis for believing that there is a known contact at
significant risk of contracting HIV infection from the
releasee and that the releasee will not inform the said
contact of the releasee's HIV status, then the parole
officer may, in accordance with policies and procedures of
the division, request that an application be made for a
court order permitting disclosure of confidential HIV-
related information pursuant to Public Health Law, section
2785.



8011.9  Severability.  If any provision of this Part or the
application thereof to any person or circumstance is judged
invalid by a court of competent jurisdiction, such judgment
shall not affect or impair the validity of the other
provisions of this Part or the application thereof to other
persons and circumstances.



405.22  Critical care and special care services (a) General
provisions.  Critical care and special care services are
those services which are organized and provided for patients
requiring care on a concentrated or continuous basis to meet
special health care  needs. Each service shall be provided
with a concentration of professional staff and supportive
services that are appropriate to the scope of services
provided.

(1)  The direction of each service, unless otherwise
specified in this section, shall be provided by a designated
member of the medical staff who has received special
training and has demonstrated competence in the service
related to the care provided.

(2)  The provision of all critical care and special care
services shall be in accordance with generally accepted
standards of medical practice. The hospital shall ensure
that written policies are developed by the medical staff and
the nursing service and implemented for all special care and
critical care services.

(i)  The written policies and procedures shall be reviewed
at least annually and revised as necessary and shall include
at a minimum the following: infection control protocols,
safety practices, admission/discharge protocols and an
organized pro-gram for monitoring the quality and
appropriateness of patient care, with identified problems
reported to the hospital-wide quality assurance program and
resolved.

(ii) The written protocols for patient admission to and
discharge from a critical care or special care unit shall
include:

(iii)     criteria for priority admissions;

(iv) alternatives for providing specialized patient care to
those patients who require such care but who, due to lack of
space, or other specified reasons such as infection or
contagious disease, are not eligible for admission according
to unit policy; and

(v)  guidelines for the timely transfer and referral of
patients who require services that are not provided by the
unit.

(3)  Each critical care unit shall be organized as a
physically and functionally distinct entity within the
hospital.

(i)  Access shall be controlled in order to regulate
traffic, including visitors, in the interest of infection
control.

(ii)  Emergency equipment and an emergency cart within each
unit shall contain appropriate drugs and equipment, as
determined by the medical staff and pharmacy service.

(4)  When critical or special care services are provided to
pediatric patients, opportunities shall be provided for
education, socialization, and play pertinent to the growth
and development needs of these patients, unless medically
contraindicated.

(b)  Organ and tissue transplantation service, Organ or
tissue transplantation services shall be performed only in
hospitals approved by the commissioner pursuant to part 710
of this Title,

(1)  General requirements. Each organ and tissue
transplantation service shall meet the following
requirements,

(i)  The hospital shall be a member of the Organ Procurement
and Transplantation Network approved by the Secretary, U.S.
Department of Health and Human Services and shall abide by
its rules and requirements,

(ii)  The hospital shall participate in a patient registry
program with an organ procurement organization designated by
the Secretary, U.S. Department of Health and Human Services,
and if the hospital utilizes the services of a designated
organ procurement organization to obtain donor organs it
shall have a written agreement covering these services,

(iii)  The criteria used for the selection of patients for
transplant services shall be consistent with professional
standards of practice, applied consistently, and made
available to the public.

(iv)  The hospital shall maintain a record of all patients
who are referred for transplantation and the date of their
referral, the results of the evaluation of the candidates
for transplantation which documents the reasons a candidate
is determined to be either suitable or unsuitable for
transplantation, the date suitable candidates are selected
for transplantation, the date the transplantation surgery
occurred, the organs or tissues utilized and the donor.