N.J. Admin. Code § 8:43G-5.2

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:43G-5.2 - Administrative and hospital-wide policies and procedures

(a) The hospital shall have written policies, procedures, and bylaws that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least:

1. Policies on the admission of patients, transfer of patients to another facility, and discharge of patients;

2. Procedures for obtaining the patient's written informed consent for all medical treatment;

3. Delineation of the responsibilities of the medical staff, nursing, and other staff in contacting the patient's family in the event of death, elopement, or a serious change in condition;

i. The facility shall promptly notify a family member, guardian or contact person designated by the patient on admission about a patient's death. The facility shall maintain confirmation and written documentation of that notification. The facility shall adopt and maintain in its manual of policies and procedures a delineation of the responsibilities of the facility's staff in making such prompt notification regarding the death of a patient.

ii. As used in this paragraph, "promptly" means as soon as possible but not later than 60 minutes after the patient's death. If a first attempt to provide notification is made in a timely fashion but is not successful, a subsequent attempt must be made within each successive 60-minute period until notification is successfully made.

iii. Written documentation shall be made in the patient's medical record of each attempt at notification, including who made the attempt, when, how notification was made, and who the notification, when successful, was given to.

4. Policies addressing bio-ethical issues affecting individual patients, including at least removal of life support systems, discontinuance or refusal of treatment, and designation not to resuscitate. In accordance with the New Jersey Advance Directives for Health Care Act ( P.L. 1991, c.201), private, religiously-affiliated health care institutions which decline to participate in the withholding or withdrawing of specified life-sustaining measures shall comply with the following:

i. The hospital shall establish written policies defining circumstances in which it will decline to participate in the withholding or withdrawing of specified life-sustaining measures in accordance with the patient's advance directive;

ii. The hospital shall provide prompt notice to patients or their families or health care representatives of these policies prior to or upon admission, or as soon after admission as is practical; and

iii. The hospital shall implement a timely and respectful transfer of the individual to another institution who will implement the patient's advance directive;

5. Procedures to ensure that there is a routine inquiry made of each adult patient, upon admission to the hospital and at other appropriate times, concerning the existence and location of an advance directive (as required and defined in the New Jersey Advance Directives for Health Care Act, P.L. 1991, c.201). If the patient is incapable to respond to this inquiry, the hospital shall have procedures to request the information from the patient's family or in the absence of family, another individual with personal knowledge of the patient, if available and known to the hospital. The procedures must assure that the patient or family's response to this inquiry is documented in the medical record. Such procedures shall also define the role of hospital admissions, nursing, social service and other staff as well as the responsibilities of the attending physician;

6. Policies which identify circumstances in which an inquiry will be made of adult individuals receiving same day surgery, same day medical services, treatment in the emergency department or out-patient hemodialysis treatment regarding the existence and location of an advance directive;

7. Procedures to request and to take reasonable steps to promptly obtain a copy of currently executed advance directives from inpatients and other critically ill patients who are under treatment at the hospital. These shall be entered when received into the medical record of the patient. When there is a question of validity, procedures for promptly evaluating the validity of the advance directive must be established;

8. Procedures for promptly alerting physicians, nurses, and other professionals providing care to patients who have informed the hospital of the existence of an advance directive in instances where a copy is not immediately available for the medical record;

9. Policies for transfer of the responsibility for care of patients with advance directives in those instances where a health care professional declines as a matter of professional conscience to participate in withholding or withdrawing life-sustaining treatment. Such transfer shall assure that the patient's advance directive is implemented in accordance with their wishes within the hospital;

10. Means to provide each adult patient upon admission, or where the patient is unable to respond, family or other representative with a written statement of their rights under New Jersey law to make decisions concerning the right to refuse medical care and the right to formulate an advance directive. This statement of rights shall be issued by the Commissioner. Appropriate written information and materials on advance directives and the institution's written policies and procedures including the withdrawal or withholding of life-sustaining treatment shall be provided to each patient and others upon request. Such written information shall also be made available in any language which is spoken as the primary language by more than 10 percent of the population of the hospital's service area;

11. Procedures for referral of patients requesting assistance in executing an advance directive or additional information to either staff or community resource persons that can promptly advise and/or assist the patient during the inpatient stay;

12. Policies to ensure application of the hospital's procedures for advance directives to patients who are receiving emergency room care for an urgent life-threatening situation; and

13. Policies and procedures to ensure that appropriate hospital staff, including direct care providers, staff that are concerned with billing for hospital services or providing financial counseling to patients, and staff otherwise engaged in providing patient advocacy are made aware of the Independent Health Care Appeals Program established pursuant to N.J.S.A. 26:2S-11, and are able to provide information to patients and their family members, or other persons on the patient's behalf, about how to contact the Independent Health Care Appeals Program.

(b) A patient shall be transferred to another hospital only for a valid medical reason, in order to comply with other applicable laws or Department rules, to comply with clearly expressed and documented patient choice, or in conformance with the New Jersey Advance Directives for Health Care Act.

The hospital's inability to care for the patient shall be considered a valid medical reason. The sending hospital shall receive approval from a physician and the receiving hospital before transferring the patient. Documentation for the transfer shall be sent with the patient, with a copy or summary maintained by the transferring hospital. This documentation shall include, at least:

1. The informed consent of the patient or responsible individual, in accordance with State law;

2. The reason for the transfer;

3. The signature of the physician who ordered the transfer;

4. The condition of the patient upon transfer;

5. Patient information collected by the sending hospital, as specified in 8:43G-15.2(e);

6. The name of the contact person at the receiving hospital; and

7. A copy of the patient's advance directive where available or notice that the individual has informed the sending hospital of the existence of an advance directive.

(c) The hospital shall not deny admission to patients on the basis of their inability to pay.

(d) Patients shall be discharged only on physician's orders or after signing a waiver that exempts the hospital and the physician from liability as a result of the patient's leaving the hospital against medical advice. Patient refusal to sign such a waiver shall be documented.

(e) The hospital shall have a patient identification system that is used for all patients in the hospital from the time of admission until the time the patient is released from the hospital.

(f) Upon arrival at a service location, an inpatient's treatment shall be initiated within 30 minutes. Following completion of treatment, the patient shall be returned to his or her hospital room within a reasonable length of time not to exceed 30 minutes.

(g) The hospital shall develop and implement a complaint procedure for patients, families, and other visitors. The procedure shall include, at least, a system for receiving complaints, a specified response time, assurance that complaints are referred appropriately for review, development of resolutions, and follow-up action.

(h) The hospital shall develop and implement a grievance procedure for all staff. The procedure shall include, at least, a system for receiving grievances, a specified response time, assurance that grievances are referred appropriately for review, development of resolutions, and follow-up action.

(i) There shall be written policies and procedures for personnel that are viewed annually, revised as needed, and implemented. They shall include at least:

1. A written job description for each category of personnel in the hospital and distribution of a copy to each newly hired employee;

2. Personnel policies in compliance with Federal requirements for Equal Employment Opportunity;

3. A system to ensure that written, job-relevant criteria are used in making evaluation, hiring, and promotion decisions;

4. A system to ensure that employees meet ongoing requirements for credentials; and

5. Written criteria for personnel actions that require disciplinary action.

(j) The hospital shall comply with all requirements of the professional licensing boards for reporting terminations, suspensions, revocation, or reduction of privileges for any health professionals licensed in the State of New Jersey.

(k) Personnel records shall be confidential material, accessible only to authorized personnel who have clearly established their identity.

(l) The hospital shall ensure that there is no smoking in the facility by employees, visitors or patients.

N.J. Admin. Code § 8:43G-5.2

Amended by 49 N.J.R. 541(a), effective 3/20/2017