(a) The facility or provider agency as program sponsor shall establish policies and procedures to protect patient rights. Such policies and procedures shall be consistent with the requirements of the program's operating certificate, including, but not limited to:

1. (1) standards governing staff conduct to ensure the protection of patient rights and to ensure the communication of such standards, rights and responsibilities to patients. When communicating, providers shall make every effort to accommodate patient differences in language and disabilities in accordance with applicable law;
2. (2) copies of a statement of the rights and responsibilities of patients shall be posted prominently and conspicuously throughout the provider's facility. This statement, at a minimum, shall include the requirements of sections 815.5 and 815.6 of this Part. Such postings shall also include contact information for the toll-free hotline to the Vulnerable Persons’ Central Register, the provider’s director, as the commissioner, the office patient advocate, and the office toll-free telephone number;

3. (3) the postings shall include the policy and procedures for addressing patient concerns or grievances with the provider and/or the office. Such policy shall include, at a minimum, the following rights:

   1. (i) to question a policy, voice a concern or grievance with the provider or the office;
   2. (ii) to receive a timely response and/or resolution;
   3. (iii) to not suffer adverse consequences or retaliation as a result; and
   4. (iv) to communicate with the provider’s director, medical director, board of directors, other responsible staff and the commissioner.
4. (4) A copy of this Part, and any other Part of this Title that is applicable to the provider, shall be provided to a patient upon request.
5. (5) The provider shall develop policies and procedures to help patients follow their treatment/recovery plan. Such policies and procedures shall specify standards and expectations for patient conduct, to achieve goals consistent with the plan, and consequences for failing to meet goals, including conduct which may result in discharge. Policies and procedures shall, at a minimum, address patient conduct with timely and appropriate incremental interventions designed to assist patients in responding positively to treatment. Such incremental interventions shall be incorporated and delivered consistent with the patient’s treatment/recovery plan; be time-limited, and documented in the patient's record. When a patient poses an imminent threat to others, immediate discharge may be warranted consistent with other provisions of this Part.
6. (6) The provider shall establish a policy and procedure for implementing quality improvements with respect to patient concerns and complaints, changes in regulatory requirements, or other factors, and shall review such policies no less frequently than once every two years. Documentation shall be kept of all such reviews.