N.J. Admin. Code § 8:111-3.8

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

Section 8:111-3.8 - Reportable events

(a) The facility shall develop policies and procedures governing the reporting and management of reportable events. Such polices shall include, but need not be limited to, the procedures in this section.

(b) The facility shall immediately notify the Department at (609) 530-7473, as well as immediately fax a report to the Department at (609) 530-4850, regarding any event occurring within the facility that jeopardizes the health, safety, or welfare of clients or staff as set forth in this subchapter, including, but not limited to, the following:

1. All fires, floods, disasters, accidents or other unanticipated events that result in serious injury or death of clients or staff, evacuation of clients from the facility or closure of the facility;

2. All deaths of clients under the supervision of the facility, including deaths known or suspected of resulting from misuse of medications prescribed or dispensed by the facility;

3. All outbreaks of communicable disease or other conditions adversely effecting multiple clients and/or staff. This does not relieve the facility from reporting certain communicable diseases to local or State health authorities pursuant to N.J.A.C. 8:57;

4. All alleged or suspected crimes that endanger the life or safety of clients or staff or that jeopardize facility operations or fiscal stability.

i. Any client or staff member against whom an alleged or suspected crime has been committed shall be advised of his or her right to report the incident to local police.

ii. Notification, or the refusal to notify police authorities, shall be documented in writing in the client or staff record, and the administrator shall be notified.

iii. The governing body shall be notified of events endangering the life and/or safety of clients and staff, or suspected crimes that jeopardize the facility's operations or fiscal stability;

5. All disciplinary actions of staff, including termination, resulting from inappropriate staff interaction with clients; and

6. All criminal convictions or disciplinary sanctions imposed on staff, board members or representatives of the governing authority by licensing or credentialing boards since the prior application for licensure.

(c) The facility shall provide the Department a written report by no later than five business days after the event or circumstances listed at (b) above. This written report does not replace the required immediate telephone contact and faxed report to the Department.

1. The written confirmation shall contain information concerning injuries to clients or staff, disruption of services and the extent of damages, etc. The written report shall also include identification of the factors that contributed to the occurrence of the event and corrective actions and timeframes being implemented by the facility to minimize the risk of further incidents.

(d) The facility shall notify the Division in writing of the resignation or termination of employment of the administrator, medical director, director of nursing or the director of substance abuse counseling services and the name(s) and qualifications of the replacement(s) or acting replacement(s) no later than seven days following the date of resignation(s) or termination(s).

(e) The facility shall develop procedures, including time-frames, for verbal and written notification to the governing authority of reportable events set forth in this section.

N.J. Admin. Code § 8:111-3.8

Amended and recodified from 10:161A-3.8 53 N.J.R. 2208(a), effective 12/20/2021