N.J. Admin. Code § 8:41-3.12

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

Section 8:41-3.12 - Standard operating procedures manual

(a) Each provider shall develop and maintain a written standard operating procedures (SOP) manual. The SOP manual shall reflect the methods of daily operation, and shall be consistent with the provisions of this chapter. A copy of the SOP manual shall be available at each location where a vehicle is garaged, shall be readily accessible to all crewmembers and shall be made available to Department staff upon demand.

(b) The SOP manual shall contain, but is not limited to, policies addressing the following:

1. Crewmember functions in the emergency department of an acute care hospital;

2. Narcotic control, storage and procurement;

3. Medication control (both vehicle and station);

4. Pronouncement of death;

5. Air medical service utilization;

6. Triage to regional trauma centers, including trauma triage policies;

7. Hospital diversions;

8. State HAZ-MAT Annex and local policies for responding to HAZ-MAT incidents;

9. Mass casualty incidents, which shall include a copy of the Emergency Operating Plan (EMS Annex);

10. Physician and nurse orientation to the base station curriculum;

11. A current copy of N.J.A.C. 8:41;

12. The quality assurance plan;

13. Vehicle sanitation and maintenance, including the provider's procedures for both DIOOS and PIOOS status;

14. The required reporting of certain events as set forth at 8:41-3.10;

15. Communicable disease guidelines;

16. Patient rights;

17. Abuse reporting, such as child, elder and domestic;

18. A nondiscrimination statement, outlining the provider's willingness to transport and treat patients regardless of a person's race, sex, creed, national origin, sexual preference, age, disability, medical condition (including, but not limited to, patients with AIDS/HIV,TB, Hepatitis B or other communicable diseases) or ability to pay;

19. Procedures for handling patients with physician issued "Do not resuscitate" orders and/or a living will; and

20. Employees' responsibilities including, but not limited to, cooperating with Department staff during inspections, the possibility of incurring monetary penalties in case of licensure violations, the importance of having all required credentials available for inspection by Department staff, approved scope of practice and the performance of duties in a professional manner.

(c) Each provider shall develop a policy to ensure that all patient information, including patient identifiable data, remains confidential and private. This policy shall be part of the SOP manual, and shall be provided to each of the provider's employees. Patient information shall only be disclosed or released:

1. If the patient, guardian, executor or other legally authorized person has requested in writing that the information be released to a specific person, entity or company;

2. In compliance with a subpoena, judicial order or applicable law, rule and/or regulation;

3. To process a claim for insurance, including Medicare or Medicaid;

4. To Department staff in the performance of their duties and/or while conducting inspection, audit and/or investigation; and

5. To effect the transfer of the patient to another health care professional receiving the patient.

N.J. Admin. Code § 8:41-3.12