reglab/statecodes huggingface dataset:
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-12.5 - Anesthesia staff; qualifications for supervising, administering, and monitoring anesthesia

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General or major
				regional anesthesia shall be administered and monitored only by the following:
1. An anesthesiologist;
2. Under the supervision of an anesthesiologist:
i. A certified registered nurse
				anesthetist;
ii. A registered nurse
				anesthetist; or
iii. A physician
				resident, dental resident, or a student nurse anesthetist participating in a
				nationally approved graduate training program leading to a recognized
				specialty;
3. Under the
				supervision of a privileged physician who has privileges in accordance with medical
				staff bylaws to administer or supervise the administration of anesthesia:
i. A certified registered nurse anesthetist;
				or
4. A dentist who has
				successfully completed a nationally approved graduate medical education program in
				anesthesiology and has privileges in accordance with the ambulatory facility centers
				policy.
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-12.7 - Anesthesia continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility's
				quality improvement program shall include a systematic review and evaluation of
				patient care, anesthesia practices and anesthesia techniques. The surgical staff
				shall identify problem-prone processes which manifest undesirable patterns. The
				facility shall develop a plan by which to collect and analyze data in order to
				evaluate outcomes or performance of the problem-prone processes. Data analysis shall
				focus on recommendations for implementing corrective actions and improving
				performance.
(b) Continuous quality
				improvement shall include morbidity and mortality conferences.
(c) The facility shall notify the Inspections,
				Compliance and Complaints Program of the Department, by telephone at (800) 792-9770
				or by fax at (609) 943- 4977 within 24 hours, and in writing within 30 days, of all
				deaths in anesthetizing locations and unexpected events or outcomes related to
				anesthesia, except those in which the patient expired prior to the administration of
				anesthesia.
1. The written report shall be
				submitted on the form entitled "Confidential Report of Anesthesia-Related Incident"
				(HFE-5), available from the Department and shall include;
i. A summary of the incident and the patient's
				risk status or the American Society of Anesthesiology (ASA) Physical Status
				Classification; and
ii. All unexpected
				intraoperative or postoperative events or outcomes related to
				anesthesia.
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-12.8 - Records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				maintain a record of all surgical procedures performed which shall include the type
				of procedure performed, operative diagnosis, type of anesthesia used, personnel
				participating, postoperative diagnosis, and any unusual or untoward
				occurrence.
(b) A preanesthesia note,
				reflecting evaluation of the patient and of the patient record prior to
				administration of anesthesia, shall be made or reviewed by the physician
				administering or supervising the administration of anesthesia and entered into the
				medical record of each patient receiving anesthesia at any anesthetizing
				location.
(c) A record of anesthesia
				that conforms with policies and procedures developed by the medical staff shall be
				made for each patient receiving sedation or anesthesia at any anesthetizing
				location.
(d) Upon arrival in the
				postanesthesia care unit, a postanesthesia note shall be entered into the patient's
				anesthesia record by a member of the facility's anesthesia team.
(e) The patient's medical record shall include a
				pathologist's report of gross and microscopic tissue surgically removed.
(f) A discharge note shall be entered into the
				patient's medical record by an anesthesia team member prior to discharge from 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-12.9 - Surgical service emergency equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Emergency equipment
				available to the operating room in a surgical service shall include at least the
				following:
1. Emergency call system to include, at
				least, an emergency communication system that connects each operating room and
				postanesthesia care unit with the control center of the suite;
2. Oxygen;
3. Difficult airway container or cart shall be
				immediately available for handling emergencies. The emergency equipment shall
				include, but not be limited to, resuscitation equipment, and equipment to open and
				maintain an airway;
4. Cardiac
				defibrillator;
5. Cardiac monitoring
				equipment;
6. Tracheotosmy set including
				sizes adaptable to children. Sizes for newborns and infants shall be made available,
				unless a facility's policy explicitly excludes the provision of services for this
				population;
7. Laryngoscopes and
				endotracheal tubes including sizes adaptable to children. Sizes for newborns and
				infants shall be made available, unless a facility's policy explicitly excludes the
				provision of services for this population;
8. Portable suction equipment with catheter
				tip;
9. Emergency drugs and supplies
				specified by the medical staff in the facility's policies and procedures;
				and
10. There shall be a mechanism for
				testing the emergency equipment on a regular basis and documenting that it is in
				working condition.
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-12.10 - Anesthesia supplies and equipment; safety systems

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Diameter index
				safety systems or equivalent systems shall be used on all large cylinders of medical
				gases and wall and ceiling outlets of medical gases.
(b) Pin index safety systems with a single washer
				shall be used on all small cylinders to prevent interchangeability of medical gas
				cylinders.
(c) All medical gas hoses and
				adapters shall be color-coded with clear labeling according to current national
				standards, that is, the Compressed Gas Association , Standard Color Marking of
				Compressed Gas Containers for Medical Use , Publication C-9 ( Edition 6 ), September
				2019, incorporated herein by reference, as amended and supplemented. That
				publication may be obtained from the Compressed Gas Association at 8484 Westpark
				Drive, Suite 220, McLean, VA 22102 (703) 788-2700,
http://www.cganet.com
.
(d) An oxygen failure-protection device
				("fail-safe" system) shall be used on all anesthesia machines to announce a
				reduction in oxygen pressure and, at lower levels of oxygen pressure, to discontinue
				other gases when the pressure of the supply of oxygen is reduced.
(e) A vaporizer exclusion ("interlock") system
				shall be used to assure that only one vaporizer, and therefore only a single agent,
				can be actuated on any anesthesia machine at one time.
(f) To prevent delivery of excess anesthesia
				during an oxygen flush, no vaporizer shall be placed in the circuit downstream of
				the oxygen flush valve.
(g) All
				anesthesia vaporizers shall be pressure-compensated in order to administer a
				constant non-pulsatile output.
(h)
				Accurate flow meters and controllers shall be used to prevent the delivery to a
				patient of an inadequate concentration of oxygen relative to the amount of nitrous
				oxide or other medical gas.
(i) Alarm
				systems shall be in place for high (disconnect), low (subatmospheric), and minimum
				ventilatory pressures in the breathing circuit for each patient under general
				anesthesia.
(j) There shall be a written
				protocol to assure that surgery does not proceed when there are disabled alarms,
				depleted batteries and inactive sensors in oxygen monitors or carbon dioxide
				monitors, improperly positioned breathing-circuit sensors, or other
				insufficiencies.
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-12.11 - Anesthesia supplies and equipment; maintenance and inspections

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A record shall be
				maintained of all service and maintenance performed on all anesthesia machines,
				ventilators, and vaporizers. The record shall include machine identification; the
				name of the servicing agent; the work performed; and the date of the work. This
				maintenance shall conform with maintenance requirements established by the machine
				manufacturer. Credentials of each servicing agent shall be approved by the machine
				manufacturer or shall be determined by the physician director of anesthesia services
				as equivalent to the credentials of manufacturers' servicing agents.
(b) All anesthesia equipment shall be inspected
				fully at the beginning of each day of use. A record of each such inspection shall be
				maintained for each machine. The inspection shall conform with a checklist that is
				supplied by the manufacturer of the machine, issued by the Federal Food and Drug
				Administration, or, alternatively, developed by the facility's anesthesia services
				and approved by the physician director of anesthesia services.
(c) All anesthesia equipment shall be inspected
				before each use. A record of each inspection shall be indicated on the patient's
				anesthesia record. Each record may consist of a checklist or single phrase
				explanation.
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-12.12 - Anesthesia supplies and equipment; patient monitoring

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An in-circuit oxygen
				analyzer shall monitor the oxygen concentration within the breathing circuit,
				displaying the percent oxygen of the total mixture, for all patients receiving
				general anesthesia.
(b) A respirometer
				(volumeter) measuring exhaled tidal volume shall be used whenever the breathing
				circuit of a patient under general anesthesia allows.
(c) The body temperature of each patient under
				general or major regional anesthesia lasting 45 minutes or more shall be
				continuously monitored and recorded at least every 15 minutes.
(d) Pulse oximetry shall be performed continuously
				during administration of general anesthesia, regional anesthesia, or conscious
				sedation, at all anesthetizing locations, unless such monitoring is not clinically
				feasible for the patient. Any alternative method of measuring oxygen saturation may
				be substituted for pulse oximetry if the method has been demonstrated to have at
				least equivalent clinical effectiveness.
(e) End-tidal carbon dioxide monitoring shall be
				performed continuously during administration of all general anesthesia, unless such
				monitoring is not clinically feasible for the patient.
(f) An electrocardiogram monitor shall be used
				continuously on all patients receiving general anesthesia, regional anesthesia, or
				conscious sedation at any anesthetizing location.
(g) Blood pressure, pulse rate, and respirations
				shall be determined and charted at least every five minutes for all patients
				receiving anesthesia at any anesthetizing location, except for local anesthesia and
				minor regional blocks.
(h) A precordial
				stethoscope or esophageal stethoscope shall be used when indicated on each patient
				receiving anesthesia. If necessary, the stethoscope may be positioned on the
				posterior chest wall or tracheal area.
(i) A peripheral nerve stimulator shall be
				available to any anesthetizing location in which patients receive general or
				regional anesthesia to monitor the patient's extent of muscle paralysis from muscle
				relaxants. Another peripheral nerve stimulator shall be available within the
				postanesthesia care unit.
(j) Monitoring
				of regional labor analgesia shall include documented temperature, pulse,
				respiration, blood pressure, and oxygen saturation until the patient is deemed
				stable based on written criteria established by the Department of Anesthesia. The
				patient shall be subsequently monitored in accordance with facility
				protocol.
(k) Supplemental oxygen and a
				delivery system appropriate to the patient's condition shall be immediately
				available for patient transport from the operating room to the postanesthesia care
				unit.
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-12.13 - Anesthesia staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Staff education
				programs and training sessions shall include patient safety and the inspection and
				use of equipment.
(b) Requirements for
				the anesthesia education program shall be as set forth in
				8:43G-5.9.
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-12.14 - Postanesthesia care policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Facilities providing
				anesthesia services shall have a postanesthesia care unit.
(b) The postanesthesia care unit shall have
				written policies and procedures that are reviewed at least every three years,
				revised more frequently as needed, and implemented. These shall include at least:
1. Criteria for admission to and discharge from
				the unit;
2. Delineation of the primary
				medical responsibility for postanesthesia and postsurgical care of each patient in
				the unit, including authority to discharge;
3. Monitoring of patients in the postanesthesia
				care unit, including availability of monitoring equipment;
4. Protocol of care for all patients;
5. Protocol for patient emergencies;
6. Orders for intravenous administration of
				medications;
7. Requirements for
				documentation of patient status; and
8.
				A requirement that patients who receive anesthesia, excluding minor regional blocks,
				do not drive themselves home after discharge and that they be accompanied home by
				another person who accepts responsibility for the patient. If the patient fails to
				comply with the requirement, the circumstances shall be documented in the patient's
				medical record.
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-12.15 - Postanesthesia care staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director with overall responsibility for postanesthesia care. The
				physician director of anesthesia services may serve as physician director of
				postanesthesia care.
(b) There shall be
				a registered professional nurse with administrative responsibility for nursing care
				provided in the postanesthesia care unit.
(c) Documentation shall be available to show that
				all registered professional nurses assigned to the postanesthesia care unit meet the
				minimum competence levels, including at least:
1.
				Management of airway and ventilatory function;
2. Monitoring of cardiac function, arrhythmia
				recognition, and treatment of life-threatening emergencies;
3. Management of the patient during altered states
				of consciousness;
4. Management of
				monitoring and respiratory equipment;
5.
				Management of fluid lines, tubes, drains, and catheters;
6. Administration of drugs and identification of
				drug-related problems; and
7.
				Recognition of the actions and interactions of anesthetic techniques.
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-12.16 - Postanesthesia care staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be at least one registered professional nurse present
				  whenever a patient is in the postanesthesia care unit, and a second health care
				  staff member shall be immediately available.
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-12.17 - Postanesthesia care patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The patient shall be
				accompanied to the postanesthesia care unit by two individuals, one of whom,
				stationed at the patient's head, shall be responsible for the patient's airway.
1. If a patient who has received conscious
				sedation or a minor regional block is able to walk to the postanesthesia care unit,
				the patient shall be accompanied by at least one individual, who shall be a member
				of the anesthesia team.
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-12.18 - Postanesthesia care units and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Postanesthesia care
				units shall be adjacent to or within the operating suite.
(b) The postanesthesia care unit shall be
				maintained as a closed unit. Access to the postanesthesia care unit shall be in
				accordance with facility policies and procedures.
(c) All staff in the postanesthesia care unit
				shall be attired in scrub attire. Individuals who are permitted limited access shall
				be attired according to facility infection control policies.
(d) Equipment and services available in the
				postanesthesia care unit shall include at least: a crash cart with defibrillator,
				drugs, pulse oximetry, electrocardiographic monitoring, body temperature monitoring,
				equipment necessary for intubation and various means of oxygen delivery. Constant
				and intermittent suction, blood pressure monitoring, adequate lighting, peripheral
				nerve stimulator, immediate access to a ventilator and end-tidal carbon dioxide
				monitoring in accordance with
				8:43A-12.17(g)  shall
				be made available. Provisions to ensure the patient's privacy shall be maintained.
1. If neither general anesthesia nor regional
				anesthesia is administered in the facility, then the requirements for pulse
				oximetry, electrocardiographic monitoring, and a peripheral nerve stimulator in (d)
				shall not apply to the postanesthesia care unit.
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-12.19 - Designation of consultant pharmacist

Current through Register Vol. 56, No. 14, July 15, 2024
If an ambulatory surgical facility does not have an institutional
				  pharmacy, the facility shall designate a consultant pharmacist who shall review all
				  facility policies and procedures concerning the administration, control, and storage
				  of medications at least semiannually. The consultant pharmacist shall not be
				  affiliated with the pharmacy which provides pharmaceutical services for 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-12.20 - Physical plant

Current through Register Vol. 56, No. 14, July 15, 2024
(a) New ambulatory
				surgical facilities shall comply with Chapter 3.7 (Outpatient Surgical Facility) of
				the construction guidelines.
(b) When
				the ambulatory surgical facility is part of an acute care hospital's surgical suite,
				support services may be shared to avoid duplication. When inpatients and outpatients
				are served in the same suite, the functional program shall describe in detail
				scheduling and techniques used to separate inpatients from outpatients.
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-12.21 - Exceptions for local anesthesia

Current through Register Vol. 56, No. 14, July 15, 2024
Facilities in which local anesthesia or minor conduction regional
				  blocks only are administered are exempt from complying with the requirements for
				  anesthesia services in this subchapter, except that such facilities shall comply
				  with the following:
				  8:43A-12.1, 12.4(d), 12.5(f), 12.5(g),
				  12.6(a)1, 12.6(a)2, 12.6(a)4 and 12.6(a)6. The facility shall also comply with
				  8:43A-12.11(g), except
				  that the frequency of determining and charting temperature, pulse, respiration and
				  blood pressure may be determined by the facility and specified in the policies and
				  procedures of the facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.1 - Maintenance of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A current, complete
				medical record shall be established and maintained for each patient and shall
				contain documentation of all services provided.
(b) Written objectives, policies and procedures,
				an organizational plan, and a quality assurance program for medical record services
				shall be developed and implemented. All medical records policies and procedures
				shall be reviewed at least annually.
(c)
				Original medical records or components of medical records shall not leave facility
				premises unless they are under court order or subpoena or removed in order to
				safeguard the record in the case of a physical plant emergency or natural disaster.
				Off-site storage of records may be used only if the Department is given prior
				notice, including the details of the storage arrangement, and only if such storage
				arrangements will ensure retrieval and delivery of the patient's medical record to
				the facility within one business day on a seven day per week, 24 hour per day, basis
				and immediate availability of medical record information through telephone and
				facsimile communications systems.
(d) A
				record system shall be maintained in which the patient's complete medical record is
				filed as one unit, and there shall be a system of access and identification for the
				medical records of all patients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.2 - Assignment of responsibility

Current through Register Vol. 56, No. 14, July 15, 2024
An employee shall be designated to act as coordinator of medical
				  record services. The facility shall designate an employee to act in the absence of
				  the coordinator to ensure staff access to the medical record at all times during the
				  hours of operation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.3 - Contents of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The complete medical
				record shall include, but not be limited to, the following:
1. Patient identification data, including name,
				date of admission, address, date of birth, race, religion (optional), sex, and the
				name, address, and telephone number of the person(s) to be notified in an
				emergency;
2. The patient's complaint or
				purpose of the visit;
3. The diagnosis
				or medical impressions;
4. Orders for
				laboratory, radiological, diagnostic, and/or screening tests and their
				results;
5. All orders for treatment,
				medication, and diets, signed by the prescriber;
6. Documentation of the medical history and
				physical examination, if performed, signed and dated by the examiner;
7. Patient assessments developed by each service
				providing care to the patient;
8. A
				patient plan of care, in accordance with the facility's policies and
				procedures;
9. Clinical notes, which
				shall be entered on the day service is rendered;
10. A medication sheet indicating at least the
				name, date, dosage, and duration of all medications prescribed;
11. A record of medications administered,
				including the name and strength of the drug, date and time of administration, dosage
				administered, method of administration, and signature of the person who administered
				the drug;
12. Documentation of drug
				allergies in the medical record and on its outside front cover and documentation of
				other allergies in the medical record;
13. An immunization record, in accordance with the
				facility's policies and procedures;
14.
				A record of referrals to or from other health care providers;
15. Documentation of any consultations ordered or
				provided;
16. Documentation that
				informed consent was obtained for any procedure or treatment provided which is
				specified in the facility's policies and procedures as requiring informed
				consent;
17. Documentation regarding an
				advance directive, if applicable;
18.
				The patient's signed acknowledgement that the patient has been informed of patient
				rights, either verbally or through written copy, and has been offered a
				copy;
19. Instructions given to the
				patient and/or family for follow-up care;
20. A record of any treatment, drug, or service
				offered by personnel of the facility and refused by the patient;
21. The discharge plan, where applicable, and a
				discharge summary sheet containing the patient's name, address, dates of admission
				and discharge, and a summary of the treatment and medication rendered during the
				patient's stay; and
22. Any
				authorizations granted by the patient for release of the patient's medical
				record.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.4 - Requirements for entries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All orders for
				patient care shall be prescribed in writing and signed and dated by the prescriber,
				in accordance with the laws of the State of New Jersey. All orders, including verbal
				orders, shall be verified or countersigned in writing within seven days.
(b) All entries in the medical record shall be
				typewritten or written legibly in ink, dated, and signed by the person entering
				them, or, if a computerized medical records system is used, authenticated.
1. If computer-generated orders with a physician's
				electronic signature are used, the facility shall develop a procedure to assure the
				confidentiality of each electronic signature and to prohibit the improper or
				unauthorized use of any computer-generated signature.
2. If a facsimile communications system (FAX) is
				used, entries into the medical record shall be in accordance with the following
				procedures:
i. The physician shall sign the
				original order, history and/or examination at an off-site location;
ii. The original shall be transmitted by FAX
				system to the facility for inclusion into the medical record;
iii. The physician shall submit the original for
				inclusion into the medical record within seven days, unless a plain-paper laser
				facsimile process was used; and
iv. The
				copy transmitted by FAX system shall be replaced by the original, unless a
				plain-paper laser facsimile process was used.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.5 - Medical records policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish and implement written policies and procedures regarding medical records
				including, but not limited to, policies and procedures for the following:
1. The protection of medical record information
				against loss, tampering, alteration, destruction, or unauthorized use. The patient's
				written consent shall be obtained for release of medical record
				information;
2. The specific period of
				time, not to exceed 30 days, within which the medical record shall be completed
				following treatment or discharge; and
3.
				The transfer of patient information when the patient is transferred to another
				health care facility, or if the patient has been an inpatient and becomes an
				outpatient at the same facility, to ensure continuity of care.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 13 - MEDICAL RECORDS › Section 8:43A-13.6 - Preservation, storage, and retrieval of medical records

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All medical records
				shall be preserved in accordance with
				26:8-5 et seq.
(b) If the facility plans to cease operation, it
				shall notify the Department in writing, at least 14 days before cessation of
				operation, of the location where medical records will be stored and of methods for
				their retrieval.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.1 - Administrator's responsibilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The administrator,
				or designee, shall ensure the development and implementation of an infection
				prevention and control program.
(b) The
				administrator shall designate an infection control professional who shall be
				responsible for the direction, provision, and quality of infection prevention and
				control services. The designated person shall be responsible for, but not limited
				to, developing and maintaining written objectives, policies and procedures, an
				organizational plan, and a quality improvement program for the infection prevention
				and control service. The infection control professional may be a consultant;
				however, there must be a health care professional on site who is responsible for the
				day to day activities related to infection control.
(c) The infection control professional shall have
				education or training in surveillance, prevention, and control of nosocomial
				infections. The infection control professional shall be certified in infection
				control within five years of beginning practice of infection control and shall
				maintain certification through the Certification Board of Infection Control and
				Epidemiology, Inc. (CBIC).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.2 - Infection control policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish an infection control committee which shall include the medical director,
				the infection control professional, and representatives from at least administration
				and the nursing service. If this facility is owned or operated by an acute care
				hospital, then the facility may participate in the hospital's infection control
				program.
(b) The infection control
				committee, with assistance from each service in the facility, shall develop,
				implement, and review, every three years or more frequently , as necessary, written
				policies and procedures regarding infection prevention and control, including, but
				not limited to, policies and procedures regarding the following:
1. In accordance with N.J.A.C. 8:57 (Communicable
				Diseases), a system for investigating, reporting, and evaluating the occurrence of
				all infections or diseases which are reportable or conditions which may be related
				to activities and procedures of the facility;
2. Identifying and reporting of HIV/AIDS as
				specified in N.J.A.C. 8:57-2, Reporting of Acquired Immunodeficiency Syndrome and
				Infection with Human Immunodeficiency Virus;
3. A system for identifying and monitoring
				nosocomial infections, in conformance with the "CDC Definitions for Nosocomial
				Infections, 1988" (order number PB 88-187117) incorporated herein by
				reference;
4. Infection control
				practices, including universal precautions, in accordance with the Occupational
				Safety and Health Administration (OSHA) rule 29 CFR Part 1910.1030 , Occupational
				Exposure to Bloodborne Pathogens, incorporated herein by reference;
5. Control measures or studies to be initiated
				following identification of an infection control problem;
6. Aseptic technique, employee health in
				accordance with N.J.A.C 8:43A-3.7, and staff training in regard to infection
				control;
7. Care of patients with
				communicable diseases;
8. Exclusion from
				work, and authorization to return to work, for personnel with communicable diseases;
				and
9. Surveillance techniques to
				identify sources and minimize transmission of infection.
NOTE: Centers for Disease Control publications can be obtained at
http://www.cdc.gov/publications
and from:
National Technical Information Service
U.S. Department of Commerce
5301 Shawnee Road Alexandria , VA 22312 or
Superintendent of Documents
U.S. Government Publishing Office
732 N. Capitol Street NW
Washington, DC 20401
(866) 512-1800
Copies of the OSHA rule 29 CFR Part 1910.1030 , which was
				  published in the Federal Register on December 6, 1991, can be obtained at
http://www.ecfr.
				  gov/current/title-29/subtitle-A/part-29
and from:
OSHA Office of Publications U.S. Department of Labor Room
				  N3101
200 Constitution Ave., NW Washington, DC
				  20220
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.3 - Infection prevention measures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Infection prevention
				activities shall be based on the Centers for Disease Control and Prevention
				Guidelines, and Healthcare Infection Control Practices Advisory Committee (that is,
				HICPAC) recommendations listed below, incorporated herein by reference, as amended
				and supplemented;
1. Guideline for Prevention of
				Catheter-Associated Urinary Tract Infections (2009 );
2. Guideline for Prevention of Intravascular
				Device-Related Infections (Infection Control and Hospital Epidemiology 1996;
				17:438-73 and American Journal of Infection Control 1996; 24:262-93);
3. Guidelines for Prevention of Surgical Site
				Infections (1999) (Infection Control and Hospital Epidemiology 1999;
				20:247-278);
4. Guidelines for
				Preventing Health-Care-Associated Pneumonia, 2003: Recommendation of CDC and the
				Healthcare Infection Control Practices Advisory Committee, published in the
				Morbidity and Mortality Weekly Report at MMWR 2004; 53 (No. RR-3), published by the
				Coordinating Center for Health Information and Service, available at
http://www.cdc.gov/mmwr/PDF/rr/rr5303.pdf
and at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
;
5. Guideline for Hand Hygiene in Health-Care
				Settings: Recommendation of the Healthcare Infection Control Practices Advisory
				Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the
				Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16), published by the
				Coordinating Center for Health Information and Service, available at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
and at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
;
6. Guideline for Infection Control in Hospital
				Personnel (1998);
7. Guideline for
				Isolation Precautions in Hospitals (Infection Control and Hospital Epidemiology
				1996; 17:53-80 and the American Journal of Infection Control 1996;
				24:24-52);
8. Guidelines for Preventing
				the Transmission of Mycobacterium tuberculosis in Health Care Facilities (Morbidity
				and Mortality Weekly Report 1994; 43:11-22); and
9. HICPAC Recommendations for Preventing the
				Spread of Vancomycin Resistance (Infection Control and Hospital Epidemiology 1995;
				16:105-113).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.4 - Sterilization of patient care items

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Methods for
				processing reusable medical devices shall conform with the following or revised or
				later editions, if in effect, incorporated herein by reference;
1. The Association for the Advancement of Medical
				Instrumentation (AAMI) , Comprehensive Guide to Steam Sterilization and Sterility
				Assurance in Health Care Facilities, ST 79;
2. AAMI, "Safe Handling and Biological
				Decontamination of Medical Devices in Health Care Facilities and in Nonclinical
				Settings," ST 35;
3. AAMI, "Ethylene
				Oxide Sterilization in Health Care Facilities: Safety and Effectiveness," 2008, ST
				41; and
4. Society of Gastroenterology
				Nurses and Associates (SGNA), "Standards of Infection Control in Reprocessing
				Flexible Gastrointestinal Endoscopes," ( 2018 ).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.5 - Care and use of sterilizers, ethylene oxide, peracetic acid, low temperature gas, plasma, and steam

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Biological
				monitoring with live spores, or an FDA approved equivalent, shall be performed as
				follows:
1. Ethylene oxide--in each load;
2. Peracetic acid--weekly;
3. Low temperature gas plasma--daily in the
				working load;
4. Steam
				sterilizers--weekly;
5. A biological
				monitor with live spores shall be performed following repair or breakdown of the
				above mentioned equipment; and
6. A
				biological monitor, or spore based enzyme, shall be used with each load containing
				implantables, and the implantable device shall not be used until the negative
				biological test is received.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.6 - Maintenance of sterile processing environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				environmental surfaces shall be maintained as follows in decontamination and clean
				processing areas:
1. Hard surface floors shall be
				kept clean.
2. Walls shall be cleaned of
				spills and splashes as necessary.
3.
				Ceilings, ventilation system vents, and sterilizer vents shall be clean and free
				from dust.
4. Storage shelves shall be
				kept clean.
5. All horizontal surfaces
				shall be disinfected each shift and as needed.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 14 - INFECTION PREVENTION AND CONTROL SERVICES › Section 8:43A-14.7 - Infection control quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
The infection control professional shall develop and implement a
				  program of quality improvement that is integrated into the facility quality
				  improvement program and includes regularly collecting and analyzing data to help
				  determine the effectiveness of infection control practices. When corrective actions
				  need to be taken based on data collected, the infection control committee shall
				  recommend, implement, and monitor those actions. The infection control professional
				  shall supervise these quality improvement activities. These quality improvement
				  activities shall be overseen by the continuous quality improvement program. (See
				  Subchapter 18).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 15 - EMERGENCY SERVICES AND DISASTER PLANS › Section 8:43A-15.1 - Disaster planning

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				have written emergency plans, policies, and procedures which shall include plans and
				procedures to be followed in case of potential hazards that could necessitate an
				evacuation, including internal and external disasters such as fire, natural
				disaster, bomb threats, or industrial or radiological accidents.
(b) The licensee shall file the written,
				comprehensive emergency plan with the Department, and shall notify the Department
				when the plan is changed.
1. The licensee shall
				submit the plan to both municipal and county emergency management officials for
				their review.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 15 - EMERGENCY SERVICES AND DISASTER PLANS › Section 8:43A-15.2 - Drills, tests, and inspections

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Drills of emergency
				plans shall be conducted on each shift at least quarterly. The facility shall
				maintain documentation of all drills, including the date, hour, description of the
				drill, participating staff, and signature of the person in charge. The drills on
				each shift shall include at least one drill for emergencies due to fire and one
				drill for emergencies due to disasters other than fire, such as storm, flood, other
				natural disaster, bomb threat, or radiological accident.
(b) The facility shall perform semi-annual visual
				inspections and annual operational tests of the building's manual-pull alarm system
				and shall maintain documentation of inspections, test dates, locations of
				manual-pull alarms tested, persons testing the alarms, and results of the
				tests.
(c) Fire extinguishers shall be
				examined annually and maintained in accordance with manufacturers' requirements,
				National Fire Protection Association (N.F.P.A.) 10, as amended and supplemented, and
				N.J.A.C. 5:70, the New Jersey Uniform Fire Code.
(d) The facility shall request, at least annually,
				that a fire inspection be performed by the local fire code authority, and the
				request shall be documented. The date of inspection, the results, and the inspector
				or agent conducting the inspection shall be documented.
(e) There shall be at least a semiannual
				inspection of the fire detection system. The date of inspection, the results, and
				the inspector or agent conducting the inspection shall be documented.
(f) There shall be at least a semiannual
				inspection of the automatic sprinkler system, if applicable. The date of inspection,
				the results, and the inspector or agent conducting the inspection shall be
				documented.
(g) There shall be at least
				monthly testing of emergency lighting. A logbook shall be maintained which shall
				include the date of each test, the results, and the person conducting the
				test.
(h) There shall be an elevator
				inspection, if applicable, in accordance with
				5:23-12.3 of the Elevator Safety
				Subcode. The date of inspection, the results, and the licensed official or inspector
				conducting the inspection shall be documented.
(i) There shall be at least an annual inspection
				of the heating and ventilation system. The date of inspection, the results, and the
				inspector or agent conducting the inspection shall be documented.
(j) The temperature of the hot water used in the
				facility shall be tested and documented in accordance with the policies and
				procedures of the facility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 15 - EMERGENCY SERVICES AND DISASTER PLANS › Section 8:43A-15.3 - Emergency medical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				have written policies and procedures that are reviewed annually, revised as needed,
				and implemented as needed to meet medical emergencies based on the type of patients
				and cases that are typically treated at the facility.
(b) The facility shall be able to respond to
				medical emergencies occurring on the premises during its hours of
				operation.
(c) Emergency medical
				services not provided at the facility shall be provided by a hospital or hospitals
				by written agreement. The facility shall have a written plan for emergency
				transportation of patients.
(d) The
				facility shall have written policies and procedures regarding emergency kits and, if
				required, emergency carts which are appropriate to the patient population served by
				the facility and approved by the medical director. The policies and procedures shall
				be reviewed annually, revised as needed, and implemented, and shall:
1. Specify the locations, contents, frequency of
				checking contents (including expiration dates), and assignments of responsibility
				for checking contents; and
2. Ensure
				that emergency kits are secure but are not kept under lock and key.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 16 - PATIENT RIGHTS › Section 8:43A-16.1 - Policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish and implement written policies and procedures regarding the rights of
				patients. These policies and procedures shall be available to patients, staff, and
				the public and shall be conspicuously posted in the facility.
(b) The staff of the facility shall receive
				in-service education concerning the implementation of policies and procedures
				regarding patient rights annually and as part of new employee orientation.
(c) The facility shall comply with all applicable
				State and Federal statutes and rules concerning patient rights.