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-3.6 - Policy and procedure manual

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A policy and
				procedure manual(s) for the organization and operation of the facility shall be
				developed, implemented, and reviewed at intervals specified in the manual(s). Each
				review of the manual(s) shall be documented, and the manual(s) shall be available in
				the facility to representatives of the Department at all times. The manual(s) shall
				include at least the following;
1. A written
				statement describing the program's treatment philosophy, objectives, and staffing
				patterns, and the services provided by the facility;
2. An organizational chart delineating the lines
				of authority, responsibility, and accountability for the administration and patient
				care services of the facility;
3. A
				description of the quality assurance program for patient care and staff performance,
				including methods for at least annual review of staff qualifications and credentials
				and of staff orientation and education;
4. Definition and specification of hours of
				operation, including all times in which patients are present in the facility,
				business hours, and full working week;
5. A system for referral of patients to sources of
				secondary and tertiary health care;
6. A
				requirement for at least one member of the medical staff to maintain admitting
				privileges at a hospital;
7. Policies
				and procedures for the maintenance of personnel records for each employee, including
				at least the employee's name, previous employment, educational background,
				credentials, license number with effective date and date of expiration (if
				applicable), certification (if applicable), verification of credentials, records of
				physical examinations, job description, records of staff orientation and staff
				education, and evaluations of job performance; and
8. Policies and procedures for complying with
				applicable statutes and protocols to report child abuse and/or neglect, abuse or
				mistreatment of elderly or disabled adults, sexual abuse, specified communicable
				disease, rabies, poisonings, and unattended or suspicious deaths. These policies and
				procedures shall include, but not be limited to, the following:
i. The designation of a staff member(s) to be
				responsible for coordinating the reporting of diagnosed and/or suspected cases of
				child abuse and/or neglect in compliance with
				N.J.S.A.
				9:6-1et seq., recording the notification to the
				Division of Child Protection and Permanency in the medical record, and serving as a
				liaison between the facility and the Division of Child Protection and
				Permanency;
ii. The notification of any
				suspected case of patient abuse or exploitation to the State Long-Term Care
				Ombudsman , pursuant to
				N.J.S.A.
				52:27G-7.1et seq., if the patient is 60 years of
				age or older;
iii. The development of
				written protocols for the identification and the treatment of children and elderly
				or disabled adults who are abused and/or neglected; and
iv. The provision at least annually of education
				and/or training programs to appropriate persons regarding the identification and
				reporting of diagnosed and/or suspected cases of child abuse and/or neglect; sexual
				abuse; domestic violence; abuse of the elderly or disabled adult; and the facility's
				policies and procedures.
Note:
				  N.J.S.A.
				  9:6-1et seq., is available at
https://www.nj.gov/dcf/reporting/links
.