N.J. Admin. Code § 8:43A-3.6

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

Section 8:43A-3.6 - Policy and procedure manual

(a) A policy and procedure manual(s) for the organization and operation of the facility shall be developed, implemented, and reviewed at intervals specified in the manual(s). Each review of the manual(s) shall be documented, and the manual(s) shall be available in the facility to representatives of the Department at all times. The manual(s) shall include at least the following;

1. A written statement describing the program's treatment philosophy, objectives, and staffing patterns, and the services provided by the facility;

2. An organizational chart delineating the lines of authority, responsibility, and accountability for the administration and patient care services of the facility;

3. A description of the quality assurance program for patient care and staff performance, including methods for at least annual review of staff qualifications and credentials and of staff orientation and education;

4. Definition and specification of hours of operation, including all times in which patients are present in the facility, business hours, and full working week;

5. A system for referral of patients to sources of secondary and tertiary health care;

6. A requirement for at least one member of the medical staff to maintain admitting privileges at a hospital;

7. Policies and procedures for the maintenance of personnel records for each employee, including at least the employee's name, previous employment, educational background, credentials, license number with effective date and date of expiration (if applicable), certification (if applicable), verification of credentials, records of physical examinations, job description, records of staff orientation and staff education, and evaluations of job performance; and

8. Policies and procedures for complying with applicable statutes and protocols to report child abuse and/or neglect, abuse or mistreatment of elderly or disabled adults, sexual abuse, specified communicable disease, rabies, poisonings, and unattended or suspicious deaths. These policies and procedures shall include, but not be limited to, the following:

i. 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 in compliance with N.J.S.A. 9:6-1et seq., recording the notification to the Division of Child Protection and Permanency in the medical record, and serving as a liaison between the facility and the Division of Child Protection and Permanency;

ii. The notification of any suspected case of patient abuse or exploitation to the State Long-Term Care Ombudsman , pursuant to N.J.S.A. 52:27G-7.1et seq., if the patient is 60 years of age or older;

iii. The development of written protocols for the identification and the treatment of children and elderly or disabled adults who are abused and/or neglected; and

iv. The provision at least annually 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; sexual abuse; domestic violence; abuse of the elderly or disabled adult; and the facility's policies and procedures.

Note: N.J.S.A. 9:6-1et seq., is available at https://www.nj.gov/dcf/reporting/links.

(b) The policy and procedure manual(s) shall be available and accessible to all patients, staff, and the public.

N.J. Admin. Code § 8:43A-3.6

Amended by R.2021 d.039, effective 5/3/2021.
See: 51 N.J.R. 1316(a), 53 N.J.R. 703(a).
Rewrote (a)8i, (a)8ii, and the Note in (a)8.
Notice of readoption with technical change, effective 1/3/2022.
See: 54 N.J.R. 60(a).