reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.1 - Provision of services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				provide preventive, diagnostic, and/or treatment services to patients. Medical
				services and nursing services, as required by this chapter, shall be provided in the
				facility. Medical services, nursing services, counseling services, pharmaceutical
				services, and laboratory and radiological services shall be provided directly by the
				facility or through written agreement.
(b) The facility shall have a written agreement
				for services not provided directly by the facility. The written agreement shall
				specify each party's responsibilities. If the service is provided in the facility,
				the written agreement shall require that services be provided in accordance with the
				rules in this chapter. If the service is provided outside of the facility, the
				written agreement shall require the provision of written documentation to the
				facility, including, but not limited to, documentation of services rendered and
				recommendations made by the party providing the service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.2 - Compliance with laws and rules

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				comply with applicable Federal, State, and local laws, rules, and
				regulations.
(b) If a health care
				facility licensed by the Department provides ambulatory care services in addition to
				other health care services, the facility shall comply with the rules in this chapter
				and with the rules for licensure of facilities which provide the other health care
				services.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.3 - Ownership

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The licensee shall disclose the ownership of
				the facility and the property on which it is located to the Department, shall make
				proof of this ownership available in the facility or at a designated location, and
				shall report any proposed change in ownership to the Director of the Division of
				Certificate of Need and Licensing in writing at least 30 days prior to the change
				and in conformance with requirements for Certificate of Need applications.
1. The Department shall not approve a change in
				ownership if the facility's ambulatory care facility assessments are in arrears,
				unless and until the arrears are satisfied.
2. If a facility appeals an assessment in
				accordance with N.J.A.C. 8:31A-2.3, a change in
				ownership may proceed, as long as the licensee establishes an escrow account
				specifically dedicated to the payment of the assessment containing the amount of the
				unpaid assessment that is under appeal.
3. If the Department approves a change in
				ownership under the circumstances in (a) 2 above, the approval shall be a
				conditional approval that is conditioned upon payment of the assessment upon
				conclusion of the appeal (in addition to any other substantive licensure conditions
				the Department may require of a facility to meet other standards this chapter
				establishes).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.4 - Submission of documents and data

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon the
				Department's request, a facility shall submit in writing any documents that this
				chapter requires to the Director of the Division of Certificate of Need and
				Licensing.
(b) The facility shall
				collect and submit to the Department, upon request, at least the following
				statistical data:
1. Number of patient visits, by
				payment source;
2. Number of distinct
				patients served, by payment source;
3.
				Number of new patients accepted; and
4.
				Number of practitioners, by type and level, providing services in the
				facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.5 - Personnel

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				develop written job descriptions and ensure that personnel are assigned duties based
				upon their education, training, and competencies, and in accordance with their job
				descriptions.
(b) All personnel who
				require licensure, certification, or authorization to provide patient care shall be
				currently licensed, certified, or authorized under the appropriate laws or rules of
				the State of New Jersey or under the applicable standards of the appropriate
				body.
(c) Staffing schedules shall be
				implemented to ensure continuity of care to patients. Provision shall be made for
				substitute staff with equivalent qualifications to replace absent staff
				members.
(d) The facility shall develop
				and implement a staff orientation plan and a staff education plan, including plans
				for each service and designation of person(s) responsible for training.
1. All personnel shall receive orientation at the
				time of employment and at least annual in-service education regarding, at a minimum,
				emergency plans and procedures, the infection prevention and control program,
				universal precautions, policies and procedures concerning patient rights, and, if
				appropriate, given the patient population of the facility, identification of cases
				of child abuse and/or elder abuse.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.7 - Employee health

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The policy and procedures manual of the
				facility shall include policies and procedures to ensure that physical examinations
				of employees are performed upon employment and subsequently and shall specify the
				circumstances under which other persons providing direct patient care services shall
				receive a physical examination and the content and the frequency of the examinations
				for employees and other persons providing direct patient care services.
(b) Each employee who cannot document the result
				of a previous rubella screening test shall be given a rubella screening test using
				the rubella hemagglutination inhibition test or other rubella screening test
				approved by the Department. Each new employee who cannot document the result of a
				previous rubella screening test shall be given the rubella screening test upon
				employment. An employee who can document seropositivity from a previous rubella
				screening test or who can document inoculation with rubella vaccine shall not be
				required to have a rubella screening test.
1. Each
				employee tested shall be informed in writing by the facility of the results of his
				or her rubella screening test.
2. Each
				employee's personnel record shall contain documentation of all tests performed and
				the results.
3. A list shall be
				maintained of all employees who are seronegative and unvaccinated, to be used in the
				event that an employee is exposed to rubella and a determination is needed as to
				whether or not the employee may continue to work.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.8 - Reportable events

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall report to the Department by
				telephone at (800) 792-9770, the resignation or termination of employment of the
				administrator, and the name and qualifications of the administrator's replacement
				within seven days of the resignation or termination.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.9 - Notices

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				conspicuously post a notice that the following information is available in the
				facility during business hours to patients and the public:
1. All waivers granted by the
				Department;
2. The list of deficiencies
				from the last annual licensure inspection and certification survey report (if
				applicable), and the list of deficiencies from any valid complaint investigation
				during the past 12 months;
3. A
				statement of patient rights;
4. The
				names of the members of the governing authority; and the addresses to which
				correspondence may be sent; and
5. The
				hours of operation and the business hours of the facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.10 - Information reportable to State Board of Medical Examiners

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with
				the Professional Medical Conduct Reform Act, P.L. 1989, c.300, the facility shall
				notify the Medical Practitioner Review Panel established by the New Jersey State
				Board of Medical Examiners if a practitioner who is employed by, who is under
				contract to render professional services to, or who has privileges at the facility:
1. Voluntarily resigns from the staff if the
				facility is reviewing the practitioner's conduct or patient care or has expressed,
				through any member of the medical or administrative staff, an intention to do
				so;
2. Voluntarily relinquishes any
				partial privileges to perform a specific procedure if the facility is reviewing the
				practitioner's conduct or patient care or has expressed, through any member of the
				medical or administrative staff, an intention to do so;
3. Has full or partial privileges summarily or
				temporarily revoked or suspended, permanently reduced, suspended or revoked, has
				been discharged from the staff or has had a contract to render professional services
				terminated or rescinded for reasons relating to the practitioner's incompetency,
				misconduct, or impairment;
4. Agrees to
				the placement of conditions or limitations on the exercise of clinical privileges or
				practice within the health care facility including, but not limited to, second
				opinion requirements, nonroutine concurrent or retrospective review of admissions or
				care, nonroutine supervision by one or more members of the staff, or the completion
				of remedial education or training;
5. Is
				granted a leave of absence pursuant to which the practitioner may not exercise
				clinical privileges or practice within the facility and if the reasons provided in
				support of the leave relate to any physical, mental, or emotional condition or drug
				or alcohol abuse, which might impair the practitioner's ability to practice with
				reasonable skill and safety; or
6. Is a
				party to a medical malpractice liability suit in which the facility is also a party
				and in which there is a settlement, judgement, or arbitration award.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.11 - Reporting to professional licensing boards

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall comply with all requirements of the
				  professional licensing boards for reporting termination, suspension, revocation, or
				  reduction of privileges of any health professional licensed in the State of New
				  Jersey.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 3 - GENERAL REQUIREMENTS › Section 8:43A-3.12 - Reporting requirements for ambulatory surgery facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As part of the
				annual licensure renewal process, all ambulatory surgery facilities shall submit to
				the Department's licensing program an audited statement that the facility has
				complied with the access requirements specified in the facility's certificate of
				need approval letter during the preceding licensure period. The audited statement
				shall include, but not be limited to, the following:
1. Total surgical case volume;
2. Surgical case volume for care provided to
				Medicaid-eligible and medically indigent persons, and its percentage of the total
				surgical case volume;
3. The cost of
				providing surgical care to Medicaid-eligible and medically indigent persons,
				excluding costs associated with bad debt or partial payment for individuals who are
				not Medicaid-eligible or medically indigent, and its percentage of the total cost of
				providing care; and
4. A description of
				the facility's free-care and partial-pay programs, including criteria of eligibility
				for each.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 4 - GOVERNING AUTHORITY › Section 8:43A-4.1 - Responsibility of the governing authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The 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 be responsible for, but not limited to, the following:
1. Services provided and the quality of care
				rendered to patients;
2. Provision of a
				safe physical plant equipped and staffed to maintain the facility and
				services;
3. Adoption and documented
				review of written laws, or their equivalent, in accordance with a schedule
				established by the governing authority;
4. Appointment, reappointment, assignment of
				privileges, and curtailment of privileges of health care professionals, and written
				confirmation of such actions;
5.
				Ensuring development and review of all policies and procedures in accordance with a
				schedule established by the governing authority;
6. Establishment and implementation of a system
				whereby patient and staff grievances and/or recommendations, including those
				relating to patient rights, can be identified within the facility. This system shall
				include a feedback mechanism through management to the governing authority,
				indicating what action was taken;
7.
				Determination of the frequency of meetings of the governing authority and its
				committees, or equivalent, conducting such meetings, and documenting them through
				minutes;
8. Delineation of the duties of
				the officers of any committees, or equivalent, of the governing authority. When the
				governing authority establishes committees, their purpose, structure,
				responsibilities, and authority, and the relationship of the committee to other
				entities within the facility, shall be documented;
9. Establishment of the qualifications of members
				and officers of the governing authority, the procedures for electing and appointing
				officers, and the terms of service for members, officers, and committee chairpersons
				or equivalent; and
10. Approval of the
				medical staff bylaws or equivalent.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 5 - ADMINISTRATION › Section 8:43A-5.1 - Appointment of administrator

Current through Register Vol. 56, No. 14, July 15, 2024
The governing authority shall appoint an administrator who shall
				  be accountable to the governing authority. The administrator, or an alternate who
				  shall be designated in writing to act in the absence of the administrator, shall be
				  available in the facility during its hours of operation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 5 - ADMINISTRATION › Section 8:43A-5.2 - Administrator's responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The administrator
				shall be responsible for, but not limited to, the following:
1. Ensuring the development, implementation, and
				enforcement of all policies and procedures, including patient rights;
2. Planning for, and administration of, the
				managerial, operational, fiscal, and reporting components of the facility;
3. Participating in the quality assurance program
				for patient care and staff performance;
4. Ensuring that all personnel are assigned duties
				based upon their education, training, competencies, and job descriptions;
5. Ensuring the provision of staff orientation and
				staff education; and
6. Establishing and
				maintaining liaison relationships and communication with facility staff and
				services, with support services and community resources, and with patients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.1 - Establishment and implementation of policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall establish and implement written patient care
				  policies and procedures governing the services provided.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.2 - Patient care policy committee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish a patient care policy committee, or its equivalent, consisting of, but not
				limited to, the administrator, the medical director, and a representative of the
				nursing service. A representative of each service offered by the facility shall
				attend all patient care policy committee meetings in which policies or procedures
				for that particular service are developed or reviewed.
(b) All patient care policies and procedures shall
				be reviewed by the patient care policy committee, in accordance with a schedule
				established by the governing authority, at least triennially. Each review shall be
				documented.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.3 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Patient care
				policies and procedures shall facilitate continuity of care to patients and shall
				include, but not be limited to, policies and procedures concerning the following:
1. Services to be provided, including preventive,
				diagnostic, and treatment services;
2.
				Patient rights;
3. The referral of
				patients to other health care providers and the use of consultant services, in order
				to provide a continuum of care for the patient;
4. The provision of emergency and after-hours care
				and treatment, including a definition of emergency;
5. Methods for obtaining and documenting informed
				consent, including definition or a listing of types of procedures for which informed
				consent will be required;
6. Advance
				directives, including, but not limited to, the following:
i. The circumstances under which an inquiry will
				be made of adult individuals receiving surgical services, anesthesia services other
				than minor conduction block, or chronic dialysis services regarding the existence
				and location of an advance directive;
ii. Requirements for provision of a written
				statement of patient rights regarding advance directives, approved by the
				Commissioner or his or her designee, to such patients upon admission; and
iii. Requirements for documentation in the medical
				record;
7. Admission of
				patients, including limitations on admission based on diagnosis, type or degree of
				disability, medical condition, patient age, or other factors. These limitations
				shall not conflict with applicable Federal and State laws prohibiting discrimination
				in the admission of patients or in the provision of health care services;
8. The facility's registration and appointment
				system;
9. Follow-up of broken
				appointments, including specification of the circumstances under which such
				follow-up will be performed;
10. The
				provision of screening services, if offered, including indications for, and
				frequency of, such services;
11. Medical
				histories and physical examinations;
12.
				Initiation, implementation, review, and revision of a written plan of care,
				including indication of the types of patients for whom a plan of care will be
				written;
13. A system whereby, whenever
				possible, the patient is cared for by the same health care professionals;
14. Methods for ensuring visual and auditory
				privacy of patients;
15. Immunization
				records, if applicable;
16. Patient
				instruction and health education;
17.
				The provision of telephone consultation to patients during the facility's hours of
				operation;
18. Discharge, termination by
				the facility, transfer, and readmission of patients, including criteria for
				each;
19. The safe-keeping of patients'
				valuables, when required; and
20. Other
				activities, as required by this chapter.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.4 - Medical history and physical examination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				specify in its policies and procedures the circumstances under which the patient's
				medical history will be obtained, the contents of the medical history, and the
				frequency of updating. The contents shall include at least past surgical procedures
				and medical/health conditions, allergies, adverse reactions to drugs, and current
				medications.
(b) The facility shall
				specify in its policies and procedures the circumstances under which a physical
				examination will be performed, the frequency, and the contents. The contents shall
				include at least an assessment of body systems.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.5 - Instructions and information for patients

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall provide printed and/or written instructions
				  and information for patients, with multilingual instructions as indicated.
				  Information shall include, but not be limited to, tests and/or procedures needed,
				  possible complications, a telephone number to call when needed, and instructions for
				  obtaining care in an emergency.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.6 - Communication assistance

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall provide interpretation services, when
				  necessary, for patients who do not speak English and for patients who are deaf. The
				  facility shall provide other communication assistance, as needed, for patients who
				  are blind.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.7 - Suitability of equipment and supplies

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall provide equipment and supplies which are
				  appropriate to the treatment needs of patients of the types and ages served by the
				  facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.8 - Financial arrangements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Records shall be
				maintained of all financial arrangements with patients, with copies furnished to the
				patient. The policies and procedures of the facility shall specify the form of
				retention and the retention schedule.
(b) Patients shall be informed, in advance, of the
				fees which are charged by the facility for the types of services and supplies
				expected to be provided to the patient, on the basis of a predetermined fee
				schedule. The facility shall post the fee schedule or a notice that the schedule is
				available in the facility. Patients shall be notified if physician or other
				practitioner fees will be billed separately.
(c) Policies and procedures shall require
				physicians and other practitioners to disclose, in advance, any separate charges,
				upon request of the patient.
(d) No
				additional charges, expenses, or other financial liabilities shall be assessed in
				excess of the predetermined rate, except:
1. Upon
				written approval and authority of the patient, who shall be given a copy of the
				written approval; or
2. In the event of
				a health emergency involving the patient and requiring immediate, special services
				or supplies to be furnished during the period of the emergency.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.10 - Calibration of instruments

Current through Register Vol. 56, No. 14, July 15, 2024
All instruments of measurement shall be calibrated in accordance
				  with manufacturers' instructions. A record of instrument calibration shall be
				  maintained.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 6 - PATIENT CARE POLICIES AND SERVICES › Section 8:43A-6.11 - Acupuncture services

Current through Register Vol. 56, No. 14, July 15, 2024
If the facility provides acupuncture services, such services
				  shall be provided in accordance with
				  45:2C-1 et seq.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 7 - MEDICAL SERVICES › Section 8:43A-7.1 - Provision of medical services

Current through Register Vol. 56, No. 14, July 15, 2024
Medical services, as required by this chapter, shall be provided
				  in the facility. Medical services shall be provided directly by the facility or
				  through written agreement. Patients may be referred to physicians outside of the
				  facility for additional medical services as required to provide a continuum of care
				  for the patient.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 7 - MEDICAL SERVICES › Section 8:43A-7.2 - Designation of medical director

Current through Register Vol. 56, No. 14, July 15, 2024
The governing authority shall designate a physician to serve as
				  medical director. The medical director shall designate, in writing, a physician to
				  act in the absence of the medical director. The medical director, or his or her
				  designee, shall be available to the facility at all times.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 7 - MEDICAL SERVICES › Section 8:43A-7.3 - Medical director's responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical director
				shall be responsible for the direction, provision, and quality of medical services
				provided to patients. He or she shall be responsible for, but not limited to, the
				following:
1. Developing and maintaining written
				objectives, policies, a procedure manual, an organizational plan, and a quality
				assurance program for the medical service. All medical policies and procedures shall
				be reviewed at least annually;
2.
				Participating in planning and budgeting for the medical service;
3. Coordinating and integrating the medical
				service with other patient care services to provide a continuum of care for the
				patient;
4. Ensuring that medical
				staffing patterns are implemented;
5. If
				the facility provides a cardiac rehabilitation program, ensuring that a physician is
				present in the facility at all times during the facility's hours of operation to
				supervise nonphysician personnel;
6.
				Assisting in developing and maintaining written job descriptions for the medical
				staff, participating in the review of credentials and delineation of privileges of
				medical staff members, and assigning duties based upon education, training,
				competencies, and job descriptions;
7.
				Participating in staff orientation and staff education activities; and
8. Approving the contents, locations, and
				frequency of checking contents, including expiration dates, of emergency kits or
				carts, equipment, and supplies, and assigning responsibility for these checks.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 7 - MEDICAL SERVICES › Section 8:43A-7.4 - Medical policies and medical staff bylaws

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical director
				shall be responsible for developing, implementing, and reviewing written medical
				policies, including medical staff bylaws, in cooperation with the medical staff.
				These shall be approved by the governing authority and shall include, but not be
				limited to, the following:
1. A plan for medical
				staff meetings and their documentation through minutes;
2. A mechanism for establishing and implementing
				procedures relating to credentials review, delineation of qualifications, medical
				staff appointments and reappointments, evaluation of medical care, and the granting,
				denial, curtailment, suspension, or revocation of medical staff
				privileges;
3. Specifications for verbal
				orders, including who may give verbal orders and who may receive them; and
4. A system for completion of entries in the
				patient medical record by members of the medical staff, including, but not limited
				to, specification of a time limit for completion of the medical record, not to
				exceed 30 days following the patient's last treatment or discharge. Entries shall be
				signed in accordance with
				8:43A-13.4 and the facility's policies
				and procedures.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 8 - NURSING SERVICES › Section 8:43A-8.1 - Provision of nursing services

Current through Register Vol. 56, No. 14, July 15, 2024
Nursing services, as required by this chapter, shall be provided
				  in the facility. Nursing services shall be provided directly by the facility or
				  through written agreement.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 8 - NURSING SERVICES › Section 8:43A-8.2 - Designation of director of nursing services

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall designate in writing a registered professional
				  nurse as the director of nursing services, who shall be on the premises of the
				  facility during its hours of operation. A registered professional nurse shall be
				  designated in writing to act in the absence of the director of nursing services.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 8 - NURSING SERVICES › Section 8:43A-8.3 - Responsibilities of director of nursing services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The director of
				nursing services shall be responsible for the direction, provision, and quality of
				nursing services provided to patients. The director of nursing services shall be
				responsible for, but not limited to, the following:
1. Developing and maintaining written objectives,
				policies, a procedure manual, an organizational plan, and a quality assurance
				program for the nursing service. All nursing policies and procedures shall be
				reviewed at least annually;
2.
				Participating in planning and budgeting for the nursing service;
3. Coordinating and integrating the nursing
				service with other patient care services to provide a continuum of care for the
				patient;
4. Ensuring that nursing
				staffing patterns are implemented;
5.
				Assisting in developing and maintaining written job descriptions for nursing
				personnel, and assigning duties based upon education, training, competencies, and
				job descriptions; and
6. Participating
				in staff orientation and staff education activities.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 8 - NURSING SERVICES › Section 8:43A-8.4 - Responsibilities of licensed nursing personnel

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Licensed nursing
				personnel shall provide nursing care to patients in accordance with the State of New
				Jersey Nursing Practice Act,
				45:11-23 et seq., as interpreted by the
				New Jersey State Board of Nursing, and written job descriptions. Services provided
				shall be documented in the patient's medical record.
(b) The nursing care needs of the patient shall be
				assessed only by a registered professional nurse.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 8 - NURSING SERVICES › Section 8:43A-8.5 - Nursing portion of the medical record

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with
				written job descriptions and with these rules, nursing personnel shall enter the
				following in the patient's medical record:
1. The
				nursing portion of the patient plan of care, in accordance with the facility's
				policies and procedures;
2. Clinical
				notes; and
3. A record of medications
				administered. After each drug administration, the following shall be documented by
				the nurse who administered the drug: name and strength of the drug, date and time of
				administration, dosage administered, method of administration, and signature of the
				nurse who administered the drug.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 9 - PHARMACEUTICAL SERVICES › Section 8:43A-9.1 - Provision of pharmaceutical services through an institutional pharmacy

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the facility has
				an institutional pharmacy, the pharmacy shall be licensed by the New Jersey State
				Board of Pharmacy and shall possess a current Drug Enforcement Administration
				registration and a Controlled Dangerous Substance registration from the Department
				in accordance with the Controlled Dangerous Substances Acts.
(b) If the facility has an institutional pharmacy,
				the facility shall designate a pharmacist who shall be responsible for the
				direction, provision, and quality of pharmaceutical services. The pharmacist shall
				be responsible for, but not limited to, the following:
1. Together with the patient care policy
				committee, developing and maintaining written objectives, policies, a procedure
				manual, an organizational plan, and a quality assurance program for the
				pharmaceutical service;
2. Participating
				in planning and budgeting for the pharmaceutical service;
3. Coordinating and integrating the pharmaceutical
				service with other patient care services to provide a continuum of care for the
				patient; and
4. Assisting in developing
				and maintaining written job descriptions for pharmacy personnel, if any, and
				assigning duties based upon education, training, competencies, and job descriptions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 9 - PHARMACEUTICAL SERVICES › Section 8:43A-9.2 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
8:43A-9.3 through 9.5 shall apply to all
				  ambulatory care facilities, regardless of whether or not the facility has an
				  institutional pharmacy.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 9 - PHARMACEUTICAL SERVICES › Section 8:43A-9.4 - Administration of medications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All medications
				administered shall be prescribed in writing. Each written order shall specify the
				name of the drug, dose, frequency, and route of administration and shall be signed
				and dated by the prescriber.
(b)
				Medications shall be dispensed only in accordance with prescriber orders and all
				Federal and State laws and rules. Medications shall be administered only in
				accordance with prescriber orders, medical staff policy, and all Federal and State
				laws and rules by licensed or authorized medical, dental, or nursing
				personnel.
(c) Medications shall not be
				removed from their original prescription containers until the time of drug
				administration.
(d) Each patient shall
				be identified prior to drug administration.
(e) Drugs dispensed for one patient shall not be
				administered to another patient.
(f)
				Drug allergies shall be documented in the patient's medical record and on its
				outside front cover. Other allergies shall be documented in the patient's medical
				record.
(g) Medication errors and
				adverse drug reactions shall be reported immediately to the nurse in charge and to
				the prescriber, and an entry shall be made in the patient's medical record. The
				incident shall be reported in accordance with procedures established by the
				facility. The incident shall be reported to the pharmacy, in accordance with
				policies and procedures approved by the patient care policy committee.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 9 - PHARMACEUTICAL SERVICES › Section 8:43A-9.5 - Storage of drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All drugs, except
				intravenous infusion solutions, shall be kept in locked storage areas. Drug storage
				and preparation areas shall be kept locked when not in use.
(b) All drugs shall be stored under proper
				conditions, as indicated by the United States Pharmacopoeia, product labeling,
				and/or package inserts.
(c) Drugs for
				external use shall be kept separate from drugs for internal use.
(d) All drugs in Schedule II of the Controlled
				Dangerous Substances Acts and amendments thereto shall be stored in a separate,
				locked, permanently affixed compartment within the locked medication cabinet,
				medication room, refrigerator, or mobile medication cart.
(e) A declining inventory of all drugs in
				Schedules I through V of the Controlled Dangerous Substances Acts and amendments
				thereto shall be made at the termination of each shift and shall be retained
				wherever these drugs are maintained.
(f)
				Drugs in single dose or single use containers which are open or which have broken
				seals, drugs in containers missing drug source or exact identification (such as lot
				number), and outdated, recalled, or visibly deteriorated medications shall be
				returned to the institutional pharmacy for disposal. In the absence of an
				institutional pharmacy, such drugs shall be brought to a location specified in the
				facility's policies and procedures for disposal in accordance with Federal and State
				laws.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 10 - COUNSELING SERVICES › Section 8:43A-10.1 - Provision of counseling services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				provide, directly or through written agreement or through a documented referral
				mechanism, dietary counseling and social work services. All patients who have been
				identified as needing, or who have requested, other counseling services such as, but
				not limited to, genetic, psychological, and drug abuse counseling shall be referred
				to appropriate providers.
(b) The
				facility shall establish and implement written policies and procedures concerning
				the identification of the need for counseling services and referral to counseling
				services. The policies and procedures, which shall be reviewed at least annually,
				shall include, but not be limited to, policies and procedures for the following:
1. The provision, direction, and method to assure
				the quality of counseling services provided to patients;
2. The development and implementation of written
				objectives, standards of practice, and an organizational plan for counseling
				services;
3. Coordinating and
				integrating the counseling services with other patient care services in the facility
				and with services in the community to provide a continuum of care for the
				patient;
4. Staff orientation and staff
				education programs for the counseling staff; and
5. Entering in the patient's medical record:
i. The counseling service elements of the patient
				plan of care; and
ii. Clinical notes.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 10 - COUNSELING SERVICES › Section 8:43A-10.2 - Provision of social work services

Current through Register Vol. 56, No. 14, July 15, 2024
Social work services which fall within the scope of practice
				  defined by the Social Workers' Licensing Act of 1991 (N.J.S.A. 45:15BB-1 et seq.)
				  and the New Jersey State Board of Social Work Examiners shall be provided by a
				  social worker.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 10 - COUNSELING SERVICES › Section 8:43A-10.3 - Provision of dietary counseling

Current through Register Vol. 56, No. 14, July 15, 2024
Dietary counseling which falls outside of the scope of practice
				  defined by the State of New Jersey Nursing Practice Act and the New Jersey State
				  Board of Nursing shall be provided by a dietitian.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 11 - LABORATORY AND RADIOLOGICAL SERVICES › Section 8:43A-11.1 - Provision of laboratory and radiological services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				provide laboratory and radiological services directly or through written
				agreement.
(b) Laboratory services shall
				be provided only by facilities which are licensed or approved by the Department, in
				accordance with N.J.A.C. 8:44 and 8:45.
(c) Radiological services shall be provided only
				by facilities which are registered by the New Jersey State Department of
				Environmental Protection, Bureau of Radiological Health, in accordance with N.J.A.C.
				7:28.
(d) The facility shall establish
				and implement policies and procedures for obtaining, identifying, storing, and
				transporting laboratory specimens.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 12 - SURGICAL AND ANESTHESIA SERVICES › Section 8:43A-12.1 - Services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If the facility
				provides surgical services to patients, the surgical and anesthesia services
				provided shall be limited to those procedures approved by the governing authority
				and the medical staff.
(b) Surgical
				procedures requiring the patient to remain in the facility for more than 24 hours
				shall not be performed in the facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 12 - SURGICAL AND ANESTHESIA SERVICES › Section 8:43A-12.3 - Surgical staff; qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director who is clinically responsible for the surgical service and is
				also board certified by the American Board of Medical Specialties.
(b) Surgical procedures shall be performed only by
				practitioners who are licensed to practice in New Jersey and have been granted
				privileges to perform those procedures by the governing body of the facility, upon
				the recommendation of the medical staff, after medical review of each practitioner's
				documented education, training, experience, and current competence.
(c) A physician and a registered professional
				nurse, at least one of whom maintains current training in Advanced Cardiac Life
				Support shall be present when surgery is in progress.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 12 - SURGICAL AND ANESTHESIA SERVICES › Section 8:43A-12.4 - Anesthesia staff; qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director of anesthesia services who is a diplomate of either the American
				Board of Anesthesiology or the American Osteopathic Board of Anesthesiology, or who
				was made a Fellow of the American College of Anesthesiology before 1982. The medical
				director of the facility may serve as physician director of anesthesia services, if
				the medical director possesses the qualifications of a physician director of
				anesthesia services as specified in this subsection.
1. Facilities in which only conscious sedation is
				administered may, in lieu of appointing a director of anesthesia services as
				specified in (a) above, ensure that each of the physicians who administer,
				supervise, or monitor the administration of conscious sedation in the facility is
				privileged by an acute care hospital, licensed in New Jersey in accordance with
				N.J.A.C. 8:43G, to administer, supervise, and monitor the administration of
				conscious sedation or credentialed in accordance with the provisions of
				13:35-4A.10, Administration of
				conscious sedation; authorized personnel.