reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 16 - INFECTION CONTROL, SANITATION AND HOUSEKEEPING › Section 8:43F-16.2 - Infection control policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				develop, implement, and review, at least annually, written policies and procedures
				regarding infection prevention and control. Written policies and procedures shall be
				consistent with the following Centers for Disease Control publications, incorporated
				herein by reference:
1. Guideline for Hand Hygiene
				in Health-Care Settings, PB85-923404, as amended or supplemented;
2. OSHA Standards 29 CFR--1910.1030, Bloodborne
				pathogens, as amended and supplemented;
3. Prevention and Control of Tuberculosis in
				Facilities Providing Long-Term Care to the Elderly, and contained in MMWR 39(RR-10),
				as amended or supplemented; and
4.
				Prevention of Nosocomial Pneumonia, PB95-176970, January 3, 1997, 46(RR-1), as
				amended or supplemented.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 16 - INFECTION CONTROL, SANITATION AND HOUSEKEEPING › Section 8:43F-16.3 - Employee health history and examinations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				require all new employees to complete a health history and to receive an examination
				performed by a physician, advanced practice nurse, or physician assistant, within
				two weeks prior to the first day of employment or upon employment. If the new
				employee receives a nursing assessment upon employment, the physician, advanced
				practice nurse or physician assistant examination may be deferred for up to 30 days
				from the first day of employment. The facility shall establish criteria for
				determining the content and frequency of physical examinations for employees, and
				shall develop policies which specify the circumstances under which other persons
				providing direct participant care services shall receive a physical
				examination.
(b) The facility shall
				develop and implement policies and procedures to ensure that all volunteers and
				students who have direct participant care responsibilities on a routine basis
				provide documentation that they have received, at a minimum, a Mantoux tuberculin
				skin test and either a physical examination or a certification of health status from
				a physician, advanced practice nurse or physician assistant.
(c) Yearly influenza immunization shall be offered
				to employees at no charge.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 16 - INFECTION CONTROL, SANITATION AND HOUSEKEEPING › Section 8:43F-16.4 - Regulated medical waste

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Regulated medical
				waste shall be collected, stored, handled, and disposed of in accordance with
				applicable Federal and State laws and regulations.
(b) The facility shall comply with the provisions
				of 13:1E-48.1 et seq., the Comprehensive
				Regulated Medical Waste Management Act, and all rules promulgated pursuant to the
				aforementioned Act, including N.J.A.C. 7:26-3A.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 16 - INFECTION CONTROL, SANITATION AND HOUSEKEEPING › Section 8:43F-16.5 - Provision of housekeeping, sanitation, and safety

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				provide and maintain a sanitary and safe environment for participants.
(b) The facility shall provide housekeeping and
				pest control services.
(c) Written
				objectives, policies, a procedure manual, an organizational plan, and a quality
				improvement program for housekeeping, sanitation, and safety services shall be
				developed and implemented.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 16 - INFECTION CONTROL, SANITATION AND HOUSEKEEPING › Section 8:43F-16.6 - Housekeeping

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A written work plan
				for housekeeping operations shall be established and implemented, with
				categorization of cleaning assignments as daily, weekly, monthly, or annually within
				each area of the facility.
(b)
				Procedures shall be developed for selection and use of housekeeping and cleaning
				products and equipment.
(c) Housekeeping
				personnel shall be trained in cleaning procedures, including the use, cleaning, and
				care of equipment.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 17 - TRANSPORTATION SERVICES › Section 8:43F-17.1 - Transportation services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				provide safe transportation services, either directly or through contractual
				arrangements, to all participants who require transportation between the facility
				and the participant's home. No participant's total transportation time between the
				facility and the participant's home shall exceed two hours daily.
1. In accordance with N.J.A.C. 8:86, the facility
				shall accommodate the special transportation needs of the participant and the
				medical equipment used by the participant.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 17 - TRANSPORTATION SERVICES › Section 8:43F-17.2 - Security and accountability during transportation

Current through Register Vol. 56, No. 14, July 15, 2024
The facility shall develop and implement plans for security and
				  accountability for the participant and the participant's personal possessions while
				  transportation services are being provided.
CASE NOTES
Where it was undisputed that a client of an adult medical day
				  care, who was 84 years old and suffering from numerous medical problems, was picked
				  up by its van in order to be transported to its facility, the van arrived at the
				  facility at about 10:15 a.m., and the client was left unattended in the van from
				  10:15 a.m. to 1:00 p.m., the day care was ordered to pay a penalty of $ 2,500,
				  pursuant to 8:43E-3.4(10), for
				  violating 8:43F-17.2. The client suffered actual
				  harm as a result of the violation for it was stipulated that the client was verbally
				  unresponsive, had labored breathing, elevated respiration and elevated vital signs,
				  and the facility, in fact, called 911 to address her condition. N.J. Dep't of Health
				  & Senior Services v. Senior Care of Marlton, OAL Dkt. No. HLT 8253-07, 2008 N.J.
				  AGEN LEXIS 75, Initial Decision (January 18, 2008).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 18 - QUALITY IMPROVEMENT › Section 8:43F-18.1 - Quality improvement program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish and implement a written plan for a quality improvement program for
				participant care. The plan shall specify a timetable and designate a coordinator(s)
				of the quality improvement program and shall provide for ongoing monitoring of staff
				and participant care services.
(b)
				Quality improvement activities shall include, but not be limited to, the following:
1. At least annual review of staff qualifications
				and credentials;
2. At least annual
				review of staff orientation and staff education;
3. Evaluation of participant care services,
				staffing, infection prevention and control, housekeeping, sanitation, safety,
				maintenance of physical plant and equipment, participant care statistics, and
				discharge planning services;
4.
				Evaluation by participants and their families of care and services provided by the
				facility;
5. Review of medication errors
				and adverse medication reactions by the consultant pharmacist;
6. Audit of participant medical records (including
				those of both active and discharged participants) on an ongoing basis to determine
				if care provided conforms to criteria established by each participant care service
				for the maintenance of quality of care; and
7. Establishment of objective criteria for
				evaluation of the participant care provided by each service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 18 - QUALITY IMPROVEMENT › Section 8:43F-18.2 - Use of restraints

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				develop policies and procedures that support a restraint-free environment for all
				adult participants.
(b) The use of any
				restraining device shall be based on an assessment and shall require a physician,
				advanced practice nurse or physician assistant order.
(c) The least restrictive device shall be used, in
				compliance with the prescriber's order.
(d) A specific plan of care shall be developed for
				the use of any restraining device.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43F - STANDARDS FOR LICENSURE OF ADULT DAY HEALTH SERVICES FACILITIES › Subchapter 18 - QUALITY IMPROVEMENT › Section 8:43F-18.3 - Personal care services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To insure quality
				personal care, facility staff shall make daily checks to assure that participants
				are maintaining personal hygiene, receiving medications as prescribed (which
				includes assuring the renewal of prescriptions as necessary and the disposition of
				outdated or discontinued medications), and participating in appropriate social and
				recreational activities.
(b) Personal
				care services shall include education in assistance with activities of daily living
				and supervision of personal hygiene.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 1 - GENERAL PROVISIONS › Section 8:43G-1.1 - Scope and purpose

Current through Register Vol. 56, No. 14, July 15, 2024
(a) These rules and
				standards apply to each licensed general, psychiatric or special hospital facility.
				They are intended for use in State surveys of the hospitals and any ensuing
				enforcement actions. They are also designed to be useful to consumers and providers
				as a mechanism for privately assessing the quality of care provided in any acute
				care hospital.
(b) This chapter contains
				rules intended to assure the high quality of care delivered in hospital facilities
				throughout New Jersey. Components of quality care addressed by these rules and
				standards include access to care, continuity of care, comprehensiveness of care,
				coordination of services, humaneness of treatment, conservatism in intervention,
				safety of environment, professionalism of caregivers, and participation in useful
				studies.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 1 - GENERAL PROVISIONS › Section 8:43G-1.3 - Classification of institutions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Hospitals shall be
				classified generally as:
1. Private, non-profit,
				which shall include any hospital owned and operated by a corporation, association,
				religious or other organization, no part of the net earnings of which is applied, or
				may lawfully be applied, to the benefit of any private shareholder or
				person;
2. Private proprietary or
				profit, which shall include any hospital owned and operated by a person, partnership
				or corporation, the net proceeds of which are subject to distribution for the
				benefit of such person, corporation or shareholders; and
3. Public hospital, which shall include any
				institution maintained, supervised or controlled by an agency of the government of
				the State or any county or municipality that provides diagnostic and/or treatment
				services for the care of two or more non-related individuals suffering from illness,
				injury or deformity.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 1 - GENERAL PROVISIONS › Section 8:43G-1.4 - Information and complaint procedure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Questions regarding
				hospital licensure may be addressed to the Licensing Office.
(b) To make a complaint about any New Jersey
				licensed health care facility, call: 1-800-792-9770 (toll-free hotline).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.1 - Certificate of Need

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Where, in accordance with
N.J.S.A. 26:2H-1
et seq., as
				amended, a Certificate of Need is required, a hospital shall not be instituted,
				constructed, expanded, or licensed to operate except upon application for and
				receipt of a Certificate of Need issued by the Commissioner .
(b) Application forms for a Certificate of Need
				and instructions for completion may be obtained from the Licensing Office.
(c) The hospital shall implement all conditions
				imposed by the Commissioner as specified in Certificate of Need approval letters.
				Failure to implement the conditions may result in the imposition of enforcement
				sanctions in accordance with
				26:2H-13 and 14.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.2 - Application for licensure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Where applicable,
				following receipt of a Certificate of Need as a hospital, any person, organization,
				or corporation desiring to operate a hospital shall make application to the
				Commissioner for a license on forms prescribed by the Department. Such forms may be
				obtained from the Department's website address
http://nj.gov/health/forms
or from
				the Licensing Office.
(b) The Department
				shall charge a nonrefundable fee of $ 10,000 for the filing of an application for
				licensure and each annual renewal of a general acute care, special or psychiatric
				hospital. These fees shall not exceed the maximum caps as set forth at
				26:2H-12, as may be amended from time
				to time.
(c) The Department shall charge
				a nonrefundable fee of $ 3,000 for the filing of an application to add services to
				an existing general acute care, special or psychiatric hospital.
(d) The Department shall charge a nonrefundable
				fee of $ 375.00 for the filing of an application to reduce services at an existing
				general acute care, special or psychiatric hospital.
(e) The Department shall charge a nonrefundable
				fee of $ 1,500 for the filing of an application for the relocation of a general
				acute care, special or psychiatric hospital.
(f) The Department shall charge a nonrefundable
				fee of $ 1,500 for the filing of an application for the transfer of ownership of a
				general acute care, special or psychiatric hospital.
(g) Each general acute care, special and
				psychiatric hospital shall be assessed a biennial inspection fee of $ 5,000 for the
				review of licensure application forms, including the regulatory compliance
				statement, to validate that the facility continues to comply with applicable State
				licensing laws, including statutes and rules and Federal Medicare and/or Medicaid
				certification laws, including statutes and regulations.
1. This biennial inspection fee shall be assessed
				every other year at licensure renewal and shall be in addition to the annual
				licensure fee for that year. The biennial inspection fee shall be assessed at the
				time of the initial licensure fee for new facilities and shall be in addition to the
				licensure fee.
2. Failure to pay the
				inspection fee shall result in non-renewal of the license for existing facilities
				and the refusal to issue an initial license for new facilities.
3. This fee shall be imposed only every other year
				even if inspections occur more frequently.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.3 - Newly constructed or expanded facilities

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The licensure
				application for a newly constructed or expanded hospital pursuant to
N.J.A.C. 8:43G-2.2
shall
				include a copy of the Certificate of Occupancy, Certificate of Continuing Occupancy
				or a Certificate of Approval issued by the municipality in which the facility has
				been constructed in accordance with construction plan approval by:
Health Plan Review Unit
Division of Codes and Standards
Department of Community Affairs
PO Box 815
Trenton, New Jersey 08625-0815
Telephone: 609-633-8151
(b) An on-site inspection of the construction of
				the physical plant shall be made at the Department's discretion by representatives
				of the Division of Health Facility Survey and Field Operations to verify that the
				building has been constructed in accordance with the final architectural plans
				approved by the Department.
(c) Any
				health care facility which intends to undertake any alteration, renovation, or new
				construction of the physical plant, whether a Certificate of Need is required or
				not, shall submit plans to the Health Plan Review Unit of the Department of
				Community Affairs for review and approval prior to the initiation of any
				work.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.4 - Surveys and temporary license

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the written
				application for licensure pursuant to
N.J.A.C.
				8:43G-2.2
is approved and the building
				is ready for occupancy, a survey of the facility by representatives of the Division
				of Health Facility Survey and Field Operations of the Department may be conducted at
				the Department's discretion to determine if the facility meets the standards set
				forth in this chapter.
1. If the Department
				conducts a survey, representatives of the Division of Health Facility Survey and
				Field Operations of the Department shall discuss the findings of the survey,
				including any deficiencies found, with representatives of the hospital
				facility.
2. The hospital facility shall
				notify the Division of Health Facility Survey and Field Operations of the Department
				in writing when the deficiencies, if any, have been corrected. Following review of
				the hospital facility's report, the Division of Health Facility Survey and Field
				Operations may schedule one or more surveys of the facility prior to
				occupancy.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.5 - Full license

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A full license shall
				be issued to the licensee on expiration of the temporary license, if the surveys by
				the Department have determined that the health care facility is operated as required
				by 26:2H-1 et seq., and amendments
				thereto, and by the rules pursuant thereto.
(b) A license shall be granted for a period of one
				year or less as determined by the Department in accordance with (a) above.
(c) The license shall be conspicuously posted in
				the facility.
(d) The license shall not
				be assignable or transferable and shall be immediately void if the hospital ceases
				to operate, if its ownership changes, or if it is relocated to a different site. A
				representative of the hospital shall notify the Department of any change in the
				ownership form or controlling interests affecting hospital governance. The
				Department shall determine whether a certificate of need or licensing application
				must be completed prior to the implementation of any ownership changes based upon
				the information filed and the criteria within
				8:33-3.3.
(e) The license, unless suspended or revoked,
				shall be renewed annually on the original licensure date, or within 30 days
				thereafter but dated as of the original licensure date.
1. The facility shall receive a request for
				renewal fee 30 days prior to expiration of the license. A renewal license shall not
				be issued unless the licensure fee is received by the Department.
2. The license may not be renewed if Departmental
				rules, regulations and/or requirements are not met.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.6 - Revocation or suspension of license

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department is
				authorized to suspend or revoke a license issued pursuant to this subchapter, order
				closure of a service or unit within the hospital, or impose a money penalty on any
				of the following grounds:
1. Violation of any
				provisions of 26:2H-1 et seq. or any rules and
				regulations issued pursuant thereto;
2.
				Permitting, aiding or abetting the commission of any illegal act in said facility;
				and/or
3. Conducting practices contrary
				to accepted procedures and detrimental to the welfare of the patient.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.7 - Surrender of license

Current through Register Vol. 56, No. 14, July 15, 2024
At least 30 days prior to voluntary surrender of its license where
				  approved by Certificate of Need, or as directed under an order of revocation,
				  refusal to renew, or suspension of license, a facility must directly notify each
				  patient and the patient's physician concerned of the intended closure. The license
				  shall be returned to the Licensing Office within seven calendar days from voluntary
				  surrender, order of revocation, expiration, or suspension of license, whichever is
				  applicable.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.8 - Waiver

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner or his or her designee may,
				in accordance with the general purposes and intent of
				26:2H-1 et seq., and amendments
				thereto, and the standards in this chapter, waive sections of this chapter if, in
				his or her opinion, such waiver would not endanger the life, safety, or health of
				the patient or public.
(b) A facility
				seeking a waiver of the standards in this chapter shall apply in writing to the
				Director of the Licensing Office.
(c) A
				written application for waiver shall include the following:
1. The nature of the waiver requested;
2. The specific standards for which a waiver is
				requested;
3. Reasons for requesting a
				waiver, including a statement of the type and degree of hardship that would result
				to the facility upon full compliance;
4.
				An alternative proposal which would ensure patient safety; and
5. Documentation to support the waiver
				application.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.9 - Action against licensee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Violations of this chapter may result in
				action by the Department to impose a fine, pursuant to
N.J.S.A.
				26:2H-1
et seq., cease admissions to a
				facility, order removal of patients from a facility, revoke, or suspend a license,
				and/or impose other lawful remedies.
(b)
				If the Department determines that operational or safety deficiencies exist, it may
				require that all admissions to the facility cease. This may be done simultaneously
				with, or in lieu of, action to revoke licensure and/or impose a fine. The
				Commissioner or his or her designee shall notify the facility in writing of such
				determination.
(c) The Commissioner may
				order the immediate removal of patients from a facility whenever he or she
				determines there is imminent danger to any person's health or safety.
(d) Any licensee made subject to action by the
				Department for suspension or revocation of license or who is assessed a fine under
				terms of this section shall have the right to a fair hearing in accordance with the
				Administrative Procedure Act,
				52:14B-1 et seq., and the Uniform
				Administrative Procedures Rules, N.J.A.C. 1:1.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.10 - Information not to be disclosed

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Information received
				by the Department through inspection authorized by
N.J.S.A.
				26:2H-1
et seq. shall not be disclosed
				to the public in such a way as to indicate the names of the specific patients or
				hospital employees to whom the information pertains. The Department shall forward
				inspection reports to the hospital facility at least 30 days prior to public
				disclosure. In all cases in which the hospital comments on the inspection report,
				the hospital comments and the inspection report shall be released simultaneously by
				the Department. In cases in which the Commissioner determines that the protection of
				public health and safety necessitates immediate public disclosure of information,
				inspection reports may be disclosed immediately.
(b) Nothing contained herein shall be construed to
				interfere with existing legislation or the established rights and privileges of the
				public prosecutor and litigants having access to hospital records, nor shall
				determinations herein be construed to interfere in any way with the orderly legal
				process of obtaining access to such records.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.12 - Mandatory services in general and psychiatric hospitals

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All general
				hospitals applying for licensure shall provide the following professional
				departments, services, facilities, and functions:
1. Administration;
2. Anesthesia Department;
3. Blood Bank;
4. Central Supply;
5. Clinical and Pathological
				Laboratories;
6. Dietary
				Services;
7. Discharge
				Planning;
8. Emergency
				Department;
9. Employee and Occupational
				Health;
10. Electrocardiogram
				Laboratory;
11. Housekeeping and Laundry
				Services;
12. Infection Control and
				Sanitation;
13. Medical
				Library;
14. Medical Records;
15. Medical/Surgical Service;
16. Medical Staff;
17. Morgue and Autopsy Facilities;
18. Nursing Service;
19. Out-Patient and Preventive Services, including
				regularly scheduled clinic services for medically indigent patients;
20. Pharmacy Department;
21. Physical and Occupational Therapy;
22. Physical Plant and Maintenance;
23. Post Anesthesia Care Unit;
24. Quality Assurance;
25. Radiology;
26. Respiratory Therapy Services; and
27. Social Work Department.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 2 - LICENSURE PROCEDURE › Section 8:43G-2.13 - Child abuse and neglect and substance-affected infants

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The facility shall
				establish and implement written policies and procedures, reviewed by the Department
				and revised as required by the Department, for reporting all diagnosed and/or
				suspected cases of child abuse and/or neglect in compliance with
				9:6-1 et seq.
(b) The facility shall have in effect written
				policies and procedures reviewed by the Department and revised as required by the
				Department to include, but not be limited to, the following:
1. 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 on a 24-hour basis, recording the notification to the
				Division of Child Protection and Permanency of the Department of Children and
				Families on the medical record, and serving as a liaison between the facility and
				the Division of Child Protection and Permanency of the Department of Children and
				Families;
2. The development of written
				protocols for the identification and treatment of abused and/or neglected children
				for the emergency room, clinic, and pediatrics, where such services exist, for
				admission and/or transfer to another facility and for protective custody through the
				use of hospital hold in accordance with N.J.S.A. 9:6-8.1 6; and
3. The provision 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 and regarding the
				facility's policies and procedures on at least an annual basis.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.1 - Administrative and hospital-wide structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall
				be an organizational chart of the hospital and each service that shows lines of
				authority, responsibility, and communication between and within services.
(b) The hospital shall have an established and
				functioning governing body responsible for establishing hospital-wide policy,
				adopting bylaws, maintaining quality of care, and providing institutional management
				and planning. The hospital shall file the following with its license application or
				license renewal application:
1. The name of each
				member of the hospital's governing body;
2. The name of the chairperson of the hospital's
				governing body;
3. The term of office of
				the chairperson and each member of the governing body; and
4. The start date and end date of the term of
				office of each member of the governing body.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.3 - Administrative and hospital-wide staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The administrator or
				chief executive officer of the hospital shall have at least one of the following
				qualifications:
1. A master's degree and at least
				three years of full-time experience in progressively responsible management
				positions;
2. A baccalaureate degree and
				at least five years of full-time experience in progressively responsible management
				positions; or
3. At least 10 years of
				full-time experience in hospital administration.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.4 - Organ and tissue donation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				develop and implement written protocols for organ and tissue donation in accordance
				with 26:6-57 et seq., and the Uniform
				Anatomical Gift Act, P.L. 1969, c.161, as amended.
(b) For the purposes of this rule, the following
				words shall have the following meanings:
1.
				"Designated requestor" means a hospital employee who has completed a course offered
				or approved by the designated Federally qualified organ procurement organization.
				This course shall be designed by the OPO with input from the regional tissue and eye
				bank community and shall incorporate the methodology to be used by the Designated
				Requestor for approaching potential donor families to request organ or tissue
				donation.
2. "OPO" means a hospital's
				designated Federally qualified organ procurement organization. The Federally
				qualified organ procurement organizations in New Jersey are:
i. NJ Sharing Network
691 Central Avenue
New Providence, NJ 07974
(800) 742-7365 and (908) 516-5400; and
ii. Gift of Life Donor Program
401 North 3rd Street
Philadelphia, PA 19123
(215) 557-8090; 800-DONORS-1 or (800-366-6771); 800-KIDNEY-1 or
				  (800-543-6391).
3.
				"Organ" means human kidney, liver, hear, lung, pancreas, and any other solid
				organ.
4. "Tissue" means human skin,
				heart valves, saphenous veins, bone and other tissue, including ocular
				tissue.
5. "Transplant recovery
				specialist" means a medical professional licensed by the State of New Jersey or
				another State or technician trained by an organ procurement organization in
				accordance with Federal standards pursuant to
				42 U.S.C. §
											274(b) and nationally accredited
				standards for human body part removal.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.5 - Administrative and hospital-wide patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To meet the needs of
				pediatric patients, the hospital shall have available medical and nursing staff with
				specialized pediatric training and shall have equipment adaptable to the needs of
				pediatric patients on-site.
(b) The
				hospital shall ensure the safe transport of patients within the hospital, according
				to each patient's medical needs. This system shall include at least
				interdepartmental reporting of incidents and changes in the patient's condition
				during transportation and during the period the patient is in another service and
				providing an accompanying health professional for those patients whose condition
				warrants it.
(c) The hospital shall
				provide interpretive services, when necessary, for patients who do not speak English
				and for patients who are deaf. The facility shall provide other communication
				assistance, as needed, for patients who are blind.
(d) The hospital shall have a system to link
				patients with clergy or spiritual counselors, upon request.
(e) For patient and staff safety, the hospital
				shall have a security system which is rigidly enforced and includes at least an
				identification system for employees, volunteers, and medical staff and control of
				access to and egress from the hospital.
(f) There shall be a means to summon immediate
				emergency response for medical emergencies occurring in the hospital.
(g) Each department in the hospital providing
				direct patient care shall have a health care professional capable of initiating
				cardiopulmonary resuscitation on duty at all times when patients are
				present.
(h) The hospital shall develop
				and implement written policies and procedures for identifying and supporting the
				needs of a breastfeeding mother and/or a child at the point of entry into the
				facility, that is, at registration in the emergency department, upon arrival for
				same-day surgery, and on admission to the facility.
1. These policies and procedures shall require
				appropriate staff to:
i. Document breastfeeding
				needs in the medical record; and
ii.
				Review these policies and procedures every three years and make revisions at any
				time as necessary.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.6 - Independent Health Care Appeals Program notice; posting

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A general hospital
				shall post, in a conspicuous place in each of its waiting rooms for members of the
				general public, the notice about the Independent Health Care Appeals Program (IHCAP
				notice) entitled, "An Explanation of an Individual's Right to Appeal Health
				Insurance Determinations," in the form that the Department of Banking and Insurance
				promulgates pursuant to
				N.J.S.A.
				26:2S-14.2 at
				N.J.A.C.
				11:24A-5.3 and 11:24A-5 Appendix, and posts to its
				website at
http://www.dobi.nj.gov/ihcapappeals
.
(b) If the Department of Banking and Insurance
				makes available the IHCAP notice in a format translated into a language other than
				English, and at least 10 percent of the population in a general hospital's service
				area speak that other language, the general hospital shall post the translated
				version of the IHCAP notice in the other language, in addition to the version in
				English, in accordance with (a) above.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.7 - Administrative and hospital-wide staff education

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				formal orientation program for all new permanent staff that includes at least
				training in patient rights as found at N.J.A.C. 8:43G-4, a tour of the hospital,
				orientation to the hospital's security system and disaster plan, and review of
				procedures to follow in case of an emergency.
(b) There shall be a formal orientation program
				for all new temporary staff, nurses retained through an outside agency, and persons
				providing services by contract which includes, at a minimum, a tour of the
				department to which the individual is assigned, orientation of the hospital's
				security system, and review of procedures to follow in case of an
				emergency.
(c) The hospital shall
				provide, evaluate, and coordinate training and educational programs for all
				departments in the hospital.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.9 - Department education programs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each department in
				the hospital shall develop, revise as necessary, and implement a written plan of
				staff education. The plan shall address the education needs, relevant to the
				service, of different categories of staff on all work shifts. The plan shall include
				education programs conducted at least annually in the service, in other areas of the
				hospital, or off-site.
(b) The plan
				shall include education programs that address at least the following:
1. Orientation of new staff to the service in
				which the individual will be employed, including a review of the service's
				equipment, policies, and procedures and identification of individual employee duties
				for receiving and evacuating patients in the event of a disaster;
2. Use of new clinical procedures, new equipment,
				and new technologies, including, where applicable, computers;
3. Individual staff requests for education
				programs;
4. Supervisor judgements about
				education needs based on assessment of staff performance;
5. Education on statutory requirements relevant to
				the specific service such as identification and reporting of victims of abuse;
				and
6. Areas identified by the
				hospital-wide quality assurance program as needing educational programs;
				and
7. Patient rights; and
8. Rights and responsibilities of staff under the
				New Jersey Advance Directives for Health Care Act ( P.L. 1991, c.201) and the
				Federal Patient Self Determination Act (
				P.L.
				101-508 ), and internal hospital policies and
				procedures to implement these laws.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.10 - Funding for regionalized services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All hospitals
				providing emergency room services shall be members in good standing of the New
				Jersey Poison Information and Education System established pursuant to
				26:2-119 et seq.
(b) All hospitals with licensed obstetric or
				pediatric beds or designated as a Community or Regional Perinatal Center pursuant to
				N.J.A.C. 8:33C shall be a member in good standing of a Maternal and Child Health
				Consortium as defined in N.J.A.C. 8:35.
(c) Prior to the designation of the Maternal and
				Child Health Consortium pursuant to the certificate of need process and after the
				expiration of the Robert Wood Johnson Foundation funding for consortia on or before
				March 1, 1993, all hospitals eligible for a perinatal adjustment in a 1993 revenue
				cap approved by the Hospital Rate Setting Commission shall make monthly payments
				based on that adjustment to the Maternal and Child Health Consortium to which they
				belong.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.11 - Occupational health structural organization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be an
				employee-management occupational health and safety committee that:
1. Meets a minimum of six times a year;
2. Establishes a procedure for receiving and
				responding to employees' occupational health and safety complaints and
				concerns;
3. Receives, investigates, and
				provides written or oral responses to employees' complaints related to occupational
				health and safety;
4. Provides
				information to the hospital staff including recommendations or actions taken by the
				committee;
5. Assists in the development
				and periodic review of all occupational health and safety policies; and
6. Conducts inspections to assure conformance with
				those policies and procedures, and to identify problems.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.12 - Occupational health policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital
				shall develop and implement a written policy to assure that staff have the right to
				voice occupational health and safety complaints or problems without
				reprisals.
(b) The hospital shall have
				available the most current version of standards and guidelines for:
1. Centers for Disease Control and Prevention
				(CDC); National Institute for Occupational Safety and Health (NIOSH). "Preventing
				Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care
				Settings." NIOSH Alert. Publication No. 2004-165; 1-58. Last update: September 2016;
				Conor TH, MacKenzie BA, DeBord DG, et al. for CDC; NIOSH. "NIOSH List of
				Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016." (Supersedes
				2014-138).
NIOSH
. Publication No. 2016-161; 1-42, available from
				NIOSH-Publications Dissemination, 4676 Columbia Parkway, Cincinnati, OH 45226-1998.
				Phone:1-800-35-NIOSH (1-800-356-4674). Fax: (513) 533-8573. Website:
www.cdc.gov/niosh
. E-mail:
				pubstaft@cdc.gov.
2. Waste anesthetic
				gases: "Recommended Standard for Occupational Exposure to Waste Anesthetic Gases and
				Vapors," National Institute of Occupational Safety and Health (NIOSH) Publication
				No. 77-140;
3. Federal regulations for
				ethylene oxide, Code of Federal Regulations:
				29 CFR
				1910.1047;
4. Federal regulations for formaldehyde, Code of
				Federal Regulations:
				29 CFR
				1910.1048;
5. Federal regulations for hazard communication,
				Code of Federal Regulation:
				29 CFR 1910.1200
				(required for private sector hospitals); and
6. The Worker and Community Right to Know Act,
N.J.S.A. 34:5A-1
et seq., and
				all rules promulgated pursuant to that Act.
Note: Copies of these standards and guidelines can be obtained on
				  the Department's website at:
http://www.state.nj.us/health/workplacehealthandsafety/right-to-know/
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.13 - Occupational health staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
The hospital shall designate an individual to provide clinical
				  guidance on occupational health and safety issues who is a physician with
				  occupational medicine background, an industrial hygienist, or a health professional
				  with two years of experience in occupational health.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.14 - Occupational health education

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall
				develop, revise as necessary, and implement a written plan of staff education. The
				plan shall address the education needs of different categories of employees with
				potential exposure to hazardous substances, including at least cytotoxic drugs,
				waste anesthetic gases, ethylene oxide, formaldehyde, and/or hazardous blood-borne
				diseases on all work shifts. The plan shall include education programs conducted in
				the employees' service, in other areas of the hospital, and off-site.
(b) The plan shall include on-going education
				programs and an orientation session that address at least the following:
1. Written materials that the employee can use for
				reference;
2. Information about the
				risks associated with these hazardous materials and/or blood-borne
				diseases;
3. Information about
				employees' responsibilities to use personal protection clothing or
				equipment;
4. Education and training
				programs for employees that comply with rules and regulations concerning the
				establishment and contents of such programs as required by OSHA's Hazard
				Communication Standard,
29 CFR 1910.1200
, effective May 25, 2012, and for which the final rule and all appendices
				are available at
http://www.osha.gov/dsg/hazcom/ghs-final-rule.html
;
				and The Worker and Community Right to Know Act,
N.J.S.A.
				34:5A-1
et seq., and for which Right to
				Know publications are available on the Department's website at:
http://www.state.nj.us/health/workplacehealthandsafety/right-to-know/
.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.15 - Occupational health continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a program of continuous quality improvement for
				  occupational health that is integrated into the hospital continuous quality
				  improvement program and includes regularly collecting and analyzing data to help
				  identify occupational health problems and their extent, and recommending,
				  implementing, and monitoring corrective actions on the basis of these data.