N.J. Admin. Code § 10:161B-3.6

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

Section 10:161B-3.6 - Policy and procedure manual

(a) The administrator shall develop, implement and ensure the review, at least annually, of a policy and procedure manual(s) about the organization and operation of the facility.

1. The administrator shall ensure that the governing authority shall participate in the review the policy and procedure manual at least annually.

2. This policy and procedure manual shall be signed and dated by the administrator and governing authority presiding officer, attesting that the policy and procedure manual was reviewed.

3. This policy and procedure manual shall be maintained on-site at the facility and available for review at all times by clients, staff, DHS and the public.

(b) The facility shall ensure that, at a minimum, the following is contained in the policy and procedure manual(s):

1. A written statement describing the program's vision and mission, staffing patterns and the services provided, including the modalities/types and ASAM level of care designation offered;

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

3. Policies regarding the program's definition of "business hours," "full-time" and "shift";

4. A description of the facility's quality assurance program, including, but not limited to, client care (including medical and nursing services) and its documentation; and staff performance and supervision, methods for at least annual review of staff performance, staff qualifications and credentials, staff orientation and education, and documentation of these staff functions-related functions;

5. Adherence to privacy and confidentiality policies and procedures ensuring the confidential maintenance of client records while the program is in operation and in the event that it ceases to operate, as required by Federal confidentiality regulations at 42 CFR Part II, and Federal HIPAA requirements at 45 CFR Part 160 ;

6. A description of the modalities of treatment provided, including a listing of services, procedures, and ASAM level of care designations which may be performed in the facility;

7. A written plan for informing persons in need of substance use disorder treatment services, their friends and family members, the public, and health care providers of the availability of the facility's services, all program fees and available financial arrangements, including a description of referral mechanisms and linkages with consultants, other health care facilities, law enforcement, social and community agencies that will provide continuity of care including designation of staff responsible for implementation of the plan;

8. Policies and procedures for making information about alcohol, tobacco and other drug use prevention and treatment available to the public;

9. Policies and procedures that ensure the accessibility of and use of telephone(s) by clients. Such policies and procedures shall:

i. Include written descriptions of situations that may preclude the use of telephones by clients;

ii. Comply with client care policies and procedures, and not violate client rights, nor be used as a tool to punish or coerce clients; and

iii. Not prevent clients from contacting the local police in the event of an emergency, or from contacting DHS to issue a complaint regarding the facility;

10. Policies and procedures for answering and responding to incoming telephone calls for clients at times other than designated business hours;

i. The program must use either an answering service, a designated on call staff, or an alternative method approved by DCN&L, to ensure that clients have access to emergency consultation services on a 24-hour-a-day basis, seven days a week.

11. Policies and procedures to provide for the assessment, diagnosis, identification and treatment of persons with co-occurring mental health disorders, or to coordinate the care and/or referral to appropriate mental health providers, so that services are provided in a coordinated fashion.

i. Clients who have been clinically assessed as being unable to participate in or benefit from the facility's services will be referred to the appropriate treatment provider, and the referral documented in the clinical record;

12. Policies addressing the confiscation and disposition of illicit drugs and weapons within the facility;

i. The policy shall include notification of appropriate parties for clients referred from the criminal justice system;

13. Policies and procedures for complying with applicable statutes and rules to report child abuse and/or neglect, abuse, or mistreatment of elderly clients and disabled adults, sexual abuse, sexual assault, specified communicable diseases, including HIV infection, poisonings, and unattended or suspicious deaths. Such policies and procedures shall include the following:

i. The designation of a staff member(s) responsible for coordinating the reporting of identified and/or suspected cases of child abuse and/or neglect in compliance with 9:6-1 et seq., recording the notification to the Division of Child Protection and Permanency (DCPP) and in the clinical record, and serving as a liaison between the facility and DCPP;

ii. If the client is 60 years of age or older, the protocols for notification of any suspected case of client abuse or exploitation to the New Jersey Office of the State Long-Term Care Ombudsman pursuant to N.J.S.A. 52:27G-7.1 et seq.;

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

iv. The provision, at least annually, of educational and/or training programs to staff on the identification and reporting of identified and/or suspected cases of child abuse and/or neglect, sexual assault or abuse, domestic violence, abuse of the elderly and/or disabled adults, and related agency policies and procedures; and

14. Policies and procedures governing the delivery of services that include, at a minimum, the following:

i. The frequency of counseling interventions and didactic sessions, including a weekly and monthly posted written schedule of all program activities; and

ii. The content of didactic sessions, including a written description or curriculum of didactic sessions offered in the facility.

N.J. Admin. Code § 10:161B-3.6

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

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