reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.16 - Sanitation policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
The sanitation service shall have written policies and procedures
				  that are reviewed every three years, revised as needed, and implemented. They
				  include, at least, scope of responsibility, assignment by designated unit, and
				  responsibility for all sanitation tasks.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.17 - Sanitation staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a designated director or supervisor of sanitation
				  with specialized training or education in institutional sanitation service. A
				  consultant may be used to fulfill this role.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.18 - Sanitation patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The water supply
				shall be adequate in quantity, of a safe sanitary quality, and from a water system
				that is constructed, protected, operated, and maintained in conformance with the New
				Jersey Safe Drinking Water Act,
				N.J.S.A.
				58:12A-1 et seq., and
N.J.A.C.
				7:10
and other applicable laws, ordinances, and regulations.
(b) Hot running water (between 105 and 120 degrees
				Fahrenheit or 41 to 49 degrees Celsius) and cold running water shall be provided in
				patient care areas.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.19 - Sanitation space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Water piping
				carrying non-potable water shall be clearly labeled as such.
(b) The sewage disposal system shall be maintained
				in good repair and operated in compliance with State and local laws, ordinances, and
				regulations.
(c) There shall be no
				direct physical connections between city and well water supplies. Any physical
				connection between a public community water supply and an unapproved water supply,
				such as a well used by a hospital for emergency purposes, must be approved by the
				New Jersey Department of Environmental Protection and the owner of the public
				community water supply and must conform with N.J.A.C. 7:10-10.
(d) There shall be no back siphonage conditions
				present.
(e) Equipment requiring water
				drainage, such as ice machines, shall be drained to a sanitary connection in a way
				that avoids splatter or overflow.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.20 - Sanitation quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
The hospital shall adhere to the water sampling schedule and the
				  chemical and biological monitoring requirements of the water supply system set by
				  the New Jersey Department of Environmental Protection. Records of the sampling and
				  monitoring shall be maintained.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.21 - Regulated medical waste policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				develop and implement and the Infection Control Program shall review, approve, and
				audit written policies and procedures for collection, storage, handling, transport
				and disposal transport of medical waste, in conformance with applicable Federal and
				State laws and regulations.
(b) The
				hospital shall comply with the provisions of
				42 U.S.C.
				§
										6903, the Medical Waste Tracking Act of
				1988 and 13:1E-48 et seq., the Comprehensive
				Regulated Medical Waste Management Act and all rules and regulations promulgated
				pursuant to the aforementioned Acts.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 13 - HOUSEKEEPING, LAUNDRY, AND SANITATION › Section 8:43G-13.22 - Regulated medical waste and solid waste management

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Policies and
				procedures for solid waste and recyclables shall be established and enforced to
				ensure appropriate collection, storage and disposal and to maintain them clean and
				odor-free and to prevent the breeding of insects or vermin.
(b) Solid waste shall be stored within the
				containers provided for it in an area that is kept clean. Waste shall be collected
				from storage area regularly to prevent nuisances such as odors, flies, other vermin,
				or rodents, and so that waste does not overflow or accumulate beyond the capacity of
				the storage containers.
(c) Plastic bags
				shall be used for solid waste removal from patient care units and supporting
				departments. Bags shall be of sufficient strength to safely contain waste from point
				of origin to point of disposal and shall be effectively closed prior to
				disposal.
(d) Garbage compactors shall
				be located on an impervious pad that is graded to a drain. The drain shall be kept
				clean and shall be connected to the sanitary sewage disposal system.
(e) Outside storage containers for solid waste
				shall be kept covered, except those used for corrugated cardboard, recyclables, or
				construction materials.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.1 - Infection control program structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital
				epidemiologist shall direct and oversee the hospital Infection Control Program. A
				hospital epidemiologist is defined as a physician who is board certified in a
				medical specialty, preferably Infectious Diseases, and has training (such as a
				Centers for Disease Control and Prevention Course, or Society for Healthcare
				Epidemiology of America, (SHEA) course, or a Master's Degree in Public Health) or at
				least five years experience in hospital epidemiology. The hospital epidemiologist
				may be a consultant.
(b) A hospital
				Infection Control Program shall be multi-disciplinary and include a hospital
				epidemiologist, infection control professional(s), a clinical microbiologist, and a
				pharmacist. In addition, the program shall have an on-going surveillance system to
				monitor nosocomial infections, antimicrobial resistance, antimicrobial use, and
				outbreaks of infectious diseases.
(c)
				There shall be a hospital infection control committee that includes representatives
				from at least: infection control, medical staff, nursing service, dietary,
				administration, clinical microbiology, respiratory care services, surgical services,
				central services, environmental services, pharmacy, and the employee health service.
				The chairman of the committee shall be the hospital epidemiologist. The committee
				shall participate in the hospital's overall quality improvement program and shall
				receive formal advice from all other services upon its request.
(d) The infection control program shall oversee,
				but not be limited to, the following activities:
1. Formulating a system for surveillance,
				prevention, and control of non-socomial infections.
i. Surveillance of nosocomial infections shall be
				performed. The surveillance process shall include at least the following elements:
(1) Identification and description of the problem
				or event to be studied;
(2) Definition
				of the population at risk;
(3) Selection
				of appropriate methods of measurements, including statistical tools and risk
				stratification;
(4) Identification and
				description of data sources and data collection personnel and methods;
(5) Definitions of numerators and
				denominators;
(6) Preparation and
				distribution of reports to appropriate groups; and
(7) Selection of specific events to be monitored
				and guided by validated, available benchmarks and appropriately adjusted for patient
				risks so that meaningful comparisons can be made.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.3 - Infection control and hospital epidemiology staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
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 (CBIC).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.5 - Infection control staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				hospital epidemiologist and infection control professional(s) who are responsible
				for coordination of the infection control program.
(b) There shall be a ratio of the equivalent of at
				least one full-time infection control professional to every 200 adjusted occupied
				beds, where the bed occupancy has been adjusted both for an outpatient factor and
				for the hospital's all-payer case mix index (CMI), using the most recent complete
				data set available to the Department and the following formula:
Click here to view image.
For every hospital, there shall be at least one half-time
				  infection control professional.
(c) Outpatient service areas provided by the
				hospital shall have a designated health care professional on site who is responsible
				for the day to day activities related to infection control.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.6 - Infection control patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Between October 1,
				or earlier if the vaccination is available, and February 1 of every year, provided a
				patient's medical condition permits, every patient aged 65 or older shall be
				provided the opportunity to receive vaccination against influenza, in accordance
				with the recommendations of the Advisory Committee on Immunization Practices of the
				Centers for Disease Control in effect at the time of vaccination, incorporated
				herein by reference. Receipt of the vaccination shall be documented on the patient's
				chart and made a part of the patient's permanent hospital record. Prior to
				administration of the vaccination, diligence shall be exercised to determine whether
				the patient has already received the influenza vaccination for the year in question.
1. Centers for Disease Control publications can be
				obtained from:
Superintendent of Documents
U.S. Government Printing Office
Washington, DC 20402
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.7 - Infection control staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Requirements for the
				infection control staff education program shall be as provided in
				8:43G-5.9.
(b) The infection control professional shall
				coordinate educational programs to address specific problems, as recommended by the
				Centers for Disease Control and Prevention, or at least annually for staff in all
				patient care areas and services.
(c)
				Orientation for all new employees shall include infection control practices related
				to blood and body fluid precautions (that is, personal protective equipment),
				isolation practices, tuberculosis education, and use of protective vaccines.
				Additional orientation shall be directed to the employee's specific area of
				service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.8 - Infection control continuous improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
The infection control professional shall develop and implement a
				  program of continuous quality improvement that is integrated into the hospital
				  continuous 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 program shall supervise these continuous quality improvement
				  activities. These quality improvement activities shall be overseen by the continuous
				  quality improvement program (See N.J.A.C. 8:43G-27, Continuous Quality
				  Improvement).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 14 - INFECTION CONTROL › Section 8:43G-14.9 - Sepsis protocols

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A hospital shall establish, implement, and
				periodically update, evidence-based protocols for the early identification and
				treatment of patients with sepsis and septic shock (sepsis protocols).
(b) The sepsis protocols shall address, at a
				minimum:
1. Screening patients for, and early
				recognition in patients of, healthcare-acquired and community-acquired sepsis and
				septic shock;
2. Identification of
				patients for whom treatment, using the sepsis protocols, is appropriate, and for
				whom treatment would be inappropriate based on patient-specific clinical and/or
				bioethical considerations, and documentation of these patient identification
				activities;
3. Treatment
				guidelines;
4. Components that are
				population-specific as clinically indicated in accordance with evidence-based best
				practices, such as perinatal, neonatal, pediatric, and adult variations that may
				exist in the identification and treatment of sepsis, with corresponding development
				and use of clinical staff training materials and practice tools that distinctly
				identify these population-specific variations; and
5. Training of clinical staff in the sepsis
				protocols and providing updated training upon substantive revision
				thereof.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.1 - Medical records structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				medical record department with the primary responsibility of maintaining medical
				records for all inpatients treated at the hospital.
(b) There shall be a system for identifying
				medical records to facilitate their retrieval by patient identifier.
(c) If the hospital ceases to operate, at least 14
				days before cessation of operation the hospital shall notify the Department in
				writing how and where medical records will be stored.
(d) The hospital shall maintain a written
				organizational chart for the medical record department that delineates lines of
				authority and responsibility in the department.
(e) There shall be a system of access to the
				medical records of all patients, including outpatients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.2 - Medical records policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical record
				department shall have written policies and procedures that are reviewed at least
				once every three years, revised more frequently as needed, and implemented. They
				shall include at least:
1. Procedures for record
				completion, including chart analysis;
2.
				Conditions, procedures, and fees for releasing medical information; and
3. Procedures for the protection of medical record
				information against the loss, tampering, alteration, destruction, or unauthorized
				use.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.4 - Medical records staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a full-time medical records director who is a
				  registered health information technician or a registered health information
				  administrator under a certification program approved by the American Health
				  Information Management Association, for which the contact information is American
				  Health Information Management Association (AHIMA), 233 N. Michigan Avenue, 21st
				  Floor, Chicago, IL 60601-5809. Phone: (312) 233-1100. Fax: (312) 233-1090. Website:
http://www.ahima.org
. E-mail:
				  info@ahima.org.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.5 - Staff education

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the medical record staff education and training
				  program shall be as provided in
				  8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 15 - MEDICAL RECORDS › Section 8:43G-15.7 - Medical record continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of continuous quality improvement for medical records that is integrated
				into the hospital continuous quality improvement program and includes regularly
				collecting and analyzing data to help identify health-service problems and their
				extent, and recommending, implementing, and monitoring corrective actions on the
				basis of these data.
(b) Continuous
				quality improvement activities for the medical record department shall include
				monitoring medical records for accuracy, completeness, legibility, and
				accessibility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.1 - Medical staff structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be an
				organized medical staff that is responsible to the governing body of the hospital.
				Bylaws governing all medical staff members shall be implemented.
(b) Applications for membership, privileges, or
				initial appointment to the medical staff shall be processed under a system that
				includes, at least, the verification of applicants' credentials, periodic review of
				privileges, and obtaining information about any disciplinary action against the
				applicant available from the New Jersey Board of Medical Examiners or the Federal
				Clearinghouse established pursuant to the Health Care Quality Improvement Act, P.L.
				99-660; 100 STAT 3743.
(c) Applications
				for medical staff membership, clinical privileges, or initial appointment submitted
				by health professionals who are not practitioners, shall be reviewed according to
				the same established criteria and procedures that govern physicians' applications,
				including obtaining information about any disciplinary action by New Jersey
				professional licensing boards.
(d) A
				committee or mechanism shall be established to be responsible for examining
				applications for appointment and reappointment to all categories of the medical
				staff. This committee shall recommend the conferring or withholding of all staff
				positions. It shall assure that all credentials are documented and
				verified.
(e) Medical staff privileges
				shall be specifically delineated and based on the practitioner's training,
				experience and demonstrations of clinical competence.
(f) The medical staff shall be divided into
				clinical departments. Each department shall be directed by a director, physician
				director, chairman or chief who is responsible for its administration and for taking
				or recommending action in those instances in which staff members fail to meet the
				department's standards of quality of care.
(g) There shall be an executive committee for the
				medical staff which performs supervisory functions, including reviewing patient care
				policies and procedures and serving as a forum for discussing patient care issues
				identified by the clinical departments.
(h) A medical staff meeting shall be held at least
				annually for all active staff members.
(i) The hospital and medical staff shall have a
				formal program addressing impaired practitioners. This program shall include the
				following components:
i. Policies and a mechanism
				which encourage the voluntary or informal identification or reporting of
				practitioner impairment to the hospital;
ii. A mechanism for monitoring physician
				performance and for the limitation of clinical privileges if appropriate;
				and
iii. A procedure for the referral of
				impaired practitioners to appropriate treatment.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.2 - Medical staff policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The medical staff
				shall have written policies, procedures, and bylaws that are reviewed at least once
				every three years; revised more frequently as needed, and implemented. They shall
				include at least:
1. Policies and procedures
				addressing the requirements for obtaining written informed consent from
				patients;
2. Requirements for the
				completeness and timing of the patient history and physical examination, including a
				listing of the minimum contents to be included in the medical record;
3. The minimum content of physician
				orders;
4. Specifications for verbal
				orders, including who may give verbal orders, who may receive them, and how soon
				they must be verified or countersigned in writing;
5. If applicable, policies and procedures related
				to the prescribing or ordering of medications or devices by certified nurse
				practitioners/clinical nurse specialists in accordance with New Jersey State Board
				of Nursing rules at N.J.A.C. 13:37-7; and
6. If applicable, the scope of practice,
				supervision, and record keeping requirements of licensed physician assistants in
				accordance with New Jersey State Board of Medical Examiners rules at N.J.A.C.
				13:35-2B.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.3 - Medical staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All physicians with
				clinical privileges shall be licensed or authorized to practice medicine by the New
				Jersey Board of Medical Examiners. All non-physicians with privileges shall be
				licensed or authorized to practice in the State of New Jersey, as required by
				law.
(b) In any subchapter of these
				rules requiring a practitioner to be Board-certified within his or her medical
				specialty, it shall be deemed acceptable to possess:
i. Board certification from one of the recognized
				boards of osteopathic medicine; or
ii.
				Board certification from a foreign Board within the specified medical specialty
				where the American Board offers reciprocity with or officially recognizes the
				foreign board certification credential.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.5 - Medical staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				establish policies and procedures for response times for emergencies.
(b) There shall be an on-call list of medical and
				surgical specialists that is available to personnel in all patient care
				units.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.6 - Medical staff patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each patient shall
				have an attending physician who has overall responsibility for the patient's care in
				the hospital.
(b) Each patient admitted
				to the hospital shall have a medical history and physical examination that includes
				a provisional diagnosis performed by a clinical practitioner within 30 days before a
				hospital or outpatient surgery admission or within 48 hours after admission.
1. If the history and physical were performed
				earlier than seven days before admission, the patient's medical history and physical
				examination record completed pursuant to (b) above shall be included in the medical
				record together with the following, subject to the timeline established in (b)2
				below with respect to outpatient surgery patients:
i. A written assessment performed by the attending
				physician, advanced practice nurse or physician assistant no earlier than seven days
				before and no later than 48 hours after the patient's admission that includes a
				physical examination of the patient to update any components of the patient's
				medical status that may have changed since the prior history and physical, to
				address any areas as to which more current data are needed and to confirm that the
				necessity of the procedure or care for which the patient was admitted is still
				present and the history and physical are still current; and
ii. Regardless of whether there were any changes
				in the patient's status noted in the assessment performed pursuant to (b)1i above,
				an update note written by the attending physician, advanced practice nurse or
				physician assistant no earlier than seven days before and no later than 48 hours
				after the patient's admission addressing the patient's current status and any
				changes thereto, which note shall be on or attached to the history and physical
				performed pursuant to (b) above; and
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.7 - Medical staff education

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the medical staff education program shall be as
				  provided in 8:43G-5.9(a) and
				  (b).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 16 - MEDICAL STAFF › Section 8:43G-16.8 - Medical staff continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a medical staff mechanism by which the quality of
				  medical care is monitored, problems identified, solutions recommended and
				  implemented, and follow-up conducted. Summary reports of these activities and
				  problems in the quality of care shall be reviewed by the medical executive
				  committee, or its equivalent.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17 - NURSE STAFFING › Section 8:43G-17.1 - Nurse staffing

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				have in place a staffing plan that addresses nurse staffing requirements and
				identifies patient needs, including, at a minimum:
1. A daily staffing schedule that ensures at least
				one registered professional nurse in charge and assigned exclusively to each patient
				care unit on each shift;
2. A provision
				that at least 65 percent of direct patient care hours in inpatient units on a
				hospital wide average be provided by licensed nursing personnel;
3. A method for assessing each unit's additional
				nursing needs for each shift, including, at a minimum, objective criteria such as:
i. Documented skills, training and competency of
				staff to plan and provide nursing services in the nursing areas where they
				function;
ii. Patient data base
				incorporating objective factors such as case mix index, specific or aggregate
				patient diagnostic classifications or acuity levels, patient profiles, critical
				pathways or care progression plans, length of stay, and discharge plans;
iii. Operational factors such as unit size,
				design, and capacity, admission/discharge/transfer index, and support service
				availability;
iv. Contingency plans to
				address critical departures from staffing plan, including policies and procedures to
				regulate closure of available beds if staffing levels fall below specified
				levels;
v. Policies and procedures for
				the reassignment of staff including float and agency staff; and
4. On-going internal institutional evaluation of
				outcome-based quality indicators related to nursing care to assess and provide a
				safe and adequate level of patient care including at least:
i. Patient injury rate;
ii. Medication process errors;
iii. Maintenance of skin integrity;
iv. Nosocomial infection rates;
v. Hospital-wide patient satisfaction with overall
				care, including nursing care;
vi.
				Nursing turnover rate;
vii. Patient
				satisfaction with pain management; and
viii. Mix of RNs, LPNs and unlicensed staff caring
				for patients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.1 - Authority, scope, and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner
				promulgates this subchapter pursuant to the authority of
N.J.S.A.
				26:2H-1
et seq., particularly
				N.J.S.A.
				26:2H-5.h.
(b) The provisions of this subchapter apply to
				general hospitals licensed pursuant to
				26:2H-1 et seq.
(c) The purpose of this subchapter is to provide
				patients, their families, and the public information as to the extent of direct care
				staffing levels provided by general hospitals; establish requirements for general
				hospitals to post, on a daily basis, information about direct patient care staffing
				levels in visible and accessible locations in specified areas of the hospitals; and
				establish procedures for general hospitals to report aggregated data to the
				Department on a monthly basis.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall
				  have the following meanings, unless the context clearly indicates otherwise.
"Direct patient care" means clinical care services provided
				  directly to patients by a registered professional nurse, licensed practical nurse,
				  physical therapist, respiratory care practitioner and/or unlicensed assistive
				  personnel.
"Number of staff" means the number of registered professional
				  nurses, licensed practical nurses, and unlicensed assistive personnel who provide
				  and are directly responsible for patient care on a particular shift, which is
				  calculated by dividing the total number of hours worked by each category of staff
				  member by the number of hours in the shift.
1. Hours worked includes the actual hours worked by any staff in
				  this definition that were present during any portion of the shift.
"Shift" means a standardized reporting period, which, for
				  inpatient units, shall consist, at the hospital's choice, of either three eight-hour
				  periods (day, evening, and night) or two 12-hour periods (day and night); and for
				  the emergency department, post-anesthesia care unit, and other licensed health care
				  professionals, shall consist of one 24-hour period.
"Staffing information" means the number of staff, the number of
				  patients present, and the ratio of the former to the latter.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.3 - Information required to be posted; retention

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For each inpatient
				unit, a general hospital shall count the number of patients and the number of staff
				based on hours worked for each category of direct patient care staff, excluding
				other licensed health care professionals, one hour before the end of each shift on
				each day of each month.
1. The results, including
				the ratio with the numerator as the number of staff for each category of direct
				patient care staff and the denominator as the number of patients, shall be posted in
				accordance with subsection (a) above.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.4 - Posting locations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A general hospital shall post direct patient
				care staffing information described at
				8:43G-17A.3(a),
				utilizing the form, "Daily Patient Care Staffing: Inpatient Units," incorporated
				herein by reference and set forth at Appendix A in a visible location that is
				accessible to patients and their families in each inpatient unit.
(b) A general hospital shall post emergency
				department and post-anesthesia care unit direct patient care staffing information
				described at 8:43G-17A.3(b) and (c),
				utilizing the forms, "Daily Patient Care Staffing: Emergency Department" and "Daily
				Patient Care Staffing: Post-Anesthesia Care Unit," incorporated herein by reference
				and set forth at Appendices B and C, in the emergency department waiting area and in
				the post-anesthesia care unit waiting area.
(c) A general hospital shall post information
				concerning the number of other licensed health care professionals, described at
				8:43G-17A.3(d) 
				utilizing the form, "Daily Patient Care Staffing - Other Licensed Health Care
				Professionals: Hospital-Wide," incorporated herein by reference and set forth at
				Appendix D, in a central location within the hospital that is open and accessible to
				the general public.
1. The hospital may, at its
				discretion, separate the information for physical therapists from that for
				respiratory care practitioners and use a different central location within the
				hospital that is open and accessible to the general public for each
				posting.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.5 - Reporting requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each general hospital shall report the
				following information to the Department once a month on a web-based interface to be
				developed and communicated by the Department, which will include the use of the
				information already collected on these forms, "Daily Patient Care Staffing:
				Inpatient Units," "Daily Patient Care Staffing: Emergency Department," "Daily
				Patient Care Staffing: Post-Anesthesia Care Unit," and "Daily Patient Care Staffing
				- Other Licensed Health Care Professionals: Hospital-Wide," as set forth at
				Appendices A through D:
1. For each inpatient unit
				type included in the "Daily Patient Care Staffing Forms: Inpatient Units," broken
				down by shift, the average of the previous month's daily ratios of staff-to-patients
				for each category of direct patient care staff and the number of inpatient units
				covered for each licensure category reported;
2. For the emergency department and the
				post-anesthesia care unit, the average of the previous month's daily number of staff
				in each category of direct patient care and the average of the daily number of
				patients; and
3. The average of the
				previous month's daily number of staff for each category of other licensed health
				care professionals.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 17A - MANDATORY STAFF LEVEL POSTING AND REPORTING STANDARDS › Section 8:43G-17A.6 - Penalty

Current through Register Vol. 56, No. 14, July 15, 2024
If the Commissioner determines that a general hospital has
				  violated any provision of this subchapter, the Department may issue an enforcement
				  action pursuant to
				  P.L.
				  2005, c. 21,
				  §2 (e),
				  26:2H-5g(e), and
				  N.J.A.C. 8:43E-3.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.1 - Nursing care structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A written
				organizational chart and written plan that delineates lines of authority,
				accountability, and communication shall be available to all nursing personnel in the
				hospital at all times.
(b) At all times
				a registered professional nurse with supervisory responsibility shall be designated
				and authorized to act in the absence of the chief nursing executive.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.2 - Nursing care policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				have written policies and procedures for the nursing care service that guide nursing
				practices in the hospital. These policies shall be reviewed at least once every
				three years, revised more frequently as needed, and implemented. These policies and
				procedures shall conform with the Nurse Practice Act,
				45:11-23 and
				13:37-1.4, 6.1, 6.2, 13.1 and
				13.2.
(b) The hospital's current
				clinical and administrative nursing policies and procedures shall be available to
				all nursing personnel on each patient care unit at all times.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.3 - Nursing care staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The nursing care
				service shall be directed on a full-time basis by a chief nursing executive who has
				at least one of the following qualifications:
1.
				Is a registered professional nurse with a baccalaureate degree from an accredited
				college or university, and five years combined clinical and progressive management
				experience in nursing;
2. Is a
				registered professional nurse with a baccalaureate degree in nursing science and
				three years combined clinical and progressive management experience in nursing;
				or
3. Is a registered professional nurse
				with a baccalaureate degree from an accredited college or university and a master's
				degree in nursing or a health related field from an accredited college or university
				and three years combined clinical and progressive management experience in
				nursing.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.4 - Nursing care; use of restraints

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The standards in
				this section shall apply to the use of physical restraints in all patient care areas
				of the hospital. Physical restraints are defined as devices, materials, or equipment
				that are attached or adjacent to a person and that prevent free bodily movement to a
				position of choice, with the exception of devices used for positioning supports
				necessary for medical treatment.
(b) The
				hospital shall have written policies and procedures regarding the use of physical
				restraints that are reviewed at least once every three years, revised more
				frequently as needed, and implemented. They shall include at least the following:
1. Protocol for the use of alternatives to
				physical restraints, such as staff or environmental interventions, structured
				activities, or behavior management. Alternatives shall be utilized whenever possible
				to avoid the use of restraints;
2.
				Protocol for the use and documentation of a progressive range of restraining
				procedures from the least restrictive to the most restrictive;
3. A delineation of indications for use, which
				shall be limited to:
i. Prevention of imminent
				harm to the patient or other persons when other means of control are not effective
				or appropriate; or
ii. Prevention of
				serious disruption of treatment or significant damage to the physical
				environment;
4.
				Contraindications for use, including at least clinical contraindications,
				convenience of staff, or discipline of the patient;
5. Identification of restraints which may be used
				in the hospital, which shall be limited to methods and mechanical devices that are
				specifically manufactured for the purpose of physical restraint;
6. Protocols for notifying the family or guardian
				of reasons for use of restraints, and for informing the patient and requesting
				consent when clinically feasible; and
7.
				Protocol for removal of restraints when goals have been accomplished.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.5 - Nursing care patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Registered
				professional nurses and licensed practical nurses shall provide patient care
				commensurate with their scope of practice, as delineated in the Nurse Practice Act.
1. Patient care may be provided by certified nurse
				practitioners/clinical nurse specialists in accordance with New Jersey State Board
				of Nursing rules at N.J.A.C. 13:37-7.
2.
				Nursing students shall render care to patients only when qualified supervision, as
				defined by the hospital and the nursing school, is available in the unit.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.6 - Nursing care services related to pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All medications
				administered by nursing personnel shall be administered in accordance with
				prescriber orders, medical staff policy, and all Federal and State laws and
				regulations.
(b) Medications for
				individual patients shall not be removed from their original prescription containers
				by nursing personnel until the time of drug administration.
(c) Drugs packaged in unit dose containers shall
				not be removed from the containers by nursing personnel until the time of drug
				administration. Such drugs shall be administered immediately after the dose has been
				removed from the container, and by the individual who prepared the dose for
				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) If
				the facility permits self-administration of drugs, nursing personnel shall implement
				policies and procedures approved by the pharmacy and therapeutics committee
				regarding self-administration of drugs.
(g) Nursing personnel shall report drug errors and
				adverse drug reactions immediately to the nurse in charge of the unit and to the
				prescriber. By the end of the shift, an entry shall be made in the patient's medical
				record. The incident shall be reported in accordance with policies and procedures
				concerning quality assurance and risk management. The incident shall be reported to
				the pharmacy, in accordance with policies and procedures approved by the pharmacy
				and therapeutics committee, within 24 hours.
(h) Drugs in patient care areas shall be
				maintained under proper conditions, as indicated by the United States Pharmacopoeia,
				product labeling, and/or package inserts.
(i) All drugs, needles, and syringes in patient
				care areas shall be kept in locked storage areas, except those drugs exempted by the
				pharmacy and therapeutics committee or equivalent under specified conditions. Drugs
				for external use shall be kept separate from drugs for internal use.
(j) Nursing personnel shall return drugs to the
				pharmacy for disposal in accordance with
				8:43G-23.6(i).
(k) Nursing personnel shall store, use, and
				dispose of needles and syringes in accordance with all applicable Federal and State
				laws and rules, including those specified at
				N.J.A.C.
				8:43G-14.12(b).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.7 - Nursing care staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Requirements for the
				nursing care education program shall be as provided in
				8:43G-5.9.
(b) All nursing staff shall receive orientation
				and annual training regarding the use of restraints, including at least:
1. Policies and procedures in accordance with
				8:43G-18.4(a);
2. Emergency and nonemergency procedures;
				and
3. Interventions by licensed and
				non-licensed nursing personnel.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 18 - NURSING CARE › Section 8:43G-18.9 - Nursing care continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a program of continuous quality improvement for
				  nursing care that is integrated into the hospital continuous quality improvement
				  program and includes regularly collecting and analyzing data to help identify
				  health-service problems and their extent, and recommending, implementing, and
				  monitoring corrective actions on the basis of these data. Issues shall be identified
				  through, at least, incident reports, infection control activities, and patient and
				  staff comment.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 19 - OBSTETRICS › Section 8:43G-19.3 - Obstetrics staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director of the obstetric service who is responsible for all obstetric
				care in the hospital and is board certified in obstetrics.
(b) There shall be a nurse manager of the
				obstetric service, which may include labor and delivery, who is a registered
				professional nurse and who has:
1. A minimum of
				three years of experience in inpatient obstetric services within the five years
				immediately preceding the date of appointment;
2. Educational preparation in maternal-fetal
				neonatal nursing, in accordance with hospital policy; and
3. Completion of 24 contact hours in
				maternal-fetal or neonatal nursing approved by a nationally recognized nurse
				education accrediting body every three years.