N.J. Admin. Code § 8:43F-18.1

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

Section 8:43F-18.1 - Quality improvement program

(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.

(c) The coordinator of the quality improvement program shall submit the results of the quality improvement program to the licensed operator at least annually and the results shall include, at a minimum, the deficiencies found and recommendations for corrections or improvements.

1. The coordinator of the quality improvement program shall immediately report deficiencies that jeopardize participant safety to the licensed operator.

2. The administrator shall implement measures to ensure that corrections or improvements are made.

N.J. Admin. Code § 8:43F-18.1

Administrative correction.
See: 38 N.J.R. 965(b).