N.J. Admin. Code § 10:161B-1.7

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

Section 10:161B-1.7 - Qualifications and responsibilities of the administrator of the facility

(a) The facility shall hire an administrator who has, at a minimum, a Master's degree and two years of full-time, or full-time equivalent, administrative or supervisory experience in a substance use disorder treatment facility.

(b) Individuals who do not meet the qualifications in (a) above, shall have a Bachelor's degree and five years of full-time, or full-time equivalent, administrative or supervisory experience in a substance use disorder treatment facility.

(c) The administrator's responsibilities shall include, but need not be limited to, the following:

1. Providing administrative oversight of the facility;

2. Ensuring the development, implementation, and enforcement of all policies and procedures as required under this chapter, including client rights;

3. Planning and administration of all operational functions including managerial, personnel, fiscal, and reporting requirements of the program;

4. Developing an organizational plan, ensuring that programs and services are consistent with the organization's mission, and monitoring their effectiveness;

5. Establishing and implementing a formal quality assurance program that:

i. Is comprehensive and integrated with the facility's programmatic quality assurance plans and programs;

ii. Addresses all levels of treatment programming and client care;

iii. Ensures that all personnel are assigned duties based upon their education, training, competencies and job description; and

iv. Uses written, job-relevant criteria to make evaluation, hiring and promotional decisions;

6. Selection and hiring responsibility for all staff as well as participating in the determination of staffing issues including, but not limited to establishing: hiring policies to ensure references, credentials and criminal history background checks of all prospective staff have been reviewed and verified; written policy regarding employment of family members, past and present governing body members and volunteers; and written policy regarding hiring of staff with past criminal convictions and/or ethical violations which ensures that convictions/violations do not impact staff ability to perform duties and that staff are of good moral character, assessment of staff performance, and employment and termination decisions;

i. The candidate/staff member shall be notified by the administrator that he or she must disclose to the administrator any disciplinary outcome imposed as a result of an investigation by any State licensing agency, law enforcement agency, or professional disciplinary review board, such as disciplinary probation, suspension of license, revocation of license, or criminal conviction at the time of initial employment, and/or during employment if the action occurs after hire;

7. Ensuring the provision of timely staff orientation, education and supervision;

8. Establishing and maintaining liaison relationships and communication with facility staff, service providers, support service providers, community resources, and clients;

9. Overseeing the development and implementation of policies and procedures, in conjunction with designated staff members, for the various services provided for in this chapter;

i. Ensuring that appropriate policies and procedures are shared with the governing authority;

10. Ensuring that admission interviews with clients and in the case of juveniles, the client's family, guardian or legally authorized representative, be conducted in accordance with established policies and procedures;

11. Implementing and monitoring the quality of all services provided at the facility, including the review of program outcomes available through NJSAMS;

i. When appropriate share program outcome data with relevant staff, DMHAS, and where necessary with the governing authority;

12. Ensuring maintenance of the physical plant as necessary to ensure client and staff safety, and otherwise keeping the facility in compliance with all applicable building, fire and safety codes;

13. Establishing policies and procedures for provision of emergency services to clients, and policies and procedures for other broader-based emergency situations resulting from either internal or external incidents or natural disasters;

i. Such policies shall include guidelines for the immediate notification to DHS of such situations, a contingency plan with a minimum of explanation of timeframes for closure and reopening of facility and or service interruption to clients, and procedures governing the dispensing and, where clinically necessary, monitoring of client treatment medications;

14. Establishing written policies and procedures for non-emergency closures (for example, holidays);

i. Such policies shall include the timely notification to DHS of such closures, the timeframes for closures and re-opening, and procedures governing the dispensing and, where clinically necessary, monitoring of medications administered to clients;

ii. Facilities shall request approval from DOH, in writing, at least 48 hours before closing for non-emergency reasons;

iii. Facilities shall not close for non-emergency reasons without written approval from DOH to do so;

15. Identifying priority populations (for example, pregnant, IV drug users, women with children, HIV, etc.) for admission and treatment as evidenced by protocol, policies and procedures to provide such treatment services, or where appropriate, referral procedures with interim services available until transfer is completed;

16. Ensuring that DHS plans of correction, licensing deficiencies and complaint reports are addressed as outlined by DHS;

i. Where necessary, ensure that such reports are shared with the governing authority in a timely manner;

17. Developing and implementing an infection prevention and control program; and

18. Developing, implementing and providing administrative oversight of a volunteer services program, if the facility along with the governing authority elects to utilize such a program.

N.J. Admin. Code § 10:161B-1.7

Amended by 48 N.J.R. 2791(a), effective 12/19/2016

Amended by 55 N.J.R. 2346(a), effective 11/20/2023