New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.2 - Administrative and hospital-wide policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital
				shall have written policies, procedures, and bylaws that are reviewed at least once
				every three years, revised more frequently as needed, and implemented. They shall
				include at least:
1. Policies on the admission of
				patients, transfer of patients to another facility, and discharge of
				patients;
2. Procedures for obtaining
				the patient's written informed consent for all medical treatment;
3. Delineation of the responsibilities of the
				medical staff, nursing, and other staff in contacting the patient's family in the
				event of death, elopement, or a serious change in condition;
i. The facility shall promptly notify a family
				member, guardian or contact person designated by the patient on admission about a
				patient's death. The facility shall maintain confirmation and written documentation
				of that notification. The facility shall adopt and maintain in its manual of
				policies and procedures a delineation of the responsibilities of the facility's
				staff in making such prompt notification regarding the death of a patient.
ii. As used in this paragraph, "promptly" means as
				soon as possible but not later than 60 minutes after the patient's death. If a first
				attempt to provide notification is made in a timely fashion but is not successful, a
				subsequent attempt must be made within each successive 60-minute period until
				notification is successfully made.
iii.
				Written documentation shall be made in the patient's medical record of each attempt
				at notification, including who made the attempt, when, how notification was made,
				and who the notification, when successful, was given to.
4. Policies addressing bio-ethical issues
				affecting individual patients, including at least removal of life support systems,
				discontinuance or refusal of treatment, and designation not to resuscitate. In
				accordance with the New Jersey Advance Directives for Health Care Act ( P.L. 1991,
				c.201), private, religiously-affiliated health care institutions which decline to
				participate in the withholding or withdrawing of specified life-sustaining measures
				shall comply with the following:
i. The hospital
				shall establish written policies defining circumstances in which it will decline to
				participate in the withholding or withdrawing of specified life-sustaining measures
				in accordance with the patient's advance directive;
ii. The hospital shall provide prompt notice to
				patients or their families or health care representatives of these policies prior to
				or upon admission, or as soon after admission as is practical; and
iii. The hospital shall implement a timely and
				respectful transfer of the individual to another institution who will implement the
				patient's advance directive;
5. Procedures to ensure that there is a routine
				inquiry made of each adult patient, upon admission to the hospital and at other
				appropriate times, concerning the existence and location of an advance directive (as
				required and defined in the New Jersey Advance Directives for Health Care Act, P.L.
				1991, c.201). If the patient is incapable to respond to this inquiry, the hospital
				shall have procedures to request the information from the patient's family or in the
				absence of family, another individual with personal knowledge of the patient, if
				available and known to the hospital. The procedures must assure that the patient or
				family's response to this inquiry is documented in the medical record. Such
				procedures shall also define the role of hospital admissions, nursing, social
				service and other staff as well as the responsibilities of the attending
				physician;
6. Policies which identify
				circumstances in which an inquiry will be made of adult individuals receiving same
				day surgery, same day medical services, treatment in the emergency department or
				out-patient hemodialysis treatment regarding the existence and location of an
				advance directive;
7. Procedures to
				request and to take reasonable steps to promptly obtain a copy of currently executed
				advance directives from inpatients and other critically ill patients who are under
				treatment at the hospital. These shall be entered when received into the medical
				record of the patient. When there is a question of validity, procedures for promptly
				evaluating the validity of the advance directive must be established;
8. Procedures for promptly alerting physicians,
				nurses, and other professionals providing care to patients who have informed the
				hospital of the existence of an advance directive in instances where a copy is not
				immediately available for the medical record;
9. Policies for transfer of the responsibility for
				care of patients with advance directives in those instances where a health care
				professional declines as a matter of professional conscience to participate in
				withholding or withdrawing life-sustaining treatment. Such transfer shall assure
				that the patient's advance directive is implemented in accordance with their wishes
				within the hospital;
10. Means to
				provide each adult patient upon admission, or where the patient is unable to
				respond, family or other representative with a written statement of their rights
				under New Jersey law to make decisions concerning the right to refuse medical care
				and the right to formulate an advance directive. This statement of rights shall be
				issued by the Commissioner. Appropriate written information and materials on advance
				directives and the institution's written policies and procedures including the
				withdrawal or withholding of life-sustaining treatment shall be provided to each
				patient and others upon request. Such written information shall also be made
				available in any language which is spoken as the primary language by more than 10
				percent of the population of the hospital's service area;
11. Procedures for referral of patients requesting
				assistance in executing an advance directive or additional information to either
				staff or community resource persons that can promptly advise and/or assist the
				patient during the inpatient stay;
12.
				Policies to ensure application of the hospital's procedures for advance directives
				to patients who are receiving emergency room care for an urgent life-threatening
				situation; and
13. Policies and
				procedures to ensure that appropriate hospital staff, including direct care
				providers, staff that are concerned with billing for hospital services or providing
				financial counseling to patients, and staff otherwise engaged in providing patient
				advocacy are made aware of the Independent Health Care Appeals Program established
				pursuant to N.J.S.A. 26:2S-11, and are able to
				provide information to patients and their family members, or other persons on the
				patient's behalf, about how to contact the Independent Health Care Appeals
				Program.