New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 161B - STANDARDS FOR LICENSURE OF OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES › Subchapter 4 - GOVERNING AUTHORITY › Section 10:161B-4.1 - Responsibility of the profit and/or non-profit governing authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Every facility shall have a governing authority, which shall assume legal
				responsibility for the management, operation, and financial viability of the
				facility. The governing authority shall have written policies and protocols for
				the following:
1. The facility's mission and
				purpose;
2. Ensuring the facility
				is operating in accordance with its mission and for the non-profit, the purpose
				for which it was granted tax-exemption;
3. Providing financial oversight to ensure
				that proper financial controls are in place;
4. Ensuring adequate financial resources as
				part of their fiduciary responsibility, which may include such responsibilities
				as personal contribution, financial planning, fundraising, grants management,
				and serving as an advocate;
5.
				Exercising duty of care (reasonable care while decision making), duty of
				loyalty (acting in the best interests of the facility without personal gain),
				and the duty of obedience (being faithful to the facility's mission while
				managing funds for that purpose);
6. Appointing and supervising an
				administrator (that is, president, chief executive officer, executive director,
				etc.) whose references, credentials, professional license, and criminal
				background are reviewed and verified, and reconciled against the organization's
				mission and administrator's scope of work;
i.
				The governing authority shall establish policies for hiring an administrator,
				including policies for individuals who may have past criminal convictions
				and/or have been sanctioned for professional ethical violations, which ensure
				that convictions/violations shall not impact his or her ability to perform
				duties.
ii. The administrator shall
				be notified by the governing authority that he or she shall disclose to the
				governing authority any disciplinary outcome imposed as a result of an
				investigation by any State licensing agency, law enforcement agency, or
				professional disciplinary review board, such as disciplinary probation,
				suspension of license, revocation of license, or criminal conviction at the
				time of initial employment, and/or during employment if the action occurs after
				hire;
7. Evaluating, at
				least annually, the performance of the administrator of the facility, including
				establishing requirements for the administrator's continuing education
				credits;
8. Approving, in writing,
				a person to be designated as the administrator's alternate;
9. Ensuring the administrator has the
				professional support needed to further the mission and goals of the
				facility;
10. Ensuring legal and
				ethical integrity, and maintaining accountability by observing legal standards
				and ethical norms;
11. Documenting
				all of its actions and those of its committees by written minutes, and
				maintaining minutes of meetings, including resolutions and motions pertaining
				to the fiscal and legal responsibilities of the governing authority;
12. Establishing a grievance mechanism
				available to both staff and clients;
13. Establishing a notice system accessible
				to all staff and clients regarding the grievance procedures that shall include
				the name, address, and telephone number for public access to the
				facility;
14. Establishing a
				feedback mechanism in order to receive and respond to staff and client
				recommendations;
15. Establish
				client complaint procedures that support client rights, are visibly posted and
				accessible to clients in client service areas and are understood by clients
				from point of service intake to leaving the program, as per
				N.J.A.C.
				10:161B-16, Client Rights;
16. Reviewing and approving plans to
				establish new programs, or to substantially alter or discontinue existing
				services, substantial changes in levels of service, and/or changes in
				populations served;
17. Ensuring
				that the client care policies required in
				N.J.A.C.
				10:161B-6 are developed and
				maintained;
18. Establishing a
				pharmacy and therapeutic committee, if so required at
				N.J.A.C.
				10:161B-14;
19. Ensuring that infection control protocols
				and practices are adhered to;
20.
				Establishing protocols regarding child abuse and neglect, sexual abuse, elder
				abuse, and institutional abuse or neglect, including duty to warn and
				protect;
21. Reviewing and
				approving the annual audits;
22.
				Reviewing and approving the facility's compensation plan for staff at least
				annually;
23. Establishing and
				approving an annual budget, including any capital projects, for all services to
				be provided at or through the facility in consultation with the administrator,
				fiscal officer, and the service directors; and reviewing with the administrator
				any material changes which may occur during the year with respect to either
				revenue or expenditures, including the reasons for the changes;
24. Designating a member to certify financial
				statements by signature, and establishing protocols to periodically review a
				sliding scale fee for services schedule as well as procedures for assessing
				income and ability to pay for services;
25. Reviewing any notices issued by DCN&L
				regarding non-compliance with any requirements of this chapter or any
				violations of law by the facility, staff, volunteers, or consultants, ensuring
				corrective measures have been taken, and where appropriate, advising DCN&L
				of such corrective measures;
26.
				Establishing policy and procedures to ensure client's confidentiality as
				required by State and Federal laws (that is, CFR42, Health Insurance
				Portability Accountability Act (HIPAA), etc.);
27. Developing conflict of interest and
				disclosure policies for members of the governing authority, and paid and
				volunteer staff; and
28. If
				multiple facilities are operated by the governing authority, identifying how
				the committees and committee functions required by this chapter will be met if
				organization wide committees are established.