Four years after New York State’s Workplace Safety Committees law (NYS Labor Law Section 27-D) went into effect on November 1, 2021, which requires private employers to establish joint labor-management workplace safety committees upon employee request, NYS Governor Kathy Hochul has added more workplace safety requirements for New York State’s hospitals. This legal alert focuses on the new requirements pertaining to general hospitals.1
On December 12, 2025, Governor Hochul signed into law Senate Bill 5294B, enacting mandatory workplace violence prevention programs for certain health care facilities. The law amends the NYS Public Health Law by adding a new Section 2832, which now requires general hospitals and nursing homes to establish a workplace violence prevention program. The purpose of the legislation, and therefore the intended purpose of the program, is to protect not only health care workers but also patients, residents, and visitors.
The law becomes effective 280 days after the governor’s signature, on or about September 18, 2026. Hospitals and nursing homes will then have until September 18, 2027, to establish their Workplace Violence Prevention Program (within one year of the effective date of the law). However, beginning January 1, 2027, hospitals will be required to conduct safety and security assessments (no less frequently than once a year) and develop a safety and security plan that addresses the workplace violence threats and hazards identified by the assessment. Thus, planning and preparation should start now.
Workplace Violence Prevention Program
The new law requires that general hospitals’ Workplace Violence Program be consistent with the regulatory requirements of The Centers for Medicare & Medicaid Services’ (CMS) hospital conditions of participation for caring for patients in a safe setting (42 CFR 482.13(c)(2)) as well as emergency preparedness (42 CFR 482.15(a) and (d)(1)) in addition to workplace violence standards of any CMS–approved accrediting organization “provided that those standards are comparable to those established by the Joint Commission.” It is important to understand that the Joint Commission standards are the minimum to be followed from an accreditation standpoint.
These federal regulations require hospitals to develop and maintain an emergency preparedness training and testing program that is reviewed and updated every two years. They also require hospitals to provide initial training in emergency preparedness policies and procedures to staff and others who provide services, document the training that is conducted, demonstrate staff knowledge of the procedures, and retrain every two years as well as when the emergency preparedness policies and procedures are significantly updated.
The Joint Commission’s most recent standards on workplace violence prevention require that hospitals:
- Have a workplace violence prevention program, led by a designated person, that is developed by a multidisciplinary team
- Provide training, education, and resources to staff and leadership (at hire and regularly thereafter)
- Establish policies and procedures to “prevent and respond to violence,” report incidents for the purpose of analyzing and trending, follow up and support victims and witnesses, and report workplace violence to the governing body
- Complete an annual worksite analysis and act to mitigate or resolve identified safety and security risks
Workplace Safety and Security Assessment
General hospitals must thereafter annually conduct a workplace safety and security assessment and develop a safety and security plan that addresses identified workplace violence threats and hazards. As part of the plan, hospitals must adopt security measures and policies (including personnel training policies) that are designed to:
- Prevent or minimize identified violent threats or hazards
- Protect employees, patients, and visitors from aggressive or violent behavior
The law requires that hospitals engage certain other stakeholders in the process of developing a plan and performing the assessments. Specifically, hospitals must actively involve employees, including any collective bargaining agents, in the assessment and development of the plan. This may be done through established general hospital safety and security committees as well as existing labor-management committees.
Workplace violence assessments are expected to be tailored to the individual hospital, so this will not be a one-size-fits-all process. Assessments should be based upon and consider the size, complexity, and local geographical factors affecting the hospital and should identify and consider relevant threats and hazards by considering:
- Incident reports and incident logs
- Concerns or complaints raised by employees, patients, visitors, and recognized collective bargaining representatives
- Safety and security considerations relating to the general hospital’s layout and access points, visitor management, and protective factors, such as access control, engineering controls to limit violence or protect employees, and alarms and communication systems
The law requires that hospitals provide information to employees and collective bargaining representatives about how to report incidents of workplace violence. It also requires that hospitals share summaries of any incident logs (which would be redacted for privacy), trends, as well as analysis to the committee responsible for workplace violence and ensure the data is a part of the workplace safety and security assessment process.
Workplace Safety and Security Plan
Based upon the findings of the workplace safety and security assessment, general hospitals must then implement a workplace safety and security plan. The plan must be updated as needed to address any new risks or conditions and must specify the methods that will be used to reduce the identified risk. The law provides methods that may be utilized, such as training, increased staffing, increased security, and engineering controls such as barriers, lighting, and alarms.
Once the workplace safety and security plan is completed, hospitals must distribute a detailed written summary of the plan to employees and collective bargaining representatives.
Additional Security Requirements
The new law also adds requirements regarding emergency department security, which are dependent upon the size of the population of the community in which the hospital is located.
A general hospital located in a city or county with a population of one million or more is required to always have at least one off-duty law enforcement officer or trained security personnel present in the emergency department unless an emergency requires a change.
A general hospital located in a city or county with a population less than one million is required to have an off-duty law enforcement officer or trained security personnel on their premises at all times “in a manner that prioritizes physical presence near, or within close proximity to, the emergency department” and with “direct responsibility to the emergency department.”
These additional security requirements do not apply to hospitals designated as critical access hospitals, sole community hospitals, or rural emergency hospitals. If internal reporting through the hospital’s workplace safety and security program or reports to law enforcement reveal the hospital is experiencing increased rates of violence against emergency department personnel, the hospital can become subject to the same requirements as general hospitals in communities with populations less than one million. The measure of increased rates of violence that will trigger this requirement is to be determined by the commissioner.
Ensuring Compliance: Next Steps for General Hospitals
- Review requirements under the new law.
- Ensure the appropriate committee is in place to address new requirements.
- Form multidisciplinary teams to ensure all meetings are productive, detailed assessments are conducted, data is neatly gathered and accurately analyzed, and plans are carried out.
- Document all action and verify results.
If you have any questions regarding the content of this alert, please contact Traci Boris, partner, at tboris@barclaydamon.com, or another member of the firm’s Health & Human Services Providers Team.
1For nursing homes, compliance with federal regulations 42 CFR 483.71(a)(3) and (b)(1) and 42 CFR 483.73(a)(1) governing nursing homes will satisfy the requirements of the new law as long as the required assessments and plans address workplace violence threats and hazards. To the extent that a nursing home’s Facility Assessment and Emergency Preparedness activities do not include assessments and plans that address workplace violence threats and hazards, the specificity of the new law provides some guidance on what regulatory agencies will want to see.