N.Y. Comp. Codes R. & Regs. tit. 10, § 420.4 – Program administration.

(a) The CAHP shall have an administrator responsible for the organization, equipment and staffing of the CAHP, consistent with the scope of services offered and patient care needs. The administrator shall:
1. (1) establish and implement administrative policies and procedures for the CAHP; and
2. (2) maintain a functional organization chart of the CAHP which delineates lines of authority, both administratively and clinically.
(b) The CAHP shall develop and implement a quality of care management program which includes a review of the appropriateness of HIV services and functions as an integral part of the Comprehensive Ambulatory HIV Program.
1. (1) Specific quality of care assessment protocols for HIV-infected patients shall be developed and monitored as an integrated part of the facility's quality management system.
2. (2) The quality management program shall promote continuous quality improvement of patient care as well as identification of target areas for continuing education programs.
(c) The CAHP shall develop and implement policies and procedures for infection control, occupational exposure to HIV and for employment of HIV infected health care workers based on currently available scientific evidence about HIV and its transmission.
(d) The CAHP shall develop and implement specific policies and procedures for the prevention of HIV and other infectious disease transmission and to further such prevention shall comply with pertinent Federal and State law and regulations and generally accepted public health practice for the prevention of infectious disease.
1. (1) Such policies and procedures shall require that all patients are:
  1. (i) instructed regarding the transmission of HIV and other infectious diseases and risk reduction measures;
  2. (ii) routinely screened and treated for sexually transmitted diseases and hepatitis B; and
  3. (iii) screened and immunized against preventable infections.
2. (2) All newly diagnosed cases of AIDS or suspected cases of AIDS shall be reported to the department as required by Part 24 of this Title.
3. (3) The CAHP shall counsel patients regarding the importance of notifying sex and needle sharing pertners of the potential exposure to HIV and the need for counseling and testing for HIV antibodies. Partner notification shall be promoted as an effective intervention by all members of the patient's care team. Partner notification and counseling assistance shall be integrated across the continuum of services offered by the program.
4. (4) The CAHP shall develop and implement specific policies for the management of tuberculosis, including the management and containment of multiple drug resistant tuberculosis, consistent with generally accepted standards of medical care and treatment.
(e) A CAHP which does not have a closed patient population such as a substance abuse treatment program shall sponsor programs that promote access to HIV-related services offered by the facility and other providers within the community, and which are designed to increase community awareness of the modes of HIV transmission and the means of HIV prevention. The program shall be designed to strengthen provider linkages across the continuum of HIV care.
(f) Ongoing educational and support programs shall be provided to all regular staff of the CAHP. Inservice education programs shall address at least the following:
1. (1) medical and psychosocial needs of culturally diverse patients;
2. (2) confidentiality and legal issues with regard to HIV infection;
3. (3) the impact of HIV disease on the family unit; and
4. (4) stress management, psychosocial support and ongoing crisis counseling.
(g) The CAHP shall have an information management program with the capacity for monitoring and analyzing case-specific records that include, at a minimum, basic demographic information.