N.J. Admin. Code § 10:44A-2.2

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:44A-2.2 - Development and maintenance of procedure manual

(a) The licensee shall develop and implement a manual of written procedures to ensure that the service delivery system complies with State law and rules governing community residences for individuals with developmental disabilities.

1. The procedures shall be reviewed annually and revised as necessary.

2. Each procedure shall be designed in accordance with the principles of normalization, age appropriateness, least restriction, person centered planning and shall be consistent with the organizational structure and management philosophy of the licensee.

3. While specific content for inclusion in a procedure shall be identified on an as-needed basis in these rules, to ensure consistency, each procedure shall include:

i. A descriptive title which is unique so as to permit easy reference and retrieval of each document;

ii. An explanation regarding the purpose of the document;

iii. A description of sequential steps required to successfully complete a task or action;

iv. Assignment of staff responsibilities at each step in the implementation; and

v. Reporting and recording requirements for each person involved.

(b) The licensee shall maintain a procedure manual containing the following documents and/or procedures:

1. A statement of philosophy, values and goals so as to govern the organization's direction and character;

2. A table of organization that illustrates lines of authority, responsibility and communication;

3. A procedure for assuring compliance with the Central Registry;

4. A New Employee Orientation Checklist, which shall include, at a minimum, all requirements at N.J.A.C. 10:44A-2.6(a)1 through 8;

5. A procedure for implementing a plan to deal with major emergencies requiring evacuation from the residence, such as a fire or a gas leak.

i. The procedure shall also address emergencies where evacuation may not be required, such as when the indoor air temperature is below 68 degrees Fahrenheit or above 82 degrees Fahrenheit for four consecutive hours;

6. A procedure for handling medical emergencies that includes the requirement to call 9-1-1 in the event of a life-threatening emergency, in accordance with N.J.S.A 30:6D-5.1 et seq. (Danielle's Law), and N.J.A.C. 10:42A;

7. Emergency coverage and on-call procedures;

8. A procedure for reporting all unusual incidents, including, but not limited to:

i. A written statement expressly prohibiting abuse, neglect, or exploitation; and

ii. A written statement regarding the obligation to report each allegation as required at N.J.S.A. 9:68.10 and 52:27G-1 et seq., and Department policy.

9. A procedure for investigations;

10. A procedure to ensure sound fiscal management of individual's personal funds;

11. A procedure for the safekeeping of valuable personal possessions;

12. A list and schedule of all charges and fees for which an individual shall be held responsible;

13. A procedure for resolving complaints and grievances of individuals that has a minimum of two levels at which the grievance shall be heard, the last of which involves the licensee or the executive director;

14. A procedure, separate from individuals' records, for internal communication, to include the use of a separate log to document critical information and the action taken by the licensee to follow-up:

i. Each log entry shall be dated and signed with the full name of the staff person making the entry;

15. A procedure for admissions that complies with the requirements at N.J.A.C. 10:44A-4;

16. A statement regarding maintaining confidentiality of individuals receiving services and records, as required at N.J.A.C. 10:41-2;

17. Written procedures for medication administration, including procedures for self-medication;

18. Written procedures for assuring compliance with the requirements for testing employees for controlled dangerous substances, in accordance with N.J.S.A. 30:6D-9.5;

19. Written procedures for the exchange of contact information of parents, family members who are actively involved in ensuring the individual's welfare, or guardians who choose to, as set forth at N.J.S.A. 30:6D-9.5 and 9.6;

20. A procedure for assuring that no employee is included on the Department of Children and Families' Child Abuse Registry, as set forth at N.J.S.A. 30:6D-73 et seq., and 9:6-8.10f;

21. A procedure to address the use of video/audio monitoring in the common areas of the residences, if applicable; and

22. A continuous quality improvement system to identify opportunities to improve services and/or supports and to resolve identified problems. The system shall include, at a minimum:

i. A written plan to identify how data is collected, analyzed, and utilized to determine patterns that identify process or systemic problems requiring further in-depth review;

ii. Input from a variety of sources, including persons receiving services, family members, and others;

iii. A written summary of satisfaction surveys;

iv. A written summary of outcomes assessments; and

v. An action plan based upon an analysis at (b)22i through iv above.

N.J. Admin. Code § 10:44A-2.2

Amended by 55 N.J.R. 171(a), effective 2/6/2023