N.J. Admin. Code § 8:43J-17.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43J-17.1 - Quality improvement program

(a) The facility shall establish and implement a written plan for a quality improvement program for child care, which shall specify a timetable and the person(s) responsible for the quality improvement program and shall provide for ongoing monitoring of staff and child-care services.

(b) The facility shall establish and implement a quality assurance committee whose members shall include:

1. A Board-certified pediatrician familiar with pediatric medical day care facility services and implementation of quality improvement programs;

2. A registered professional nurse with special expertise in the care of medically complex children; and

3. A certified child life specialist or a social worker with expertise in the care of medically complex children and their families.

(c) Quality improvement activities shall include, but not be limited to, the following:

1. Quarterly reviews by the quality improvement committee of the complete records for at least half of the children served by the pediatric medical day care facility at the time of the quality assurance review.

(d) At a minimum, each quarterly quality assurance committee review shall address:

1. The quality of care evidenced by review of a child's record for compliance with the requirements of 8:43J-14.3;

2. Parent involvement, which can be shown by involvement in the development of an interdisciplinary plan of care to be rendered in the pediatric medical day care facility, attendance at interdisciplinary staffing conferences and participation in individual and/or group education sessions scheduled by the center, which include clearly written, practical and appropriately targeted training materials and scheduled individual and/or group education sessions for parent and other family members;

3. Formal discharge transition procedure, including:

i. Documentation that placement in the pediatric medical day care facility is no longer appropriate for the child;

ii. Evidence of pre-discharge conference involving the parent, representatives of the pediatric medical day care facility professional staff and agencies involved in child care after discharge to ensure a smooth transition; and

iii. A written discharge summary signed by the pediatric medical day care facility nursing director within two weeks of the child's discharge;

4. A review of the goals in each child's interdisciplinary plan of care, progress in achieving the goals, identification of unmet goals and correction plans;

5. At least annual review of:

i. Staff qualifications;

ii. Staff credentials;

iii. Staff orientation; and

iv. Staff education;

6. Evaluation of child care services, staffing, infection prevention and control, housekeeping, sanitation, safety, maintenance of physical plant and equipment, child care statistics and discharge planning services;

7. Evaluation by children and their families of care and services provided by the facility;

8. Review of medication errors and adverse medication reactions by the consultant pharmacist;

9. Audit of child medical records (including those of both active and discharged children) on an ongoing basis to determine if care provided conforms to criteria established by each child care service for the maintenance of quality of care; and

10. Establishment of objective criteria for evaluation of the child care provided by each service.

(e) The coordinator of the quality improvement committee shall submit the results of the quality improvement committee's review to the licensed operator, administrator, medical director and nursing director within 15 working days of its review.

1. The results shall include, at a minimum, the deficiencies found and recommendations for corrections or improvements.

i. The coordinator of the quality improvement program shall immediately report deficiencies that jeopardize child safety to the license holder.

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

N.J. Admin. Code § 8:43J-17.1