N.J. Admin. Code § 8:135-3.4

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

Section 8:135-3.4 - General procedures

(a) This section delineates the conditions and procedures applicable to all transfers to and from State psychiatric hospitals.

(b) Each CEO shall designate a staff member to function as a transfer coordinator who, for purposes of transfer arrangement, shall report directly to the CEO.

(c) The transfer coordinator of a hospital that is requesting a patient's transfer (sending hospital) shall transmit a written request for the transfer that includes a statement of the factors that the clinical determination specifies, from among the factors specified at N.J.A.C. 8:135-3.3(a), as the basis of the transfer, to the transfer coordinator of the hospital to which the patient's transfer is proposed (receiving hospital).

1. All requests for transfers shall be supported by clinical considerations.

(d) A transfer that is proposed as a response to overcrowding, life-safety concerns, natural catastrophes, or consolidation of services shall require the approval of the Assistant Commissioner of the Division.

(e) A facility shall adhere to the following procedures in conducting a non-emergency transfer of a patient:

1. The transfer coordinators of the sending and receiving hospitals shall confer as to the proposed transfer.

i. If both concur as to the proposed transfer, they shall arrange a specific date and time for the transfer to occur.

ii. Hospital staff shall actively encourage patient input into non-emergency transfer decisions.

iii. At least seven days prior to the transfer date, staff at the sending hospital shall notify the county adjuster for each affected county, and the transferring patient's family and attorney of the transfer decision, the reason for the transfer, and their respective procedural rights, as specified in this chapter.

iv. The sending hospital shall arrange a transferring patient's transportation to the receiving hospital.

2. If the transfer coordinators do not concur as to the proposed transfer, each coordinator shall refer the transfer request to the CEOs of the respective hospitals for resolution.

3. If the CEOs do not obtain a resolution, the case shall be referred for resolution to the Division Medical Director, who, in making a decision on the proposed transfer, may request clinical and technical input from hospital central office staff.

4. In instances of continuing disagreement, the Assistant Commissioner of the Division shall resolve the disagreement.

5. All transfer requests are to be handled in a timely manner.

6. The basis for the transfer decision shall be documented in the patient's record.

(f) A facility shall adhere to the following procedures in conducting an emergency transfer of a patient:

1. For the purposes of this subchapter, the term, "emergency," means that a patient poses imminent danger of serious bodily harm to self or others, as evidenced by a recent incident or a change in the patient's psychiatric status, which:

i. An available treatment alternative that is less restrictive than transfer cannot adequately address;

ii. Requires removal of the patient from the patient's current setting; and

iii. The factors at N.J.A.C. 8:135-3.3(a)4 or 8 shall serve as the exclusive basis for an emergency transfer.

2. Emergency transfers shall take place only upon prior agreement between the CEOs of the institutions.

3. Staff at the sending hospital shall notify the relevant County Adjuster(s), family, and attorney of the resident being transferred of the transfer and the reason for the transfer as soon as possible after the transfer decision has been made.

4. The transfer coordinator or, when unavailable, the administratively responsible person of the sending hospital must contact directly the CEO or transfer coordinator at the receiving institution and transmit verbally the factors supporting the transfer, as well as the reasons for the emergent nature of the transfer. Supporting documentation must be faxed prior to the final decision to transfer.

5. If, after transfer, the CEO of the receiving hospital objects to an emergency transfer, that CEO shall review the case with the CEO of the sending hospital.

6. If the CEOs cannot obtain a resolution, the matter shall be referred to the Division Medical Director who, in reviewing the transfer, may request clinical and technical input from hospital central office staff.

7. In instances of continuing disagreement, the Assistant Commissioner of the Division shall resolve the disagreement.

8. The basis for the transfer decision shall be documented in the patient's record.

N.J. Admin. Code § 8:135-3.4

Amended by 48 N.J.R. 713(a), effective 5/2/2016

Amended and recodified from 10:36-3.4 by 55 N.J.R. 2258(b), effective 11/9/2023