New Jersey Administrative Code › Title 8 - HEALTH › Chapter 111 - FOOD AND DRUGS › Subchapter 1 - DEFINITIONS AND QUALIFICATIONS › Section 8:111-1.7 - Qualifications and responsibilities of the administrator of the facility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each facility shall
				hire an administrator who has, at a minimum, a Master's degree and two years of
				full-time, or full-time equivalent, administrative or supervisory experience in a
				licensed substance use disorders treatment facility.
(b) Individuals who do not meet the qualifications
				in (a) above must have a Bachelor's degree and five years of full-time, or full-time
				equivalent, administrative or supervisory experience in a licensed substance use
				disorders treatment facility.
(c) The
				administrator's responsibilities shall include, but need not be limited to, the
				following:
1. Providing administrative oversight
				of the facility;
2. Ensuring the
				development, implementation and enforcement of all policies and procedures as
				required under this chapter, including client rights;
3. Planning and administration of all operational
				functions including managerial, personnel, fiscal and reporting requirements of the
				facility;
4. Developing an
				organizational plan and ensuring that facilities and services are consistent with
				the organization's mission, while monitoring their effectiveness;
5. Establishing and implementing a formal quality
				assurance program that is comprehensive and integrated with the facility's
				programmatic quality assurance plans and programs; address all levels of treatment
				programming and client care; ensure that all personnel are assigned duties based
				upon their education, training, competencies and job description; while utilizing
				written, job-relevant criteria to make evaluation, hiring and promotional
				decisions;
6. Selecting and hiring
				responsibility for all staff, as well as participating in the determination of
				staffing issues including, but not limited to, establishing and maintaining policies
				ensuring references, credentials and criminal history background checks of all
				prospective staff and making certain that they have been reviewed and verified;
				developing written policies regarding the employment of family members, past and
				present governing body members and volunteers; developing written policies regarding
				hiring staff with past criminal convictions and/or ethical violations that ensure
				that the convictions/violations do not impact staff ability to perform duties; and
				developing policies for assessing staff performance, determining employment and
				termination decisions;
i. The administrator shall
				advise candidates and staff members that candidates and staff members must disclose
				to the administrator any disciplinary outcome imposed as a result of an
				investigation by any State licensing agency, law enforcement agency or professional
				disciplinary review board, such as disciplinary probation, suspension of license,
				revocation of license or criminal conviction at the time of initial employment
				and/or during employment if the action occurs after hire.
7. Ensuring the provision of timely staff
				orientation, education and supervision;
8. Establishing and maintaining liaison
				relationships and communication with facility staff, service providers, support
				service providers, community resources and clients;
9. Overseeing the development and implementation
				of policies and procedures, in conjunction with designated staff members, for the
				various services provided for in this chapter.
i.
				Ensuring that appropriate policies and procedures developed and implemented under
				this paragraph are shared with the governing authority;
10. Ensuring that admission interviews with
				clients are conducted in accordance with the facility's policies and procedures.
i. Admissions interviews with adolescent clients
				shall include the client's family, guardian or legally authorized
				representative;
11.
				Implementing and monitoring the quality of all services provided at the facility,
				including the review of program outcomes available through NJSAMS;
i. When appropriate, share facility outcome data
				with relevant staff, DMHAS, the Department and, when necessary, the governing
				authority;
12. Ensuring
				maintenance of the physical plant as necessary to ensure client and staff safety,
				and otherwise keeping the facility in compliance with all applicable building, fire
				and safety codes;
13. Establishing
				policies and procedures for provision of emergency services to clients, including
				policies and procedures for broader-based emergency situations resulting from either
				internal incidents, external incidents, or natural disasters.
i. Such policies shall include guidelines for the
				immediate notification to the Department of such situations, a contingency plan with
				a minimum of explanation of timeframes for service interruption to clients, closure
				and reopening of a facility and procedures governing the dispensing and, when
				necessary, monitoring of client treatment medications;
14. Establishing written policies and procedures
				for non-emergency closures.
i. Policies
				established under this paragraph shall include the timely notification to the
				Department of such closures, the timeframes for service interruption, closures and
				reopening, and procedures governing the dispensing and, where clinically necessary,
				monitoring of medications administered to clients.
ii. Facilities shall submit a written request to
				the Department at least 48 hours before closing for non-emergency reasons.
iii. Facilities shall not close for non-emergency
				reasons without receiving written approval from the Department to do
				so;
15. Identifying priority
				populations (for example, pregnant, intravenous drug users, women with children,
				HIV, etc.) for admission and treatment as evidenced by protocols, policies, and
				procedures to provide such treatment services, or where appropriate, referral
				procedures with interim services available until transfer is completed;
16. Ensuring that plans of correction, licensing
				deficiencies, and complaint reports are addressed as specified by the Department.
i. Ensure that such reports are shared with the
				governing authority in a timely manner;
17. Developing and implementing an infection
				prevention and control program;
18.
				Developing and implementing client safety policies and procedures that include, but
				are not limited to, forbidding staff to engage in client coercion, sexual harassment
				and sexual relationships with clients; and
19. Developing, implementing and providing
				administrative oversight of a volunteer services program, if the facility along with
				the governing authority elects to utilize such a program.