N.J. Admin. Code § 10:31-2.6

Current through Register Vol. 56, No. 17, September 3, 2024

Section 10:31-2.6 - Written policies and procedures

(a) Written policies and procedures shall be developed to ensure that the screening service/affiliated emergency service system complies with Federal and State law (30:4-27.1 et seq.) and rules and regulations governing these services for persons with mental illness.

(b) Each policy and/or procedure shall be designed to ensure accessibility to services and to ensure that consumers receive treatment in the least restrictive, clinically appropriate setting, as close to their own community as possible, with the achievement of wellness and recovery as its goal. Service provision shall balance the value of liberty with the need for safety or treatment.

1. The policy and procedures manual shall be reviewed and revised annually, and updated as necessary. The review and revision process shall be documented.

2. Provider policy and procedures shall require attempts to obtain informed patient consent to receive treatment, except where involuntary treatment is legally authorized and consistent with State law.

3. The policy and procedure manual shall include policies and procedures setting forth confidentiality standards and procedures that are to be followed in all aspects of the screening services or AES's provision of services to consumers that are consistent with all applicable Federal and State law, including, but not limited to, the Privacy Rule implementing the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160 and 164, N.J.S.A. 30:4-24.3, and N.J.A.C. 10:37-6.79.

4. The policies shall require, to the extent permitted under applicable confidentiality laws, contact with the consumer's family, spouse, civil union partner, or significant other and current or previous service providers to determine what the clinical needs of the consumer and what services would best meet those needs in the best interest of the consumer. Agency policy shall require that the extent of these efforts be documented in the consumer's record.

5. The screening service shall develop written protocols that describe the role of the screening service staff with police at the scene of an outreach.

6. The screening service shall have written policies and procedures for providing outreach services.

7. Written policies and procedures regarding the provision of extended crisis evaluation services shall include, but not be limited to, the following: admission criteria, intensive observation and continuous monitoring of consumers, use of physical restraints, administration and monitoring of medication, and documentation of all treatment interventions provided to consumers while in extended crisis evaluation beds.

i. Policies and procedures for the use of physical restraints and the administration and monitoring of medication shall be consistent with Division and Department of Health requirements, and any other applicable Federal and State laws.

ii. Screening services shall submit aggregate data on restraint use to the Division on a quarterly basis.

8. The screening service shall develop and maintain written protocol and procedures for use of various medication techniques, including emergency stabilization regimes.

9. Interventions on behalf of the consumer shall be documented in a clinical record.

10. The screening service shall develop and maintain policies and procedures that address clinical supervision of screeners possessing temporary certification in the completion of their assessment process.

11. All duties to be performed by psychiatrists shall be described in the screening service's policies and procedures.

12. Records of the certification of screeners and completion or fulfillment of recertification requirements shall be maintained in the screening service.

N.J. Admin. Code § 10:31-2.6

Amended by 50 N.J.R. 537(a), effective 1/16/2018