N.J. Admin. Code § 8:111-1.5

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:111-1.5 - Qualifications and responsibilities of the director of nursing services and licensed nursing personnel

(a) Every facility required to provide nursing services shall designate a director of nursing who shall, at a minimum, meet the following qualifications:

1. Be a registered professional nurse pursuant to 45:11-26 et seq. with at least one year in nursing supervision or nursing administration; and

2. One year full-time experience with the management of addictions in a licensed substance use disorders treatment facility.

(b) For a facility providing detoxification services, the individual shall have one year of supervisory experience or three years of experience in an opioid treatment facility or detoxification facility.

(c) Every facility that is required to provide nursing services shall designate a director of nursing, or designee who meets the criteria of director of nursing (pursuant to (a) above), who shall be on the premises or available on-site, or respond within 30 minutes during the facility's hours of operation.

(d) The director of nursing services shall be responsible for the direction, provision and quality of nursing services provided to clients, including the following:

1. Providing administrative oversight of the facility's nursing services, and where appropriate, directly supervising the facility's nursing staff;

2. Assisting the administrator of the facility in developing and maintaining written objectives, policies and procedures related to nursing services, developing an organization plan, and developing a quality assurance program for nursing services, and reviewing all nursing policies and procedures, minimally, on an annual basis;

3. In conjunction with the administrator and the governing authority of the facility, planning and budgeting for nursing services;

4. Ensuring the coordination and integration of nursing services with other client care services to ensure continuity of care for each client;

5. Ensuring that the facility complies with required nursing staffing patterns;

6. Assisting in the development of written job descriptions for the nursing staff and assigning duties of the nursing staff;

7. Participating in staff orientation and staff education activities, when applicable; and

8. Participating in team conferences with the multidisciplinary team and the client care committee (if the facility chooses to establish a client care committee).

(e) All nursing personnel shall possess the appropriate current nursing license necessary to provide the services set forth in this subchapter. All nursing personnel shall be a member in good standing.

(f) Licensed nursing personnel shall, at a minimum, be responsible for the following:

1. Participating in the development of client treatment plans;

2. Providing face-to-face health care monitoring for the facility's clients;

3. Where medically and clinically appropriate, participating on the multidisciplinary treatment team; and

4. Providing required documentation in the client records.

(g) Only a registered professional nurse shall assess the nursing care needs of clients.

(h) All nursing services provided shall be documented in the nursing portion of the client care plan and shall comport with the facility's policies and procedures governing client documentation and with this subchapter. Such documentation shall include, but need not be limited to, the following:

1. Clinical notes;

2. A record of medications administered including, but not limited to:

i. The date the medication is ordered by the physician and the date the medication is to be discontinued;

ii. The name and strength of the medication;

iii. The date and time of the administration of the medication;

iv. Effects of medication (if indicated);

v. The dosage administered;

vi. Method of administration;

vii. The signature of the nurse who administered the medication or identification of the nurse by an entry code if a computerized clinical record system is used. If initials are used, a section shall be included identifying the respective signature and title for all initials; and

viii. The reason the client refused to receive the medication or why the client did not receive the medication at the designated time, if applicable; and

3. A record of medication self-administered by clients shall be maintained in the nursing portion of the client care plan and the medication administration record. Such documentation shall include:

i. Whether medication was taken orally, injected, inserted, topically or otherwise administered by a client to himself or herself;

ii. Verification of the dose with the prescriber's orders;

iii. Verification that the client took his or her own individual dose;

iv. If self-administration is observed, a recording of the observation that the client has taken his or her own medication orally, by way of injection, topically or insertion in nursing portion of the client care plan and medication administration record; and

v. Signature of the nurse who observed the client's self-administration of medication or identification of the nurse by an entry code if a computerized clinical record system is used.

N.J. Admin. Code § 8:111-1.5

Recodified from 10:161A-1.5 53 N.J.R. 2208(a), effective 12/20/2021