New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.11 - Hospital satellite facilities and off-site ambulatory care service facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A
				satellite hospital facility may be operated under the effective supervision of an
				existing hospital.
(b) Individual
				licenses shall not be required for separate hospital buildings and services located
				on the same or adjoining grounds, if these are operated under one
				management.
(c) All off-site ambulatory
				care service facilities, including mobile units, must be licensed to operate by the
				Department. A hospital may seek licensure and classification of off-site ambulatory
				care service facilities as either "free-standing" or "hospital-based" facilities.
				Both "free-standing" and "hospital-based" off-site ambulatory care service
				facilities shall be separately inspected and separately licensed in accordance with
				the provisions set forth at
N.J.A.C. 8:43A
, Standards for Licensure
				of Ambulatory Care Facilities. All off-site ambulatory care service facilities ar
1. The hospital-based off-site ambulatory care
				service facility is integrated with and subordinate and accountable to the hospital.
				Services provided at the off-site location are clinically integrated with other
				departments of the hospital and staff members are employees of the hospital. Where
				applicable, credentialing of hospital-based ambulatory care service facility staff
				is performed by the hospital credentialing committee. Where applicable, the
				hospital-based ambulatory care service facility is required to comply with the
				provisions set forth at
				8:43G-4.1, Patient rights.
2. The hospital-based ambulatory care service
				facility administrator is subordinate to and reports to an identified administrator
				at the hospital. The hospital Chief Medical Officer (or similar official) is also
				responsible for the medical direction of the hospital-based ambulatory care service
				facility.
3. If the hospital is
				accredited, the hospital-based ambulatory care service facility is included in the
				accreditation and the accrediting body recognizes the hospital-based ambulatory care
				service facility as part of the hospital.
4. The hospital-based off-site ambulatory care
				service facility is operated under common ownership and control and by the same
				governing body as the hospital. The factors considered in evaluating this criterion
				are one or more of the following:
i. The
				hospital-based ambulatory care service facility and the hospital are subject to
				common by-laws and operating decisions of the governing body;
ii. Final responsibility for administrative
				decisions, personnel actions and approval of hospital-based ambulatory care service
				facility medical staff appointments rests with the hospital;
iii. The hospital-based ambulatory care service
				facility functions as a department of the hospital; and/or
iv. The hospital has written policies, procedures
				and protocol applicable to the hospital-based ambulatory care service facility,
				assuring that the requirements of this section are followed.
5. The director of the hospital-based ambulatory
				care service facility must function under the day-to-day supervision of the
				hospital. The factors considered in evaluating this criterion are one or more of the
				following:
i. The hospital-based ambulatory care
				service facility director (or the individual responsible for the day-to-day
				operation of the hospital-based ambulatory care service facility) reports daily and
				is accountable to the chief executive officer of the hospital and also reports to
				the hospital governing body through the chief executive officer;
ii. Medical records, billing, laundry,
				housekeeping, purchasing and all other administrative functions of the
				hospital-based ambulatory care service facility are integrated with those of the
				hospital; and/or
iii. The hospital has
				written policies, procedures and protocol applicable to the hospital-based
				ambulatory care service facility, assuring that the requirements of this section are
				followed.
6. All
				hospital-based ambulatory care service facility clinical services are integrated
				with those of the hospital. The factors considered in evaluating this criterion are
				one or more of the following:
i. Hospital-based
				ambulatory care service facility professional staff have clinical privileges in the
				hospital;
ii. Where applicable, the
				hospital-based ambulatory care service facility medical director reports to the
				chief medical officer (or similar official) of the hospital on a daily
				basis;
iii. All hospital medical staff
				and other professional committees are responsible for all medical activities at the
				hospital-based ambulatory care service facility;
iv. Medical records for patients treated in the
				hospital-based ambulatory care service facility are integrated into the unified
				records system of the hospital;
v.
				Patients treated at the hospital-based ambulatory care service facility are
				considered patients of the hospital and have full access to all hospital
				services;
vi. Patient services provided
				at the hospital-based ambulatory care service facility are integrated with
				corresponding hospital inpatient and/or outpatient services, as appropriate;
				and/or
vii. The hospital has written
				policies, procedures and protocol applicable to the hospital-based ambulatory care
				service facility, assuring that the requirements of this section are
				followed.
7. The
				hospital-based ambulatory care service facility is held out to the public as part of
				the hospital such that patients know they are entering the hospital and will be
				billed accordingly.
8. The hospital and
				the hospital-based ambulatory care service facility are financially integrated. The
				factors considered in evaluating this criterion are one or more of the following:
i. The hospital and the hospital-based ambulatory
				care service facility have a written agreement for the sharing of income and
				expenses; and/or
ii. The hospital-based
				ambulatory care service facility reports its costs, including total revenues and
				total expenses, as part of the hospital's audited financial statements and uses the
				same accounting system for the same cost reporting period as the hospital.
9. The hospital-based ambulatory care
				service facility accepts and provides care to patients in accordance with the
				provisions as set forth in
				8:43G-5.2(c)  and,
				accordingly, shall not deny admission to patients on the basis of their inability to
				pay.