reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 32 - SAME-DAY STAY › Section 8:43G-32.20 - Same-day medical services continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of continuous quality improvement for same-day medical service that is
				integrated into the hospital continuous quality improvement program and includes
				regularly collecting and analyzing data to help identify health-service problems and
				their extent, and recommending, implementing, and monitoring corrective actions on
				the basis of these data.
(b) The
				infection control program shall monitor infection control practices and outcomes for
				same-day medical patients. If same-day medical patients are treated on inpatient
				units, the infection control program for those units shall fulfill this
				requirement.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 32 - SAME-DAY STAY › Section 8:43G-32.21 - Observation services; scope

Current through Register Vol. 56, No. 14, July 15, 2024
The standards set forth in
				  8:43G-32.22 and 32.23 shall apply to a
				  service, unit, or area(s), separate from the emergency department and designated by
				  the hospital for the purpose of monitoring and/or observing patients who have not
				  yet been determined to require inpatient admission.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 32 - SAME-DAY STAY › Section 8:43G-32.22 - Observation service policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				have a clearly defined plan and written policies and procedures for the use of an
				observation service that are reviewed at least once every three years, revised as
				needed, and implemented. These policies and procedures shall include at least:
1. Criteria for admission to and discharge from
				the service;
2. Professional nursing
				supervision and nurse staffing;
3.
				Criteria for length of stay (which shall be less than 24 hours total stay within the
				hospital unless the patient has been admitted);
4. Quality assurance and review; and
5. Use of beds on an inpatient unit for
				observation as set forth at
				8:43G-32.23(b).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 32 - SAME-DAY STAY › Section 8:43G-32.23 - Observation service space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Prior to
				implementation, the hospital shall inform the Department in writing of the location
				and the number of spaces in the service.
(b) The hospital may mix observation beds and
				inpatient beds in the same room provided the following requirements are met:
1. Observation patients are included in the
				patient-to-nurse staffing ratio of the nursing unit on which the observation patient
				is placed; and
2. Policies and
				procedures specific to the use of an inpatient unit for observation purposes are in
				place prior to the commencement of this practice.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.1 - Social work structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each hospital shall
				have an organized social services department or function, with social services
				performed by social workers under the direction of a licensed social
				worker.
(b) There shall be an
				organizational chart or alternative documentation clearly delineating the lines of
				responsibility, authority and communication for the social services department or
				function.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.2 - Social work policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The social work
				department shall have written policies and procedures that are reviewed at least
				once every three years, revised more frequently as needed, and implemented. The
				policies and procedures concerning the scope of social work services shall address
				the following areas: counseling, discharge management and planning, social work
				assessment, consultation and referral, patient advocacy, community liaison, and
				education.
(b) The social work
				department shall have a protocol to ensure that social work services are offered to
				all patients who need or request them.
(c) The social services department or function
				shall have criteria for identifying at the time of admission and promptly assessing
				high-risk patients in need of psychosocial intervention and/or discharge
				planning.
(d) The social work department
				shall participate in the development and review of the hospital's agreements with
				extended and long-term care facilities.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.3 - Social work staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				director of the social work department who is licensed by the New Jersey State Board
				of Social Work Examiners in compliance with rules at N.J.A.C. 13:44G.
(b) Each social worker shall be certified or
				licensed by the New Jersey State Board of Social Work Examiners.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.6 - Social work patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				system for clinical staff to refer patients directly to the social work
				department.
(b) The social worker shall
				consult with members of other disciplines in providing patient care
				services.
(c) Each patient who has
				received social work intervention shall be informed that he or she may call the
				social work department with questions after discharge.
(d) Families or guardians shall be included in
				services provided by the social work department, where indicated.
(e) The social work department shall assist
				patients directly or indirectly in identifying the need for, implementing, and
				verifying guardianship as part of discharge planning.
(f) The social work department shall coordinate
				child-abuse reporting and follow-up services with appropriate follow-up agencies in
				accordance with 9:6-1 et seq. The department shall
				participate in reporting and follow-up services for other victims of
				abuse.
(g) When a patient is transferred
				to another health care facility or linked to another health care agency after
				discharge, the social work department shall assure that relevant social work
				services documentation or information, if available, is provided to that agency or
				facility in order to assure continuity of care.
(h) When social work intervention is provided, the
				social work department shall enter into the medical record:
1. The reason for intervention;
2. The name or names of social workers involved
				and dates of intervention;
3. A social
				work assessment;
4. A treatment plan and
				referrals; and
5. Notes reflecting
				interventions before discharge.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.8 - Social work space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All reasonable
				efforts shall be made for privacy in patient and family interviews and in the
				handling of confidential phone calls by social workers.
(b) Social work department files on patients shall
				be kept physically secure and confidential.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.9 - Social work staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the social work staff education program shall be
				  as provided in 8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 33 - SOCIAL WORK › Section 8:43G-33.10 - Social work continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a program of continuous quality improvement for
				  social work that is integrated into the hospital continuous quality improvement
				  program and pertains to the scope of social work services provided. The program
				  shall include regularly collecting and analyzing data to help identify
				  health-service problems and their extent, and recommending, implementing, and
				  monitoring corrective actions on the basis of these data.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.1 - Surgery structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be an organizational chart, or alternative
				  documentation that delineates the lines of authority, responsibility, and
				  accountability of staff in surgery services.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.3 - Surgery policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Surgery services
				shall have written policies and procedures that are reviewed at least every three
				years, revised more frequently as needed, and implemented. They shall include at
				least:
1. Aseptic practices;
2. Infection control policies for the surgical
				suite, including attire which is commercially laundered;
3. Processing, packaging, and sterilization of
				materials in the suite; and
4. Special
				procedures for handling of trash from the surgical suite.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.4 - Surgery staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director who is clinically responsible for surgical services and is board
				certified.
(b) There shall be a person
				with administrative responsibility for the surgical service.
(c) Each surgical suite shall have available a
				roster of physicians with delineation of current surgical privileges, including
				those with temporary privileges.
(d) The
				hospital shall maintain a list of surgical procedures that require the presence of a
				physician to act as first assistant.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.5 - Surgery staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A registered
				professional nurse shall be assigned to circulating nurse duties in each room where
				surgery is being performed.
(b) All
				registered professional nurses in the unit shall maintain certification in Basic
				Cardiac Life Support.
(c) During
				scheduled hours of operation, personnel who have received special training in
				cleaning the surgical suite shall be assigned to the surgical suite for cleaning and
				related duties.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.6 - Surgery patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A patient
				identification system shall be implemented and patient identification shall be
				verified prior to any surgical procedure.
(b) There shall be a policy and procedure to
				verify the site and side of any and all surgical procedures. The procedure site and
				side shall be documented on the operative consent form.
(c) There shall be oral verification of the
				correct site and side of the surgical procedure in the operating room by a surgical
				team member in accordance with hospital policy.
(d) There shall be a system to ensure that
				surgical patients' personal effects are secured during surgery.
(e) The surgery services staff shall take
				precautions to prevent patient falls and injuries during transportation, transfer,
				and positioning through the use of side rails or restraint straps, and control
				devices on stretchers and operating tables.
(f) Each surgical patient shall have a medical
				record in accordance with the medical records policies of the hospital. The medical
				record shall be available to surgical suite personnel prior to surgery and shall
				include at least:
1. A written informed consent
				form signed by the patient or legal guardian or authorized person according to
				hospital policy that includes identification of the physician(s) performing the
				procedure prior to all procedures requiring informed consent;
2. A completed preoperative checklist;
3. A medical history and the results of a physical
				examination; and
4. Diagnostic tests
				results as determined by hospital policy.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.7 - Surgery space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The surgical suite
				shall be maintained as a closed unit. Access to the surgical suite shall be
				restricted in accordance with hospital policies and procedures.
(b) All staff in the surgical suite shall be
				attired in scrub attire. Individuals who are permitted limited access shall be
				attired according to hospital infection control policies.
(c) Procedures shall be in place for the handling
				of soiled laundry and trash, which shall be bagged and collected at the termination
				of each procedure and transported to the soiled holding area.
(d) Procedures shall be in place for the handling
				of soiled laundry and trash, which shall be placed in closed containers in each
				operating room. Medical waste and sharps shall be handled in accordance with current
				applicable State and Federal rules and regulations.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.8 - Surgery supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Emergency equipment
				available in the surgical suite shall include at least the following:
1. An emergency call system to include at least an
				emergency communication system that connects each operating room and postanesthesia
				care unit with the control center of the suite.
2. A difficult airway container or cart shall be
				immediately available for handling emergencies. The following items are required for
				inclusion in the difficult airway container or cart:
i. Manual breathing apparatus;
ii. A cardiac monitor;
iii. A defibrillator;
iv. A portable suction setup;
v. A thoractomy set; and
vi. A tracheostomy set and endotracheal tubes
				including sizes adaptable to newborns, infants and children; and
3. There shall be a mechanism for
				testing the emergency equipment on a regular basis and documenting that it is in
				working condition.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 34 - SURGERY › Section 8:43G-34.11 - Surgery continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				complete and current record of all surgical procedures.
(b) The hospital's quality improvement program
				shall include a systematic review and evaluation of patient care, anesthesia
				practices and anesthesia techniques. The surgical staff shall identify problem-prone
				processes which manifest undesirable patterns. The hospital shall develop a plan by
				which to collect and analyze data in order to evaluate outcomes or performance of
				the problem-prone processes. Data analysis shall focus on recommendations for
				implementing corrective actions and improving performance.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.1 - Postanesthesia care policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The postanesthesia
				care unit shall have written policies and procedures that are reviewed at least
				every three years, revised more frequently as needed, and implemented. They shall
				include at least:
1. Criteria for admission to and
				discharge from the unit;
2. Delineation
				of the primary medical responsibility for postanesthesia and postsurgical care of
				the patient in the unit;
3. Monitoring
				of patients in the postanesthesia care unit, including availability of monitoring
				equipment;
4. Protocol of care for all
				patients;
5. Protocol for patient
				emergencies;
6. Orders for intravenous
				administration of medications; and
7.
				Requirements for documentation of patient status.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.2 - Postanesthesia care staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director with overall responsibility for postanesthesia care. The
				physician director may also be the director of anesthesia services.
(b) There shall be a registered professional nurse
				with administrative responsibility for nursing care in the postanesthesia care
				unit.
(c) Documentation shall be
				available to show that all registered professional nurses assigned to the
				postanesthesia care unit meet the minimum competence levels, including at least:
1. Management of airway and ventilatory
				functions;
2. Monitoring of cardiac
				function, arrhythmia recognition, and treatment of life-threatening
				emergencies;
3. Management of the
				patient during altered states of consciousness;
4. Management of monitoring and respiratory
				equipment;
5. Management of fluid lines,
				tubes, drains, and catheters;
6.
				Administration of drugs and identification of drug-related problems; and
7. Recognition of the actions and interactions of
				anesthetic techniques.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.3 - Postanesthesia care staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be at
				least two health care personnel, one of whom is a registered professional nurse and
				the other of whom is either a licensed practical nurse, a registered professional
				nurse, or a physician, present whenever a patient is in the postanesthesia care
				unit.
(b) There shall be a ratio of at
				least one registered professional nurse for every three patients in the
				postanesthesia care unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.4 - Postanesthesia care patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The patient shall be
				accompanied to the postanesthesia care unit by two individuals, one of whom,
				stationed at the patient's head, shall be responsible for the patient's
				airway.
(b) An oral report on the
				patient's condition shall be given to postanesthesia care unit nursing staff by a
				member of the anesthesia team when the patient is admitted to the postanesthesia
				care unit.
(c) A member of the
				anesthesia team shall stay with the patient in the postanesthesia care unit at least
				until the patient's vital signs, including temperature, pulse, respiration, and
				blood pressure, are recorded.
(d) The
				postanesthesia care unit staff shall continually evaluate the condition of each
				patient and maintain an accurate written report of his or her vital signs, with an
				objective scoring system used to track the patient's recovery from anesthesia from
				the time of admission to the unit until discharge.
(e) Electrocardiographic monitoring shall be
				conducted for each patient, unless such monitoring is not clinically feasible for
				the patient.
(f) Each patient shall be
				monitored by pulse oximetry, unless such monitoring is not clinically feasible for
				the patient.
(g) The postanesthesia care
				unit shall have immediate access to end-tidal carbon dioxide monitoring, if general
				anesthesia is administered to intubated patients in the facility.
(h) The medical record maintained for each patient
				in the postanesthesia care unit shall include at least such preoperative data as
				allergies, physical and mental impairments, prostheses, electrocardiogram, vital
				signs, radiologic findings, laboratory values, drug use, and mobile
				limitations.
(i) The Post Anesthesia
				Care Unit record maintained for each patient in the postanesthesia unit care shall
				include at least such postoperative data as the patient's general condition,
				respiration, consciousness, circulation, temperature, special problems or
				precautions, summary of fluids received during surgery, and oxygen
				saturation.
(j) Patients shall be
				discharged from the postanesthesia care unit using discharge criteria, including
				authority to discharge, which have been developed through the postanesthesia
				policies and procedures set forth at
				8:43G-35.1(a)1.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.6 - Postanesthesia care supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Postanesthesia care
				units shall be adjacent to or within the operating suite and the obstetrics
				suite.
(b) The postanesthesia care unit
				shall be maintained as a closed unit. Access to the postanesthesia care unit shall
				be in accordance with hospital policies and procedures.
(c) All staff in the postanesthesia care unit
				shall be attired in scrub attire. Individuals who are permitted limited access shall
				be attired according to hospital infection control policies.
(d) Equipment available in the postanesthesia care
				unit shall include at least a crash cart with defibrillator, drugs, pulse oximetry,
				electrocardiographic monitoring, body temperature monitoring, equipment necessary
				for intubation and various means of oxygen delivery. Constant and intermittent
				suction, blood pressure monitoring, adequate lighting, peripheral nerve stimulator,
				immediate access to a ventilator, and end-tidal carbon dioxide monitoring in
				accordance with 8:43G-35.4(g)  shall be
				made available. Provisions to ensure the patient's privacy shall be made.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.7 - Postanesthesia care staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the postanesthesia education program shall
				  conform to the standards set forth in
				  8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 35 - POSTANESTHESIA CARE › Section 8:43G-35.9 - Postanesthesia care continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital's
				quality improvement program shall include a systematic review and evaluation of
				patient care, anesthesia practices and anesthesia techniques. The surgical staff
				shall identify problem-prone processes which manifest undesirable patterns. The
				hospital shall develop a plan by which to collect and analyze data in order to
				evaluate outcomes or performance of the problem-prone processes. Data analysis shall
				focus on recommendations for implementing corrective actions and improving
				performance.
(b) Continuous quality
				improvement activities shall include at least the monitoring of outcomes for
				patients receiving anesthetic agents and postdischarge follow-up of surgical
				procedures.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All satellite emergency departments shall be
				owned and operated by an acute care general hospital and shall comply with the rules
				in this subchapter and all applicable requirements of this chapter. All satellite
				emergency departments shall provide emergency treatment and care within the scope of
				this subchapter for those patients, who are transported by basic life support (BLS)
				transport service and other ambulatory arrivals.
(b) A satellite emergency department shall be
				licensed only to replace the full service emergency department of a licensed general
				acute care hospital which has approval from the Department to cease operation of all
				of its licensed acute care beds. The satellite emergency department shall be located
				in as close proximity to the closed full service emergency department as is
				possible. This location shall require the prior written approval of the Department.
1. For each full service emergency department
				which has closed, only one satellite emergency department shall be licensed to
				provide care.
2. Priority for licensing
				satellite emergency departments shall be given to the entity or its parent which was
				previously licensed to operate the full service emergency department or to an entity
				with a formal affiliation to one of the latter at the time licensing of the
				satellite emergency department is requested.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall
				  have the following meanings, unless the context clearly indicates otherwise.
"Advanced life support" means an advanced level of pre-hospital,
				  inter-hospital, and emergency service care which includes basic life support
				  functions, cardiac monitoring, cardiac defibrillation, telemetered
				  electrocardiography, intravenous therapy, administration of specific medications,
				  drugs and solutions, use of adjunctive ventilation devices, trauma care, and other
				  techniques and procedures authorized by the Commissioner.
"Basic life support" means a basic level of pre-hospital care
				  which includes patient stabilization, airway clearance, cardiopulmonary
				  resuscitation, control of hemorrhage, initial wound care, fracture stabilization,
				  and other techniques and procedures specified in
				  8:40A-1.2 and authorized by the
				  Commissioner.
"Department" means the New Jersey State Department of Health and
				  Senior Services.
"Licensee" means acute care hospital authorized by the Department
				  to own and operate a satellite emergency department and on whom the responsibility
				  for maintaining acceptable standards in all areas of operation of the satellite
				  emergency department.
"Low utilization" means an average of 16 patients or less over an
				  eight hour consecutive period of time for the most recent six months prior to the
				  request to reduce hours of operation.
"Satellite emergency department" means a facility, which is owned
				  and operated by a licensed New Jersey general acute care hospital, which shall
				  provide emergency care and treatment for patients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.3 - Services in satellite emergency departments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All laboratory
				services provided in the satellite emergency department shall comply with the
				requirements of N.J.A.C. 8:45, Standards for Clinical Laboratory Services, and all
				radiology services shall comply with applicable requirements of N.J.A.C. 7:28-19,
				Medical Exposure to Ionizing Radiation by Radiological Technologists.
(b) All satellite emergency departments applying
				for licensure shall provide the following services:
1. Basic life support emergency care and
				services;
2. Basic and stat laboratory
				services including:
i. Arterial blood
				gases;
ii. Creatinine;
iii. Electrolytes;
iv. Glucose (blood);
v. CBC;
vi. Strep screening;
vii. Urinalysis; and
viii. Pregnancy tests;
3. Basic radiology services, which shall include
				at a minimum non-enhanced and non-contrasted radiographs;
4. Emergency contraception, upon request, to
				sexual assault victims and medically and factually accurate and objective verbal and
				written information about emergency contraception and sexually transmitted diseases,
				pursuant to N.J.A.C. 8:43G-12A; and
5.
				The hospital shall develop and implement written policies and procedures to support
				breastfeeding for a mother and/or child who presents at an SED, in accordance with
				8:43G-12.2(j)  and
				12.4(e).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.5 - Patient rights

Current through Register Vol. 56, No. 14, July 15, 2024
Every New Jersey satellite emergency department patient has the
				  same rights as required in N.J.A.C. 8:43G-4, with the exception of
				  8:43G-4.1(a)  14. None
				  of the patient rights shall be abridged by the satellite emergency department or the
				  hospital that owns and operates the satellite emergency department. The
				  administrator of the satellite emergency department or the administrator of the
				  hospital licensed to operate the satellite emergency shall be responsible for
				  developing and implementing policies to protect patient rights and to respond to
				  questions and grievances pertaining to patients rights.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.6 - Administrative and structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A satellite
				emergency department may be licensed as a free-standing ambulatory care facility
				owned and operated by a hospital or as part of the hospital. If licensed as an
				ambulatory care facility, it must comply with the general ambulatory care facility
				requirements set forth in N.J.A.C. 8:43A as well as this subchapter. If the
				satellite emergency department is licensed as part of the hospital, it shall comply
				with the requirements set forth in
				8:43G-2.5 and the criteria set forth in
				8:43G-2.11, as well as this
				subchapter.
(b) An administrator of the
				satellite emergency department shall be designated in writing.
(c) The satellite emergency department shall have
				policies and procedures which pertain to:
1. All
				staff;
2. Admission and discharge of
				patients;
3. Procedures for obtaining
				patient's written consent for all medical treatment;
4. Patient advance directives;
5. Elder abuse;
6. Domestic violence;
7. The ability of family members and significant
				others to remain with patients during treatment;
8. Referrals to primary care physicians and
				specialists, to assure access to all appropriate clinical services and specialties
				even though immediate consultation is not necessary;
9. Transfer protocol;
i. Written transfer agreements must be in place
				assuring timely response to accomplish basic and advanced level transfers from a
				satellite emergency department to an acute care facility;
ii. Transfers requiring basic life support
				services shall be accomplished by a licensed ambulance in accordance with N.J.A.C.
				8:40;
iii. Transfers requiring advanced
				life support care shall be accomplished with a critical care transport team
				including a registered nurse and a licensed ambulance in accordance with N.J.A.C.
				8:40-6.22; and
iv. Transfers may be by
				other means as deemed appropriate by the physician;
10. Pharmacy services, including controlled
				substances;
11. Procedural
				sedation;
12. Infection
				control;
13. Dietary;
14. Linens;
15. Housekeeping;
16. Lab services;
17. Payment source;
18. Policies and procedures for handling an
				unexpected influx of patients; and
19.
				Policies and procedures for maintaining a record of hospital employees, medical
				staff members, and volunteers who can speak languages other than English or know
				sign language for the hearing impaired and can provide interpretive services to
				patients. This record shall include the work shifts of hospital employees.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.7 - Reportable events

Current through Register Vol. 56, No. 14, July 15, 2024
The satellite emergency department shall comply with the
				  requirements of N.J.A.C. 8:43G-5.6.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.8 - Administrative and staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Physician
				qualifications for satellite emergency departments are as follows:
1. There shall be a physician director of the
				satellite emergency department, who may also be the director of the hospital's
				emergency department, who is board certified in emergency medicine or who has five
				years of full-time experience in emergency medicine, which may include three years
				residency in emergency medicine, within the past seven years. If the physician
				director of the satellite emergency department is not the physician director of the
				hospital emergency department, then there shall be coordination of all care and
				services between the two to ensure care delivery and quality improvement in
				accordance with 8:43G-5.16.
2. Each physician practicing in the satellite
				emergency department, except residents functioning under supervision as part of a
				hospital's graduate residency training program, consulting physicians, and private
				physicians who are attending to their patients in the satellite emergency
				department, shall meet at least one of the following qualifications:
i. Board certification or current eligibility to
				be certified in emergency medicine;
ii.
				Successful completion of an approved residency program in emergency medicine, family
				medicine, general internal medicine, general surgery, or general pediatrics;
				or
iii. Three years of full-time
				clinical experience in emergency medicine within the past five years.
3. Each physician practicing in the
				satellite emergency department, except residents functioning under direct
				supervision as part of the hospital's residency program, consulting physicians, and
				private physicians who are attending to their patients in the emergency department,
				shall attain provider status in Advanced Cardiac Life Support and either Advanced
				Pediatric Life Support or Pediatric Advanced Life Support within 12 months of
				initial assignment, and shall continuously maintain this status thereafter.
				Physicians who are board certified in emergency medicine shall be exempt from this
				requirement.
4. Each physician
				practicing in the satellite emergency department, except residents functioning under
				direct supervision as part of a hospital's graduate residency program, consulting
				physicians, and private physicians who are attending to their patients in the
				satellite emergency department, shall attain provider status in Advanced Trauma Life
				Support within 12 months of initial assignment, and shall continuously maintain this
				status thereafter. Physicians who are board certified in emergency medicine shall be
				exempt from this requirement.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.9 - Staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The satellite
				emergency department shall have all personnel identified in
				8:43G-36.8(a)  onsite
				at all times during hours of operation.
(b) No patient who comes to the satellite
				emergency department shall be discharged to home or another facility without being
				seen and evaluated by qualified medical personnel. This evaluation shall occur
				within four hours of the patient's coming to the satellite emergency
				department.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.10 - Administrative and staff education

Current through Register Vol. 56, No. 14, July 15, 2024
The satellite emergency departments shall comply with the
				  requirements of 8:43G-5.7 and 5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.11 - Occupational health structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
The satellite emergency department shall comply with the
				  requirements of 8:43G-5.11, 5.12, 5.13, 5.14 and
				  5.15.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.13 - Mandatory equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				equipment shall be located within the satellite emergency department at all times:
1. Basic and stat laboratory equipment/supplies,
				with at least the capability to perform the following laboratory testing and
				evaluation:
i. Arterial blood gases;
ii. Creatinine;
iii. Electrolytes;
iv. Glucose (blood);
v. CBC;
vi. Strep screening;
vii. Urinalysis; and
viii. Pregnancy tests;
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.14 - Continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The satellite
				emergency department shall comply with
				8:43G-5.15.
(b) On a quarterly basis, beginning with the
				closest calendar quarter after commencing operation, the satellite emergency
				department shall submit the following information to the Department's Licensing
				Office:
1. The total volume of patients for the
				quarter;
2. The number of transfers to
				the hospital licensed to operate the satellite emergency department (which
				statistics shall identify a breakout of all BLS and ALS levels);
3. The number of transfers to other
				hospitals;
4. The mode of arrival at the
				satellite emergency department for each patient during the quarter; and
5. The number of transfers for further diagnostic
				study.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 36 - SATELLITE EMERGENCY DEPARTMENTS › Section 8:43G-36.15 - Physical plant

Current through Register Vol. 56, No. 14, July 15, 2024
A building or structure being considered for use as a satellite
				  emergency department, located independent from an acute care hospital shall comply
				  with all the requirements of Use Group B in chapter 20 of the
NFPA
				  101
:
Life Safet
. National Fire Protection Association
				  (NFPA). This book is available from NFPA, 1 Batterymarch Park, Quincy, MA
				  02269-7471. Phone: (800) 344-3555. Fax: 800 593-NFPA. Website: www.nfpa.orgy
Code, 2012 Edition
. A satellite emergency department that remains
				  located in a former acute care hospital shall continue to comply with the
				  requirements of
N.J.A.C. 8:43A-19.1
of the
				  Manual of Standards for Licensing of Ambulatory Care Facilities.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 37 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY SERVICES › Section 8:43G-37.1 - Extracorporeal shock wave lithotripsy services

Current through Register Vol. 56, No. 14, July 15, 2024
All general hospitals providing extracorporeal shock wave
				  lithotripsy services shall conform to the applicable criteria set forth in this
				  chapter as well as the provisions set forth in N.J.A.C. 8:43A-29.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.1 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Special hospitals
				providing long term acute care services shall comply with all standards set forth in
				this subchapter and all applicable provisions of this chapter.
(b) The rules in this subchapter apply to special
				hospitals providing long term acute care services either as a freestanding facility
				or as part of a licensed general hospital (hospital within a hospital).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.2 - Compliance with rules and laws

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All special
				hospitals providing long term acute care services (LTAC) shall be licensed by the
				Department and comply with the licensing procedures set forth at N.J.A.C.
				8:43G-2.
(b) All beds maintained by a
				special hospital providing long term acute care services shall be licensed as long
				term acute care beds.
(c) All special
				hospitals providing long term acute care services shall comply with the rules of the
				United States Department of Health and Human Services at 42 CFR Part 412 et al.
				incorporated herein by reference as amended and supplemented.
(d) All special hospitals applying for licensure
				shall provide or arrange for the provision of the following professional
				departments, services, facilities or functions:
1.
				Administration;
2. Anesthesia/Sedation
				Services;
3. Blood Bank;
4. Central Supply;
5. Clinical and Pathological
				Laboratories;
6. Dietary
				Services;
7. Discharge
				Planning;
8. Employee and Occupational
				Health;
9. Electrocardiogram
				Laboratory;
10. Housekeeping and Laundry
				Services;
11. Infection Control and
				Sanitation;
12. Medical
				Library;
13. Medical Records;
14. Medical Services;
15. Medical Staff;
16. Morgue and Autopsy Facilities;
17. Nursing Service;
18. Pharmacy Department;
19. Physical and Occupational Therapy;
20. Physical Plant and Maintenance;
21. Post Anesthesia Care Unit;
22. Quality Assurance;
23. Radiology;
24. Respiratory Therapy Services; and
25. Social Work Department.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.3 - Special hospital policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Special hospitals
				shall have written policies and procedures that are reviewed at least once every
				three years, revised more frequently as needed, and implemented. They shall include
				at least:
1. Criteria for admission to, and
				discharge and transfer from, the hospital;
2. A visitors policy that specifies visiting hours
				and number of visitors permitted each patient at one time, subject to the discretion
				of the patient's physician or primary care nurse;
3. Protocols for transfer and transport of
				patients within the hospital or from the hospital to another facility, including who
				shall accompany the patient being transferred or transported;
4. A policy defining the physician specialist and
				consulting physician to be called for patient emergencies, including a response time
				for physicians to respond to patient emergencies;
5. Standing orders for patient
				emergencies;
6. A policy on the removal
				of a patient's life support system pursuant to N.J.A.C. 8:43G-4; and
7. Educational policies for the patient and
				families to manage their present and future healthcare needs.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.4 - Special hospital staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director with clinical responsibility for the care rendered throughout the
				facility.
(b) The physician director
				shall be board certified in internal medicine and licensed or authorized to practice
				medicine by the New Jersey Board of Medical Examiners.
(c) A physician shall visit each patient at least
				on a daily basis and as needed.
(d) A
				physician shall be present in a freestanding special hospital providing LTAC
				services at all times. A hospital-within-hospital LTAC shall have a physician
				availability agreement with the host facility, which arranges for physician
				consultative or care services to be available within 15 minutes of the LTAC's
				notification of the host facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.5 - Staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Nursing staff shall
				be determined by the acuity of illness of the patient. The hospital shall develop
				written policies and procedures for determining and relating patient acuity to
				nursing staff levels.
(b) There shall be
				a full-time director of nursing or nursing administrator who is a registered
				professional nurse licensed by the New Jersey Board of Nursing pursuant to
				45:11-23 et seq. and N.J.A.C. 13:38,
				who has at least two years of supervisory experience in providing care to patients
				with acute illness/injury superimposed on complex or multiple
				co-morbidities.
(c) In the case of
				specialized care units treating ventilation dependent patients, the facility shall
				provide staffing for the nursing unit on which the ventilation beds are located that
				includes the 24-hour per day presence on the unit of at least one registered nurse
				and the 24-hour per day on site presence of at least one respiratory
				therapist.
(d) There shall be a
				mechanism in place to access nutritional support services for advice on both enteral
				and parenteral nutritional techniques.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 38 - LONG TERM ACUTE CARE HOSPITALS GENERAL REQUIREMENTS › Section 8:43G-38.6 - Quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of continuous quality improvement which includes regularly collecting and
				analyzing data to help identify health-service problems and their extent, and for
				recommending, implementing, and monitoring corrective actions on the basis of these
				data.
(b) The continuous quality
				improvement activities shall include morbidity and mortality conferences.
(c) The continuous quality improvement program
				shall include review of cases involving removal of life support.