DAL: Recent Amendments to 10 NYCRR Part 405 Concerning General Hospitals Including Pediatric Minimum Standards

April 16, 2014

Dear Chief Administrative Officer:

This letter is to inform you of recent amendments to 10 NYCRR Part 405 concerning general hospitals, which became effective on December 31, 2013. Facilities are required to be compliant with the regulations effective March 31, 2014. These amendments update the minimum standards for administration, radiology/nuclear medicine, pharmacy services, admission and discharge, quality assurance, respiratory, emergency, surgical, and anesthesia services, and include new requirements for pediatric care, including standards for pediatric intensive and emergency care.

The pediatric minimum standards are the recommendation of the Emergency Medical Services for Children Advisory Committee, an advisory committee to the Commissioner of Health on medical and public health issues concerning infants and children and are consistent with national standards from the; American Academy of Pediatrics, Society of Critical Care Medicine, American College of Surgeons, American College of Emergency Physicians, American Pediatric Surgical Association, and Federal EMS for Children Program.

The purpose of these regulations is to improve the care of children. For example, prior to these revisions there were no specific minimum standards for pediatric critical care. These regulations address this and direct hospitals to have the proper personnel and equipment to care for children and to transfer those that they cannot care for to an appropriate facility. The following sections of 10 NYCRR Part 405 are amended:

  • 405.3 Administration - This section is updated to reflect more current terminology used for certain health professions, such as social workers and respiratory therapists.
  • 405.6 Quality Assurance - This section is updated to assure hospitals admit only those patients for which they have the appropriate staff, resources and equipment, and transfer those patients if they do not have the capability (exception given for disasters).
  • 405.7 Patient Rights - This is amended to establish a "Parent's Bill of Rights" which advises parents/guardians of their rights under the amendments and requires distribution and posting of the Parent's Bill of Rights.
  • 405.9 Admission/Discharge and 405.19 Emergency Services - These sections are amended to require written policies and procedures pertaining to the review and communication of laboratory and diagnostic test/service results ordered for a patient while admitted or receiving emergency services. Prior to discharge, all "critical value" laboratory and diagnostic tests/service results are to be reviewed and communicated to the patient by a physician (MD), physician assistant (PA) or nurse practitioner (NP) familiar with the patient's presenting condition. "Critical value" results are defined as those that suggest a life threatening or otherwise significant condition such that requires immediate medical attention. All laboratory and diagnostic test results are to be forwarded to the patient's primary care provider, if known, after review by an MD, PA or NP.
  • 405.7 Patient Rights - In regards to pediatric patients, this section allows one parent/guardian to stay with the patient at all times, to the extent possible given the patient's health and safety.
  • 405.15 Radiology - This section is updated to meet current standards of practice, e.g. "linear accelerators" are added, and "MVE units" is deleted. It also requires a policy be developed for imaging studies for newborns and pediatric patients that includes clinical appropriateness, dosage, beam collimation, image quality and shielding.
  • 405.12 Surgical Services, 405.13 Anesthesia Services and 405.14 Respiratory Services -These sections are amended to reflect current practices, such as deleting reference to antiquated medical terms and adding that equipment must be age and size appropriate.
  • 405.17 Pharmaceutical Services – This section is updated to require all patients be weighed using metric system values to assist in preventing medication errors.
  • 405.19 Emergency Services – This section is amended to require Pediatric Advanced Life Support (PALS)training when children are being treated.
  • 405.20 Outpatient Services - This section is amended to clarify ambulatory surgery services must have the appropriate equipment necessary to meet the needs of all patients and adds the parents, legal guardian or health care agent.
  • 405.22 Critical Care and Special Services - This section is amended to add new requirements for Pediatric Intensive Care Units (PICU), which must be approved by the Department. This includes staffing and pediatric advanced life support training (PALS) requirements. The PICU must have a minimum average annual pediatric patient admission number of 200 per year.

Enclosed with this letter is a Frequently Asked Questions document to assist you with implementation. Should you have any questions, please contact me at (518) 402-1004.


Ruth Leslie
Division of Hospitals and Diagnostic Treatment Centers