New Jersey Administrative Code › Title 8 - HEALTH › Chapter 111 - FOOD AND DRUGS › Subchapter 4 - GOVERNING AUTHORITY › Section 8:111-4.1 - Responsibility of the governing authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Every facility shall have a governing authority, which shall assume legal
				responsibility for the management, operation, and financial viability of the
				facility. The governing authority shall have written policies and protocols for the
				following:
1. The organization's mission and
				purpose;
2. Ensuring that the
				organization is operating in accordance with its mission and, for non-profits, the
				purpose for which it was granted tax-exemption;
3. Providing financial oversight to ensure that
				proper financial controls are in place;
4. Ensuring adequate financial resources as part
				of their fiduciary responsibility, which may include such responsibilities as
				personal contribution, financial planning, fundraising, grants management and
				serving as an advocate;
5. Exercising
				duty of care (reasonable care while decision making), duty of loyalty (acting in the
				best interests of the organization without personal gain) and the duty of obedience
				(being faithful to the organization's mission while managing funds for that
				purpose);
6. Appointing and supervising
				an administrator (that is, president, CEO, executive director, etc.) whose
				references, credentials, professional license and criminal background are reviewed
				and verified, and reconciled with the organization's mission and administrator's
				scope of work.
i. The governing authority shall
				establish policies for hiring an administrator, including policies for individuals
				who may have past criminal convictions and/or have been sanctioned for professional
				ethical violations, which ensure that convictions/violations shall not impact his or
				her ability to perform duties.
ii. The
				governing authority must advise the administrator that he or she must disclose to
				the governing authority 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. Evaluating, at least annually, the performance
				of the administrator of the facility, including establishing requirements for the
				administrator's continuing education and professional development;
8. Approving, in writing, a person to be
				designated as the administrator's alternate;
9. Ensuring that the administrator has the
				professional support needed to further the mission and goals of the
				organization;
10. Ensuring legal and
				ethical integrity and maintaining accountability by observing legal standards and
				ethical norms;
11. Documenting all of
				the governing authority's actions and those of its committees by written minutes and
				maintaining minutes of meetings, including resolutions and motions pertaining to the
				fiscal and legal responsibilities of the governing authority;
12. Establishing a grievance mechanism available
				to both staff and clients;
13.
				Establishing a written notice system accessible to all staff and clients regarding
				the grievance procedures that shall include the name, address and telephone number
				for public access to the agency;
14.
				Establishing a feedback mechanism in order to receive and respond to staff and
				client recommendations;
15. Establishing
				client complaint procedures that support client rights, that are conspicuously
				posted and accessible to clients in client service areas and are understood by
				clients from point of service admission to discharge, as per N.J.A.C.
				8:111-6;
16. Reviewing and approving
				plans to establish new programs, or to substantially alter or discontinue existing
				services, substantial changes in levels of service and/or changes in populations
				served;
17. Ensuring that the client
				care policies required at N.J.A.C. 8:111-6are developed and maintained;
18. Establishing a pharmacy and therapeutic
				committee, if so required at N.J.A.C. 8:111-14.1(b);
19. Ensuring that infection control protocols and
				practices are adhered to;
20.
				Establishing protocols regarding child abuse and neglect, sexual abuse, elder abuse
				and institutional abuse or neglect, including duty to warn and protect;
21. Reviewing and approving the annual
				audits;
22. Reviewing and approving the
				facility's compensation plan for staff at least annually;
23. Establishing and approving an annual budget,
				including any capital projects, for all services to be provided at or through the
				facility in consultation with the administrator, fiscal officer and the service
				directors; and review with the administrator any material changes that may occur
				during the year with respect to either revenue or expenditures, including the
				reasons for the change;
24. Designating
				a member to certify financial statements by signature and establishing protocols to
				periodically review a sliding scale fee for services schedule, as well as procedures
				for assessing income and ability to pay for services;
25. Reviewing any notices issued by the Division
				regarding non-compliance with any requirements of this chapter or any violations of
				law by the facility, staff, volunteers, or consultants, ensuring corrective measures
				have been taken, and where appropriate, advising the Division of such corrective
				measures;
26. Establishing policy and
				procedures to ensure client's confidentiality as required by State and Federal laws
				(such as 42 CFR Part 2, HIPAA, etc.);
27. Developing conflict of interest and disclosure
				policies for members of the governing authority, paid and volunteer staff;
				and
28. If multiple facilities are
				operated by the governing authority, identifying how the committees and/or committee
				functions required by this chapter will be met if organization-wide committees are
				established.