reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.8 - Pediatric and pediatric intensive care continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a program of continuous quality improvement for
				  each pediatric 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. The data shall
				  include, but not be limited to, the number of pediatric admissions to the adult
				  intensive care unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.9 - Scope of pediatrics standards

Current through Register Vol. 56, No. 14, July 15, 2024
The standards in
				  8:43G-22.10 through 22.12 shall apply
				  only to hospitals that have a separate, designated unit or service for
				  pediatrics.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.10 - Pediatric staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The physician
				director of the pediatric service shall be board certified in pediatrics.
(b) The nurse with administrative responsibility
				for nursing care in pediatrics shall be a registered professional nurse with at
				least three years of experience in pediatrics.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.12 - Pediatrics space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A minimum of 10
				percent of the beds used for pediatric care shall be capable of functioning as
				isolation rooms.
(b) Each pediatric unit
				shall have at least one playroom with recreation equipment and child-size tables and
				chairs.
(c) There shall be an adult
				supervising when children under seven years of age are present in the recreation
				room or playroom.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.13 - Scope of pediatric intensive care standards

Current through Register Vol. 56, No. 14, July 15, 2024
The standards in
				  8:43G-22.14 through 22.22 shall apply
				  only to hospitals that have a separate, designated unit or service for pediatric
				  intensive care.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.14 - Pediatric intensive care structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a multidisciplinary pediatric intensive care
				  committee or its equivalent that includes at least representatives of nursing,
				  medical staff, administration, respiratory therapy, and social work. This committee
				  shall meet regularly to discuss unit administration and ways of improving
				  interdisciplinary communication on the pediatric intensive care unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.15 - Pediatric intensive care staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				full-time physician director of the pediatric intensive care service who is board
				certified or board eligible in pediatric critical care.
(b) The pediatric intensive care unit shall be
				covered at all times by at least one physician, present in the hospital or on call,
				who is board certified or board eligible in pediatrics and has either five years of
				experience in pediatrics or has completed a fellowship in a pediatric
				subspecialty.
(c) The pediatric
				intensive care unit shall have physicians with each of the following pediatric
				subspecialties on staff: anesthesiology, cardiology, hematology/oncology, infectious
				diseases, nephrology, neurology, pulmonary, radiology, and surgery.
(d) The pediatric intensive care unit shall have a
				formal consultative relationship with physicians in the following pediatric
				subspecialties: endocrinology, gastroenterology, neurosurgery, otolaryngology, and
				urology.
(e) Specific privileges for
				physicians who admit patients to the pediatric intensive care unit shall be
				delineated by the hospital with participation of the physician director of the
				pediatric intensive care unit.
(f) The
				nurse with administrative responsibility for nursing in the pediatric intensive care
				unit shall be a registered professional nurse with specialized training in pediatric
				critical care and at least three years of experience in a pediatric intensive care
				unit.
(g) There shall be a health
				professional trained in resuscitation of children available within the unit at all
				times.
(h) Effective January 1, 1992,
				there shall be a health professional certified in advanced pediatric life support
				available within the unit at all times.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.16 - Pediatric intensive care staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician who can handle pediatric emergencies, other than the physician assigned to
				the emergency department, in the hospital at all times.
(b) There shall be at least one registered
				professional nurse to every two patients in the pediatric intensive care
				unit.
(c) There shall be at least one
				full-time clerical support staff person assigned full or part time to the pediatric
				intensive care unit.
(d) The services of
				the following staff with specialized training or experience in pediatrics shall be
				available to pediatric intensive care unit patients and their families: child-life
				specialist, social worker, physical therapist, occupational therapist, psychiatrist,
				and nutritionist.
(e) The hospital shall
				have available a transport team staffed by health professionals with special
				training in pediatrics.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.17 - Pediatric intensive care patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				services shall be available to the pediatric intensive care unit at all times:
1. Blood bank;
2. Dialysis;
3. Hematology;
4. Laboratory;
5. Nuclear medicine;
6. Pharmacy;
7. Radiology;
8. Computer tomography; and
9. Respiratory therapy.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.19 - Pediatric intensive care space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be at
				least one isolation room in the pediatric intensive care unit. There shall be
				additional isolation rooms based on a ratio of one room to every six pediatric
				intensive care beds.
(b) The pediatric
				intensive care unit shall be a closed unit, and no traffic to other departments or
				units shall pass through it.
(c) There
				shall be a room nearby the pediatric intensive care unit where the physician can
				sleep.
(d) There shall be a sitting room
				or lounge area nearby the pediatric intensive care unit for the families of patients
				in the unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.20 - Pediatric intensive care supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The pediatric
				intensive care unit shall have immediate access to equipment that has the capability
				for continuous monitoring of at least:
1. Arterial
				pressure;
2. Central venous
				pressure;
3.
				Electrocardiogram;
4. Heart
				rate;
5. Intracranial
				pressure;
6. Pulmonary arterial
				pressure;
7. Respiration;
8. Temperature; and
9. Three simultaneous pressure
				capability.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22 - PEDIATRICS › Section 8:43G-22.22 - Pediatric intensive care continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
The continuous quality improvement program for pediatric
				  intensive care shall include interhospital exchanges or information and case reviews
				  with pediatric specialists in other hospitals.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.1 - Scope of children's hospital designation standards

Current through Register Vol. 56, No. 14, July 15, 2024
The standards set forth in this subchapter shall apply only to
				  hospitals that are licensed as children's hospitals.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.2 - Organizational structure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				have a governing body, which shall carry out the following responsibilities:
				safeguard the program's resources; approve the children's program's long range plan;
				and approve the children's program's operation plans. The governing body shall meet
				either of the following criteria:
1. Constitute a
				separate, autonomous governing body of either a subsidiary corporation or
				multi-hospital system; or
2. Constitute
				a standing committee of the governing body charged with ongoing children's program
				review, together with a dedicated fundraising program for the children's hospital,
				which reports periodically to the standing committee.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.3 - Continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
The hospital shall have an organized quality improvement program
				  for each pediatric service which 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. The data
				  shall include, but not be limited to, the number of child admissions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.4 - Medical staff and teaching program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				be a teaching site for an organized academic department of pediatrics of an approved
				medical school program.
(b) The hospital
				shall be engaged in an ongoing clinical research program.
(c) The pediatric teaching program shall be
				approved by the Residency Review Committee of the Accreditation Council for Graduate
				Medical Education (ACGME) or any other group approved by the State Board of Medical
				Examiners for a minimum of 12 pediatric resident positions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.5 - Building and facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The children's
				program shall have adequate physical space and facilities provided either in a
				separate building(s) or in a defined and contiguous space within a building reserved
				for the housing of children which shall include:
1. Inpatient facilities separate from
				obstetrics;
2. Organized and accessible
				outpatient clinics for children that shall have, at a minimum, space reserved for
				children at scheduled times; and
3. A
				discrete pediatric area within the emergency department by October 21,
				2005.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 22A - LICENSURE OF CHILDREN'S HOSPITAL DESIGNATION › Section 8:43G-22A.6 - Essential special care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By October 21, 2003,
				all licensed children's hospitals shall operate a pediatric intensive care unit in
				accordance with N.J.A.C. 8:43G-22.
(b) A
				licensed children's hospital not licensed to operate a pediatric intensive care unit
				on October 21, 2002 shall file a licensing application to initiate such a unit in
				accordance with (a) above. Such a licensing application shall be filed in accordance
				with the procedures described in
				8:43G-2.2 through 2.5, as
				applicable.
(c) By October 21, 2003, all
				licensed children's hospitals shall operate a regional perinatal center in
				accordance with N.J.A.C. 8:43G-19, and applicable provisions of N.J.A.C. 8:33C,
				including 8:33C-3.4(a)  3 through
				10.
(d) A licensed children's hospital
				not licensed to operate a regional perinatal center on October 21, 2002 shall file a
				licensing application to initiate such a service, including neonatal intermediate
				and intensive care unit(s), in conformance with (c) above. Such a licensing
				application shall be filed in accordance with the procedures described in
				8:43G-2.2 through 2.5, as
				applicable.
(e) A licensed children's
				hospital not also licensed to operate a pediatric intensive care unit or a regional
				perinatal center on October 21, 2002 shall not be required to obtain certificate of
				need approval to establish such a unit or center, including neonatal intensive or
				intermediate care unit(s) within the center.
1. A
				licensed children's hospital without a licensed pediatric intensive care unit may
				establish such a unit with a maximum size of six beds without certificate of need
				approval.
2. A licensed children's
				hospital without a licensed neonatal intermediate or intensive care unit may
				establish such a unit(s) with a maximum size of four bassinets for an intermediate
				care nursery and six bassinets for an intensive care nursery without certificate of
				need approval.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.1 - Pharmacy structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital shall
				have a pharmacy that is licensed by the New Jersey State Board of Pharmacy, with a
				current Drug Enforcement Administration registration and a controlled dangerous
				substance registration from the Department.
(b) A multidisciplinary pharmacy and therapeutics
				committee, or an equivalent multidisciplinary body which includes a pharmacist
				licensed to practice pharmacy in New Jersey, shall meet at least quarterly and
				document its activities, findings, and recommendations.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.2 - Pharmacy policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The pharmacy and
				therapeutics committee, or its equivalent, shall review, approve, and ensure
				implementation of policies and procedures addressing at least the following areas:
1. Outpatient pharmacy services;
2. Administration of drugs;
3. Use of patients' previously acquired drugs,
				including requirement for physician orders and pharmacy identification of the drugs
				before use;
4. Admixture of intravenous
				solutions, including quality control and safety procedures for laminar airflow hoods
				and labeling;
5. Storage and
				distribution of drugs, including at least dispensing devices (if used in the
				hospital), emergency drugs and kits, and control and accountability of controlled
				substances in accordance with applicable laws and regulations;
6. Stop orders and discontinue orders, including
				the length of time all orders stay in effect, stoppage of drugs on the day a patient
				undergoes surgery in conformance with the prescriber's specifications, and
				notification of the prescriber of the expiration of a drug order;
7. Identification, reporting, reviewing, and
				monitoring of adverse drug reactions and medication errors;
8. Identification and prevention of food/drug
				interactions and responsibility of pharmacy, nursing, and dietary services,
				including responsibility for the following:
i.
				Ensuring that appropriate food or fluid requirements are met when administering
				medication;
ii. Adjusting the contents
				of the patient's meal tray whenever an increase or decrease in a specific nutrient
				is ordered; and
iii. Educating the
				patient about potential food/drug interactions prior to discharge and
9. Current reference materials kept at
				drug distribution stations and in the pharmacy, and made available to medical and
				nursing staff;
10. Control and
				limitation of use of drugs marked "sample";
11. Approval and maintenance of an up-to-date
				formulary;
12. Pharmacists'
				clarifications of physician orders; and
13. Self-administration of drugs, if permitted by
				the hospital, including a requirement for written prescriber orders, storage of
				drugs, labeling of drugs, documentation of self-administration in the patient
				medical record, patient training and education, and precautions to ensure that a
				patient does not take the drugs of another patient.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.3 - Pharmacy staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pharmaceutical
				services shall be directed by a registered pharmacist licensed to practice pharmacy
				in New Jersey.
(b) A pharmacist licensed
				to practice pharmacy in New Jersey shall be responsible for compounding, preparing,
				labeling, transferring between containers, and dispensing drugs, including direct
				supervision of supportive personnel, as defined at
				13:39-1.2.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.4 - Pharmacy staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A pharmacist
				licensed to practice pharmacy in New Jersey shall be on duty or on call at all
				times.
(b) When, in the pharmacist's
				absence from the hospital, a registered professional nurse removes a drug from the
				designated pharmacy stock or night cabinet for use in an emergency, this action
				shall be recorded by the nurse and checked by a pharmacist on a daily
				basis.
(c) If the hospital operates a
				decentralized pharmaceutical service, there shall be a pharmacist licensed to
				practice pharmacy in New Jersey assigned to each satellite pharmacy during the
				satellite pharmacy's hours of operation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.6 - Pharmacy patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pharmaceutical
				services shall be available to patients at all times.
(b) The hospital shall have in effect a unit dose
				drug distribution system with individual cassettes or containers that bear the
				patient's identification. The system shall cover at least the medical/surgical,
				obstetric, pediatric, and psychiatric units and include scheduled cart exchanges at
				least every 24 hours, including weekends and holidays.
1. The hospital may substitute an alternative
				method of distributing drugs for the unit dose drug distribution system if the
				hospital demonstrates to the Department that the method has at least equivalent
				clinical effectiveness and the Department approves the use of the alternative
				method.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.8 - Pharmacy space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The pharmacy shall
				maintain drugs under proper conditions, as indicated in the United States
				Pharmacopoeia, product labeling, and/or package inserts.
(b) All drugs, needles, and syringes shall be kept
				in locked storage areas except those drugs exempted by the pharmacy and therapeutics
				committee or its equivalent under specified conditions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 23 - PHARMACY › Section 8:43G-23.10 - Pharmacy 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 the pharmacy 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
				pharmacy service shall have in effect a patient profile system for monitoring drug
				therapy. This system shall be used by the hospital to identify inappropriate
				prescribing practices.
(c) The pharmacy
				service shall inspect at least once every two months all patient care areas in the
				hospital, and at least once every three months all other areas of the hospital where
				drugs intended for administration to patients are dispensed, administered, or
				stored. The pharmacy service shall maintain a record of the inspections. Identified
				problems shall be addressed.
(d) A
				quality improvement program of the pharmacy service shall monitor, at a minimum, the
				use of drugs, including medication errors and use of antibiotics. Serious or
				consistent patterns of medication error shall be reported to the pharmacy and
				therapeutics committee or its equivalent.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.1 - Plant maintenance structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				multidisciplinary safety committee that develops a comprehensive hospital-wide
				safety program that is reviewed at least once every three years, revised more
				frequently as needed, and implemented.
(b) There shall be a mechanism to report all
				incidents, injuries and safety hazards to the safety committee.
(c) The safety committee shall review all reports
				and be responsible for ensuring that all reports are referred appropriately and
				follow-up action is documented.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.2 - Plant maintenance policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The building
				maintenance service shall have written policies and procedures that are reviewed at
				least once every three years, revised more frequently as needed, and
				implemented.
(b) The building
				maintenance service shall have a written preventive maintenance program for
				buildings, equipment and utilities.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.3 - Plant maintenance staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The building
				maintenance service shall be under the supervision of an employee with at least one
				of the following qualifications:
1. Five years of
				experience in health care plant maintenance, three of which shall be in a
				supervisory capacity;
2. A baccalaureate
				degree in engineering from an accredited college or university and three years of
				experience in health care plant maintenance, two of which shall be in a supervisory
				capacity; or
3. A current professional
				engineer license in New Jersey and three years of experience in health care plant
				maintenance, two of which shall be in a supervisory capacity.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.4 - Plant maintenance services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Records of
				preventive maintenance inspections and repairs of electrical and mechanical systems
				shall be maintained for at least one year.
(b) The building maintenance service shall be
				provided with copies of the written instructions for operating and maintaining
				departmental and unit equipment. These instructions shall be systematically retained
				in the departments or units in which the equipment is used.
(c) All life-sustaining equipment shall be plugged
				into outlets connected to the emergency power supply.
(d) Routine maintenance inspections of elevators
				shall be conducted in accordance with local ordinances.
(e) The standby emergency generator shall be
				checked weekly, tested under load monthly, and serviced in accordance with accepted
				engineering practices.
(f) Floors,
				ceilings, and walls shall be free of cracks and holes, discoloration, residue
				build-up, water stains, and other signs of disrepair.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.6 - Plant maintenance staff education

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the plant maintenance education program shall be
				  as provided in 8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.8 - Physical plant general compliance for new construction, alteration, or renovation

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				The hospital shall comply with the New Jersey Uniform Construction Code (
N.J.A.C. 5:23
under Use Group I-2), standards imposed by the United
				States Department of Health and Human Services, the New Jersey Departments of Health
				and Community Affairs and the Guidelines for Design and Construction of Residential
				Health, Care, and Support Facilities, 2014 edition. Facility Guidelines Institute;
				American Society for Healthcare Engineering, which is incorporated herein by
				reference, as amended and supplemented, and is available from the Facility
				Guidelines Institute, Inc., 350 N. Saint Paul St., Suite 100, Dallas, TX 75201.
				Website:
www.fgiguidelines.org
. E-mail:
				info@fgig(R)uidelines.org.
(b) The
				hospital shall submit plans and specifications to Health Plan Review Unit, Division
				of Codes and Standards, Department of Community Affairs, P.O. Box 815, Trenton, New
				Jersey 08625-0815, for approval prior to construction, alteration, or
				renovation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 24 - PLANT MAINTENANCE AND FIRE AND EMERGENCY PREPAREDNESS › Section 8:43G-24.9 - Construction and renovation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Whenever
				construction and renovation projects are planned in and around a health care
				facility, a risk assessment shall be conducted to determine the impact of the
				project on patient areas, personnel, and mechanical systems.
1. The infection control program shall review
				areas of potential risk and populations at risk. The infection control program shall
				approve control measures, if necessary.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 25 - POST MORTEM › Section 8:43G-25.1 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				have written policies and procedures for post mortem services that are reviewed at
				least once every three years, revised more frequently as needed, and implemented.
				These policies shall delineate the responsibilities of the medical staff, nursing,
				and post mortem services staff, and shall include procedures for at least the
				following:
1. Identifying the body;
2. Safe and proper handling to prevent damage to
				the body;
3. Safeguarding personal
				effects of the deceased and release of personal effects to the appropriate
				individual;
4. Handling of toxic
				chemicals by morgue and housekeeping staff;
5. Infection control, including disinfection of
				equipment;
6. Identifying and handling
				high-risk and/or infectious bodies, in accordance with Centers for Disease Control
				guidelines, and in compliance with
				26:6-8;
7. Release of the body to the county morgue or
				funeral director;
8. Autopsy
				requests;
9. Availability of autopsy
				reports, including reports of microscopic autopsy findings, to physicians and in
				medical records, within specified time frames; and
10. Completion of autopsy, including microscopic
				and other procedures, within specified time frames.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 25 - POST MORTEM › Section 8:43G-25.2 - Post mortem staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
The physician who routinely performs or supervises the
				  performance of autopsies shall be Board Certified in Pathology.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 25 - POST MORTEM › Section 8:43G-25.3 - Post mortem patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Bodies and body
				parts in the morgue shall be kept refrigerated or in chemical fixation in a
				non-putrescent state.
(b) The medical
				staff shall attempt to secure autopsies in cases of unusual deaths, deaths from
				unknown causes, and cases of medicolegal and educational interest, unless otherwise
				provided for by law.
(c) Autopsies shall
				be performed only with the consent of the patient's family or guardian in accordance
				with 26:6-50. Consent shall not be required
				for medical examiner cases.
(d) The
				hospital shall notify the county medical examiner or prosecutor immediately upon a
				patient's death when the circumstances of the death fall within the criteria
				specified in 52:17B-86 of the State Medical
				Examiners Act, 52:17B-78 et seq.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 25 - POST MORTEM › Section 8:43G-25.4 - Post mortem space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
The morgue shall be equipped with refrigerated space to store at
				  least two bodies. Hospitals with more than 100 beds shall provide additional space
				  using a ratio of one space to every additional 100 beds.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 25 - POST MORTEM › Section 8:43G-25.5 - Post mortem supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
Refrigerated spaces in the morgue shall be maintained at
				  temperatures between 32 and 45 degrees Fahrenheit (0 and 7.2 degrees Celsius) and
				  shall have an automatic alarm system that monitors the temperature.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.1 - Scope of psychiatry standards

Current through Register Vol. 56, No. 14, July 15, 2024
The standards in this subchapter shall apply only to hospitals
				  that have a separate, designated unit or service for psychiatry.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.2 - Psychiatry policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The psychiatric
				service shall have written policies and procedures that are reviewed annually,
				revised as needed, and implemented. These policies and procedures shall be readily
				available on the inpatient unit and include at least the following:
1. Criteria for admission to and discharge from
				each component of the psychiatric unit. Admissions criteria shall be based solely on
				the patient's needs and the ability of the unit to meet these needs, and discharge
				policies shall preclude punitive discharge;
2. Safety and security precautions for the
				prevention of suicide, assault, elopement, and patient injury;
3. Emergency procedures for medical
				emergencies;
4. Infection control
				practices for the day/dining room, equipment, and rooms used by more than one
				patient. If these special practices are included in the hospital-wide infection
				control policies and procedures manual, which is available on the unit, then
				additional policies and procedures do not have to be developed by the psychiatric
				service for infection control;
5.
				Patient privileges;
6. Patient rights as
				delineated at N.J.A.C. 8:43G-4;
7.
				Family interviews for assessment and treatment purposes;
8. A clinical services plan describing the
				services provided;
9. Content of patient
				evaluations, including the components of care, time frames for goals, and staff
				assigned to the patient;
10. Release of
				information, in conformance with applicable statutes and the policies of the medical
				records department;
11. Informed
				consent, with special policies for patients undergoing electro-convulsive
				therapy;
12. Patient grievance
				procedures;
13. Criteria for use of
				seclusion in accordance with procedures delineated in the current or revised or
				later edition, if in effect, of the American Psychiatric Association Task Force
				Report No. 22 on Restraint and Seclusion, incorporated herein by reference,
				available from the American Psychiatric Association, 1400 K Street NW, Washington,
				D.C. 20005;
14. Review by physician
				director or designee of restraints or seclusion used in excess of 72 consecutive
				hours for a patient; and
15. Criteria
				for physician monitoring of patients in restraints more frequently than every 24
				hours based on patient acuity.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.3 - Psychiatry staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Psychiatric care
				services shall be clinically supervised by a physician director who is responsible
				for the direction and quality of care provided by the medical staff.
(b) Any physician currently holding the position
				of director shall have completed a residence in psychiatry or neurology and shall be
				able to demonstrate the skills and experience at least equivalent to certification
				by the American Board of Psychiatry and Neurology. Effective July 1, 1990 any newly
				appointed physician director shall be board certified or shall meet the training and
				experience requirements for examination by the Board and shall be examined within
				two years of eligibility.
(c) Nursing on
				the psychiatric care unit shall be directed by a registered professional nurse with
				at least three years of clinical psychiatric experience.
(d) The social worker assigned to the inpatient
				psychiatric unit shall have at least a master's degree in social work from a
				graduate school of social work accredited by the Council on Social Work Education,
				or a bachelor's degree from an accredited social work program and one year of
				experience in social work or mental health.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.5 - Psychiatry staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A psychiatrist shall
				be on-site or on call at all times.
(b)
				Nurse staffing shall be based on hospital acuity levels, but in no case shall fewer
				than two nursing staff members, at least one of whom is a registered professional
				nurse, be on the unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.7 - Psychiatry patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Psychiatric patients
				shall receive, when needed, all medical, surgical, diagnostic, and treatment
				services as ordered by a physician. If such services are not available within the
				hospital, qualified consultants and attending physicians shall be available and
				arrangements established for transferring patients to a facility where the needed
				services can be provided.
(b) All
				patients shall receive a complete history and physical examination by a physician,
				advanced practice nurse or physician assistant within 24 hours of admission to the
				psychiatric unit.
(c) The following
				services shall be available as part of the program of the psychiatric care unit:
1. Individual, group, and family
				therapy;
2. Psychotropic
				medications;
3. Rehabilitative
				services;
4. Psychological services,
				including testing, provided by a psychologist licensed by the State of New Jersey;
				and
5. Recreational therapy.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.9 - Psychiatry space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Interviews between
				staff and patients shall be conducted in a private setting.
(b) The unit shall have access to at least one
				acute care/seclusion room.
(c) Acute
				care/seclusion rooms shall be at least 100 square feet and shall be large enough to
				provide access to the patient from all sides of the bed or mattress and have room
				for emergency life-sustaining equipment.
(d) Patients in acute care/seclusion rooms shall
				be either under direct observation in a room near the nurses station or observed
				through the use of electronic monitoring equipment.
(e) The unit shall have a day room/dining room
				that allows for social interaction, dining, and therapy.
(f) Opportunities to participate in structured
				physical exercise programs shall be made available to patients.
(g) There shall be space in each patient room for
				storage of patients' personal belongings. There shall be a system for securing
				patients' valuable belongings.
(h) The
				psychiatric care unit shall comply with the suicide prevention regulations as
				provided in Guidelines for Design and Construction of Residential Health, Care, and
				Support Facilities, 2014 edition. Facility Guidelines Institute; American Society
				for Healthcare Engineering, which is incorporated herein by reference, as amended
				and supplemented, and is available from the Facility Guidelines Institute, Inc., 350
				N. Saint Paul St., Suite 100, Dallas, TX 75201. Website:
www.fgiguidelines.org
. E-mail:
				info@fgiguidelines.org.
(i) Authorized
				security personnel shall have immediate access to locked units.
(j) There shall be a system for summoning help
				from other areas of the unit in an emergency.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.11 - Psychiatry supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The restraint
				equipment needed by the unit shall be immediately available on the unit and
				accessible to unit staff.
(b) The
				recreation and therapy equipment and supplies needed for psychiatric care shall be
				available on the unit and stored in locked storage.
(c) Locked storage areas shall be available for
				supplies and the safekeeping of the individual, ongoing creative projects of
				patients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.12 - Psychiatry staff education

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Requirements for the
				psychiatry service education program shall be as provided in
				8:43G-5.9.
(b) The staff of the psychiatric unit shall
				receive annual training in handling the assaultive patient.
(c) The non-medical and non-nursing professional
				staff shall receive annual training in drug effects and side effects.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 26 - PSYCHIATRY › Section 8:43G-26.14 - Psychiatry quality assurance methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of quality assurance for psychiatric services that is integrated into the
				hospital quality assurance 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 ongoing quality assurance
				program of the psychiatric service shall include incident review and monitoring of
				such areas as suicide, attempted suicide, elopement, assaults, slips and falls,
				patient abuse and neglect, use of seclusion, and use of restraints.
(c) The medical staff shall review, on at least an
				annual basis, use of restraints, discharge planning, and outcomes.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 27 - CONTINUOUS QUALITY IMPROVEMENT › Section 8:43G-27.1 - Continuous quality improvement structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The governing
				authority of the hospital (such as the board of trustees) shall have ultimate
				responsibility for the continuous quality improvement program.
(b) The hospital shall have a hospital-wide
				continuous quality improvement program based on a written continuous quality
				improvement plan that is implemented and that monitors the quality of patient
				care.
(c) Each clinical department shall
				have continuous quality improvement activities that are part of the overall
				hospital-wide plan, a multi-department plan, or an internally generated
				plan.
(d) There shall be a
				multidisciplinary committee responsible for the direction of the continuous quality
				improvement program. The committee shall include at least representation from the
				medical staff, nursing, and administration. The committee shall establish a
				mechanism to include participation of all disciplines in identifying areas of review
				that affect patient care throughout the hospital.
(e) The hospital shall perform risk management
				functions. Reports generated by risk management activities shall be routinely
				provided to the multidisciplinary committee responsible for coordinating the quality
				improvement program.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 27 - CONTINUOUS QUALITY IMPROVEMENT › Section 8:43G-27.2 - Continuous quality improvement policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The continuous
				quality improvement plan shall be reviewed at least annually and revised as
				necessary. Responsibility for reviewing and revising the plan shall be designated in
				the plan itself.
(b) The continuous
				quality improvement plan shall delineate lines of communication between the
				continuous quality improvement program and the medical staff, chief executive
				officer or administrator, and governing authority.
(c) The hospital-wide continuous quality
				improvement plan shall specify procedures for the development, implementation, and
				coordination of quality reviews. The plan shall also establish a mechanism for the
				evaluation of the continuous quality improvement program.
(d) The program shall disseminate its findings and
				the results of continuous quality improvement activities, as defined in the
				continuous quality improvement plan.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 27 - CONTINUOUS QUALITY IMPROVEMENT › Section 8:43G-27.3 - Continuous quality improvement staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be an individual responsible for coordinating all
				  aspects of the continuous quality improvement program.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 27 - CONTINUOUS QUALITY IMPROVEMENT › Section 8:43G-27.5 - Continuous quality improvement patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be an
				ongoing process of monitoring patient care. Evaluation of patient care throughout
				the hospital is criteria-based, so that certain review actions are taken or
				triggered when specific quantified, predetermined levels of outcomes or potential
				problems are identified.
(b) The
				continuous quality improvement coordinator shall be available to provide ongoing
				consultation to each department including assistance with the development of
				specific indicators used to evaluate service outcome in each department.
(c) The program shall follow up on its findings to
				assure that effective corrective actions have been taken, including at least policy
				revisions, procedural changes, educational activities, and follow-up on
				recommendations, or that additional actions are no longer indicated or
				needed.
(d) The continuous quality
				improvement program shall identify and establish indicators of quality care specific
				to the hospital that are monitored and evaluated and encompass at least:
1. Surgical case review;
2. Drug usage;
3. Medical record review;
4. Blood usage;
5. Pharmacy and therapeutics function;
				and
6. Appropriateness of specific
				diagnostic and therapeutic procedures, as selected by the continuous quality
				improvement program.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 27 - CONTINUOUS QUALITY IMPROVEMENT › Section 8:43G-27.6 - Performance measurement and assessment system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall
				establish a Quality Improvement Advisory Committee (QIAC), including provider,
				consumer and individuals with quality of care research expertise representation, to
				advise the Department in developing a hospital performance measurement and
				assessment system. The data collected through this system shall be used by the
				Department to:
1. Promote the standardized
				reporting of data by hospitals;
2.
				Provide the Department with information on the performance of hospitals to support
				the Department's oversight role;
3.
				Assist general hospitals to measure and improve the quality of care provided within
				their facilities;
4. Support efforts to
				inform consumers about performance of individual hospitals and the industry as a
				whole; and/or
5. Any other purpose
				consistent with this chapter, particularly N.J.A.C. 8:43G-17.