N.J. Admin. Code § 10:37B-11.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:37B-11.2 - Content of the policies and procedures manual

(a) The PA's policies and procedures shall set forth the required parameters and processes in sufficient detail to guide staff in the performance of their duties and to give clear notice to consumers, families, and other interested parties as to the services provided, consumers' rights, and consumers' responsibilities expected in the program.

(b) Participation criteria. The manual shall have a section dedicated to inclusionary and exclusionary criteria to be used by the PA in determining whether a particular consumer could benefit from community support services. The participation criteria shall:

1. Comply with the standards set forth in N.J.A.C. N.J.A.C. 10:37B-2.1 and requirements in affiliation agreements or contracts with the Division; and

2. Specify intake procedures that are consistent with N.J.A.C. 10:37B-2.

(c) Medication. The manual shall a have a section that delineates medication procedures consistent with N.J.A.C. N.J.A.C. 10:37B-4.3 and that:

1. Requires medication education to consumers and staff annually;

2. Contains procedures for facilitating proper medication administration and self-administration techniques, and responding to medication errors;

3. Requires that unless a consumer self-administers his or her own medication without staff assistance, staff shall document the type, dose, date, and time a specific medication is administered or self-administered; the name and title of the person administering or assisting in self-administering the medication; any medication that was refused by the consumer; and any medication errors; and

4. Provides procedures to avoid interruptions in a consumer's medication regimen and to note any deviation from regular medication in the consumer's record.

(d) Confidentiality. The manual shall have a section setting forth confidentiality standards and procedures that are to be followed in all aspects of the PA's provision of community support services and 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. N.J.S.A. 30:4-24.3 and N.J.A.C. 10:37-6.79.

1. The confidentiality standards and procedures shall encourage family participation in developing the assessments, rehabilitation plan, and revisions to the extent disclosures to family members are permitted under the applicable Federal and State confidentiality laws.

(e) Consumer rights. The manual shall have a section delineating consumer rights consistent with N.J.A.C. 10:37-4.5; that requires that consumers be given notice of their right to appeal any decision of the PA in accordance with N.J.A.C. 10:37-4.6, Client complaint/agency ombuds procedure; and that creates procedures to implement additional consumer rights regarding termination of service agreement requirements of N.J.A.C. N.J.A.C. 10:37B-3.2(c).

(f) Staff training and responsibilities. The manual shall have a section delineating staff training requirements and responsibilities, consistent with N.J.A.C. N.J.A.C. 10:37B-5.3, 10:37D, and 10:77A-2.4.

(g) Safety. The manual shall set forth rules and procedures that will promote and assure the safety of consumers, staff, visitors, and the general public, including, but not limited to:

1. Measures that will respond appropriately to violence and expressions of suicidal thoughts or threats of any kind;

2. Providing, as needed, emergency response services in accordance with N.J.A.C. 10:37B-4.4(b)25; and

3. Appropriate responses to the presence or possession of contraband as determined by the policy of the PA or weapons.

(h) Health care. The manual shall set forth procedures for monitoring a consumer's health care and for accessing needed healthcare services.

(i) Principles. The manual shall state that staff shall provide services consistent with the principles of wellness and recovery and of community support services.

(j) Advance directives. The manual shall include a section on advance directives for mental health care.

(k) End-of-life concerns. The manual shall specify procedures to respond to a consumer's end-of-life concerns.

(l) The PA shall maintain policies and procedures for providing ongoing on-call clinical support to direct care staff and conducting routine case conferences.

N.J. Admin. Code § 10:37B-11.2

Adopted by 48 N.J.R. 1636(a), effective 8/15/2016

Amended by 55 N.J.R. 1737(a), effective 8/7/2023