New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES › Subchapter 1 - DEFINITIONS AND QUALIFICATIONS › Section 8:43A-1.3 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall
				  have the following meanings, unless the context clearly indicates otherwise:
"Abortion facility" means a facility which performs termination
				  of pregnancy, in accordance with
				  N.J.A.C. 13:35-4.2, as a
				  single modality. Facilities which offer multiple or comprehensive surgical services,
				  inclusive of termination of pregnancy, are designated as ambulatory surgery
				  facilities. Whereas all of the rules at N.J.A.C. 8:43A-12apply to ambulatory surgery
				  facilities, only those rules at N.J.A.C. 8:43A-12which are relevant to the levels of
				  anesthesia used in a particular abortion facility shall apply to that
				  facility.
"Addiction Professionals Certification Board of New Jersey, Inc."
				  means the entity by that name for which the contact information is Addiction
				  Professionals Certification Board of New Jersey, Inc., 1200 Tices Lane, Suite 104,
				  East Brunswick, NJ 08816 (732) 249-1991, telefacsimile (732) 249-1559,
www.certbd.com
.
"Advance directive" means a written statement of the patient's
				  instructions and directions for health care in the event of future decision making
				  incapacity. An advance directive may include a proxy directive or an instruction
				  directive, or both.
"Affiliated community perinatal center" means a licensed hospital
				  designated within a maternal and child health service region with which the birth
				  center has a formal agreement for transfer and back-up services. This hospital must
				  be designated as either a community perinatal center--intermediate or intensive or a
				  regional perinatal center, in accordance with N.J.A.C. 8:33C.
"Ambulatory care facility" means a health care facility or a
				  distinct part of a health care facility in which preventive, diagnostic, and
				  treatment services are provided to persons who come to the facility to receive
				  services and depart from the facility on the same day.
"Ambulatory care facility assessment" means the annual assessment
				  established by N.J.S.A. 26:2H-18.57, which applies to certain licensed health care
				  facilities, which assessment the Department administers pursuant to N.J.A.C.
				  8:31A.
"Ambulatory surgery facility" means a surgical facility in which
				  ambulatory surgical cases are performed and which is licensed as an ambulatory
				  surgery facility, separate and apart from any other facility license. (The
				  ambulatory surgery facility may be physically connected to another licensed
				  facility, such as a hospital, but is corporately and administratively
				  distinct.)
"Ambulatory surgical case" and "same day surgical case" are
				  synonymous terms for a surgical procedure performed on a patient in a surgical
				  facility generally requiring anesthesia, with a facility-based post surgery period
				  of at least one hour, and generally without the requirement of an overnight
				  stay.
"American Academy of Health Care Providers in the Addictive
				  Disorders" means the entity by that name for which the contact information is
				  American Academy of Health Care Providers in the Addictive Disorders, 314 West
				  Superior Street, Suite 508, Duluth, MN 55802, (218) 727-3940, telefacsimile (218)
				  722-0346,
www.americanacademy.org
.
"American Board of Medical Physics" means the entity by that name
				  for which the contact information is American Board of Medical Physics, 12100 Sunset
				  Hills Road, Suite 130, Reston, VA 20190-5202, (703) 481-5001, telefacsimile (703)
				  435-4390,
www.acmp.org/abmp
.
"American College of Radiation Oncology" means the entity by that
				  name for which the contact information is American College of Radiation Oncology,
				  5272 River Road, Bethesda, MD 20816, (301) 718-6515, telefacsimile: (301) 656-0989,
www.acro.org
.
"American College of Radiology" means the entity by that name for
				  which the contact information is American College of Radiology, 1891 Preston White
				  Dr, Reston, VA 20191, (703) 648-8900,
www.acr.org
.
"American Osteopathic Board of Radiology" means the entity by
				  that name for which the contact information is American Osteopathic Board of
				  Radiology, 119 East Second Street, Milan, MO 63556-1331, 800-258-AOCR (2627) or
				  (660) 265-4011, telefacsimile (660) 265-3494,
http://www.aocr.org/certification/index.asp
.
"American Society for Radiation Oncology" means the entity for
				  which the contact information is American Society for Radiation Oncology, 251 18th
				  Street South, 8th Floor, Arlington, VA 22202, (703) 502-1550,
https://www.astro.org
.
"Association for the Advancement of Medical Instrumentation"
				  means the entity by that name for which the contact information is Association for
				  the Advancement of Medical Instrumentation, PO Box 1211, Annapolis Junction, MD
				  20701-0211, (800) 877-249-8226 or 240-646-7031, telefacsimile (301) 206-9789,
www.aami.org
.
"Available" means ready for immediate use (pertaining to
				  equipment) or capable of being reached (pertaining to personnel), unless otherwise
				  defined.
"Birth center" means a health care facility or a distinct part of
				  a health care facility which provides routine prenatal and intrapartal care to
				  low-risk maternity patients who are expected to deliver neonates of a weight greater
				  than 2,499 grams and of 36 weeks gestational age and who require a stay of less than
				  24 hours after birth. "Routine intrapartal care" means labor and delivery services
				  not requiring surgical intervention.
"Bylaws" means a set of rules adopted by the facility for
				  governing its operation. A charter, articles of incorporation, or a statement of
				  policies and objectives is an acceptable equivalent.
"Cardiac rehabilitation program" means a health care service in
				  which an individualized program of physical exercise is prescribed for each cardiac
				  patient.
"Certificate of Need and Healthcare Facility Licensure Program"
				  means the health care facility licensing unit within the Division of Certificate of
				  Need and Licensing of the Health Systems Branch of the Department, for which the
				  contact information is Certificate of Need and Healthcare Facility Licensure
				  Program, Division of Certificate of Need and Licensing, NJ Department of Health, PO
				  Box 358, Trenton, NJ 08625-0358, (609) 292-5960, website address for forms:
www.nj.gov/health/forms
.
"Chronic dialysis" means dialysis rendered to a patient with end
				  stage renal disease in whom recovery of renal function is not expected.
"Cleaning" means the removal by scrubbing and washing, as with
				  hot water, soap or detergent, and vacuuming of infectious agents and of organic
				  matter from surfaces on which and in which infectious agents may find conditions for
				  surviving or multiplying.
"Clinical note" means a written, signed, and dated notation made
				  by a health care professional who renders a service to the patient. Clinical notes
				  are written into the patient's medical record the day service is rendered.
"Clinical practitioner" means a physician, dentist, podiatrist,
				  certified nurse midwife, physician assistant, or nurse practitioner.
"Commissioner" means the Commissioner of Health.
"Commission on Dietetic Registration" means the entity by that
				  name for which the contact information is Commission on Dietetic Registration, 120
				  South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995, (312) 899-0040 extension
				  5500 or toll-free (800) 877-1600 extension 5500, telefacsimile (312) 899-4772,
www.cdrnet.org
.
"Commission on Radiation Protection" means the entity by that
				  name that is in, but not of, the Department of Environmental Protection for which
				  the contact information is Commission on Radiation Protection, PO Box 415, Trenton,
				  NJ 08625-0415, (609) 984-5636, telefacsimile (609) 633-2210.
"Communicable disease" means an illness due to a specific
				  infectious agent or its toxic products which occurs through transmission of that
				  agent or its products from a reservoir to a susceptible host.
"Community perinatal center-birthing center" means a licensed
				  birth center designated within a maternal and child health service region, in
				  accordance with N.J.A.C. 8:33C.
"Comprehensive outpatient rehabilitation facility" means an
				  ambulatory care facility which provides at least medical, physical therapy, and
				  social or psychological services in a coordinated manner. The term applies to
				  facilities which are certified or eligible for certification as comprehensive
				  outpatient rehabilitation facilities in accordance with 42 CFR Part 485 , Subpart
				  B.
"Comprehensive rehabilitation agency" means an ambulatory care
				  facility which provides at least medical, physical therapy, and social or
				  psychological services in a coordinated manner.
"Conspicuously posted" means placed at a location within the
				  facility accessible to and seen by patients and the public.
"Construction guidelines" means the Guidelines for Design and
				  Construction of Health Care Facilities, 2006 edition, incorporated herein by
				  reference, as amended and supplemented, published by the American Institute of
				  Architects, for which the contact information is the American Institute of
				  Architects, 1735 New York Avenue NW, Washington DC 20006-5292, (800) 242-3837 or
				  (202) 626-7541, telefacsimile (202) 626-7519,
www.aia.org
.
"Contamination" means the presence of an infectious or toxic
				  agent in the air, on a body surface, or on or in clothes, bedding, instruments,
				  dressings, or other inanimate articles or substances, including water, milk, and
				  food.
"Controlled Dangerous Substances Acts" means the Controlled
				  Substances Act of 1970 (Title II, Public Law 91-513 ) and the New Jersey Controlled
				  Dangerous Substances Act of 1970, N.J.S.A. 24:21-1 et seq.
"Coordinating Center for Health Information and Service" means
				  the Coordinating Center for Health Information and Service of the Centers for
				  Disease Control and Prevention (CDC) in the U.S. Department of Health and Human
				  Services. This entity publishes the Morbidity and Mortality Weekly Report, for which
				  the contact information is Morbidity and Mortality Weekly Report, Centers for
				  Disease Control and Prevention, 1600 Clifton Rd., MS E-90, Atlanta, GA 30333, (404)
				  498-1150, telefacsimile (404) 498-2389,
www.cdc.gov/mmwr
.
"Council on Social Work Education" means the entity by that name
				  for which the contact information is Council on Social Work Education, 1725 Duke
				  Street, Suite 500, Alexandria, VA 22314-3457, (703) 683-8080, telefacsimile (703)
				  683-8099,
www.cswe.org
.
"Counseling" means provision of information intended to direct
				  the behavior of a patient. Counseling services include, but are not limited to,
				  dietary counseling, social work, and/or drug counseling services.
"Current" means up-to-date, extending to the present time.
"Department" means the Department of Health.
"Disinfection" means the killing of infectious agents outside the
				  body, or organisms transmitting such agents, by chemical and physical means,
				  directly applied.
"Division of Health Facility Survey and Field Operations" means
				  the division of the Health Systems Branch of the Department, for which the contact
				  information is Division of Health Facility Survey and Field Operations, NJ
				  Department of Health, PO Box 367, Trenton, NJ 08625-0367, (609) 292-9900.
"Documented" means written, signed, and dated.
"Drug" means a substance as defined in the New Jersey State Board
				  of Pharmacy Rules, N.J.A.C. 13:39. The word "medication" is used interchangeably
				  with the word "drug" in this chapter.
"Drug abuse treatment services" means methadone detoxification,
				  methadone maintenance, and/or drug-free counseling programs.
"Drug administration" means a procedure in which a prescribed
				  drug is given to a patient by an authorized person in accordance with all laws and
				  rules governing such procedures. The complete procedure of administration includes
				  removing an individual dose from a previously dispensed, properly labeled container
				  (including a unit dose container), verifying it with the prescriber's orders, giving
				  the individual dose to the patient, seeing that the patient takes it (if oral), and
				  recording the required information, including the method of administration.
"Employee" means:
1. Full and part-time employees;
2. Persons a facility engages who are in direct contact with
				  patients or who provide patient care;
3. Volunteer staff; and
4. Physicians and other clinical practitioners who are either
				  salaried by the facility or have clinical privileges to provide medical care at the
				  facility.
"Epidemic" means the occurrence in a facility of one or more
				  cases of an illness in excess of normal expectancy for that illness, derived from a
				  common or propagated source.
"Family planning services" means comprehensive reproductive
				  health care services including contraception, pregnancy detection, options
				  counseling, diagnosis and/or treatment of sexually transmitted diseases, routine
				  gynecological and cancer screening services, health promotion activities, and Level
				  I infertility services. Family planning services may also include prenatal and
				  postpartum care, other gynecological services including colposcopy and cryotherapy,
				  menopausal services, and/or Level II and III infertility care. Family planning
				  services do not include termination of pregnancy.
"Full-time" means relating to a time period established by the
				  facility as a full working week, as defined and specified in the facility's policies
				  and procedures.
"Governing authority" means the organization, person, or persons
				  designated to assume legal responsibility for the management, operation, and
				  financial viability of the facility.
"Health care facility" means a facility so defined in N.J.S.A.
				  26:2H-1 et seq.
"Healthcare Plan Review Unit" means the Healthcare Plan Review
				  Unit within the Bureau of Construction Project Review in the Division of Codes and
				  Standards of the Department of Community Affairs, for which the contact information
				  is Healthcare Plan Review Unit, Bureau of Construction Project Review, Division of
				  Codes and Standards, Department of Community Affairs, PO Box 817, Trenton, NJ
				  08625-0817, (609) 633-8151.
"Hospital" means a facility as N.J.A.C. 8:43G, Hospital Licensing
				  Standards, defines that term.
"Job description" means written specifications developed for each
				  position in the facility, containing the qualifications, duties and
				  responsibilities, and accountability required of employees in that position.
"Licensed nursing personnel" (licensed nurse) means registered
				  professional nurses or practical nurses licensed by the New Jersey State Board of
				  Nursing.
"Maternal and Child Health Consortium (MCHC)" means a voluntarily
				  formed non-profit organization, consisting of all inpatient or ambulatory perinatal
				  and pediatric care providers and related community organizations in a maternal and
				  child health service region, as described at N.J.A.C. 8:33C.
"Maternal and child health service region" means the perinatal
				  and pediatric service delivery area described at N.J.A.C. 8:33C.
"Medical record" means all records in the facility which pertain
				  to the patient's health care.
"Medically indigent" means those individuals lacking third-party
				  health or medical insurance coverage whose income is less than or equal to 200
				  percent of the value determined by the United States Department of Health and Human
				  Services Income Poverty Guidelines,
				  42 U.S.C.
				  §
										9902.(2).
"Medication" means a substance as defined by the New Jersey State
				  Board of Pharmacy Rules, N.J.A.C. 13:39. The word "drug" is used interchangeably
				  with the word "medication" in this chapter.
"Monitor" means to observe, watch, or check.
"Operating room" means a room specifically dedicated to the
				  performance of surgical cases which meets the State Uniform Construction Code at
				  N.J.A.C. 5:23-3 and the Department's licensing requirements. For the purposes of
				  this definition, rooms specifically dedicated to endoscopic and cystoscopic
				  procedures are not considered operating rooms.
"Plan of care" means a written plan which is based upon the
				  patient assessments performed by all services participating in the patient's care
				  and which includes care and treatment to be provided. Each professional discipline
				  which provides care to the patient develops its own portion of the plan of
				  care.
"Prescriber" means a person who is authorized to write
				  prescriptions in accordance with Federal and State laws.
"Primary care" means the provision by a health care facility of
				  preventive, diagnostic, treatment, management, and reassessment services to
				  individuals with acute or chronic illness. The term is used in reference to
				  facilities providing family practice, general internal medicine, general pediatrics,
				  obstetrics, gynecology, and/or clinical preventive services, including community
				  health centers providing comprehensive primary care. Comprehensive primary care may
				  include the provision of sick and well care to all age groups, from perinatal and
				  pediatric care to geriatric care. Primary care is further characterized by the fact
				  that it represents the initial point of contact between an individual and the health
				  care system, by the assumption of responsibility for the person regardless of the
				  presence or absence of disease, by the ongoing responsibility for coordination of
				  medical care for the person, by its family-centeredness, and by its community
				  orientation.
"Satellite" means an affiliate of a separately licensed
				  ambulatory care facility. A satellite is located at a site distinct from, and within
				  30 miles of, that of the separately licensed ambulatory care facility, but shares
				  the same governing authority and provides the same principal service as the
				  separately licensed ambulatory care facility.
"Secondary care" means care delivered by a specialist or
				  subspecialist following referral by the primary care source. This may include
				  ambulatory or inpatient care.
"Signature" means at least the first initial and full surname and
				  title (for example, R.N., L.P.N., D.D.S., M.D., D.O.) of a person, legibly written
				  with his or her own hand. If electronic signatures are used, they shall be used in
				  accordance with
				  N.J.A.C.
				  8:43A-13.4.
"Staff education plan" means a written plan which describes a
				  coordinated program for staff education for each service, including in service
				  programs and on-the-job training.
"Staff orientation plan" means a written plan for the orientation
				  of each new employee to the duties and responsibilities of the service to which the
				  employee has been assigned, as well as to the personnel policies of the
				  facility.
"State Long-Term Care Ombudsman" or "Ombudsman" means the entity
				  by that name established pursuant to
				  N.J.S.A.
				  52:27G-1 et seq., particularly at 52:27G-3, for
				  which the contact information is New Jersey Long-Term Care Ombudsman, PO Box 852,
				  Trenton, NJ 08625-0852, toll-free telephone intake line 1-877-582-6995,
				  telefacsimile (609) 943-3479, email
ombudsman@ltco.nj.gov, website
https://www.nj.gov/ltco
.
"Sterilization" means a process of destroying all microorganisms,
				  including those bearing spores, in, on, and around an object.
"Substance-affected infant" means the term as defined at
				  N.J.A.C. 3A:26-1.2.
"Surgical facility" means a structure or suite of rooms which has
				  the following characteristics:
1. One or more rooms dedicated for use as operating rooms, which
				  are specifically equipped for the performance of surgery, designed and constructed
				  to accommodate invasive diagnostic and surgical procedures;
2. One or more postanesthesia care units or a dedicated recovery
				  area where the patient may be closely monitored and observed until discharged;
				  and
3. Is not a surgical practice.
"Surgical practice" means a structure or suite of rooms which has
				  the following characteristics:
1. No more than one room dedicated for use as an operating room
				  which is specifically equipped to perform surgery, designed and constructed to
				  accommodate invasive diagnostic and surgical procedures;
2. One or more postanesthesia care units or a dedicated recovery
				  area where the patient may be closely monitored and observed until discharged;
				  and
3. Established by a physician or physician professional
				  association surgical practice solely for his/her/their private medical
				  practice.
"Tertiary care" means specialized inpatient or outpatient
				  care.
"Tuberculosis Control Program" means the Tuberculosis Control
				  Program within the Division of HIV, STD, and TB Services of the Public Health
				  Services Branch of the Department, for which the contact information is Tuberculosis
				  Control Program, Division of HIV, STD, and TB Services, NJ Department of Health, PO
				  Box 363, Trenton, NJ 08625-0363, telephone (609) 826-4878, telefacsimile (609)
				  826-4879, website
https://www.nj.gov/health/hivstdtb/tb/
.