N.J. Admin. Code § 8:42C-3.5

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

Section 8:42C-3.5 - Policy and procedure manual

(a) The hospice shall establish, implement, and review at least annually, a policy and procedure manual(s) for the organization and operation of the hospice.

1. Each review of the manual(s) shall be documented, and the manual(s) shall be available in the hospice at all times.

2. The manual(s) shall include at least the following:

i. A written narrative of the hospice describing its philosophy and objectives, and the services provided by the facility;

ii. An organizational chart delineating the lines of authority, responsibility, and accountability, so as to ensure continuity of care to patients;

iii. A description of the quality assurance program for patient care and staff performance;

iv. Definition and specification of full-time employment; and

v. Policies and procedures for complying with applicable statutes and protocols to report child abuse and/or neglect, sexual abuse and abuse of elderly or disabled adults, specified communicable disease, rabies, poisonings and unattended or suspicious deaths including, but not limited to, the following:

(1) The development of written protocols for the identification and treatment of children and elderly or disabled adults who are abused and/or neglected;

(2) The designation of a staff member(s) to be responsible for coordinating the reporting of child abuse and/or neglect in compliance with N.J.S.A. 9:6-1 et seq., memorializing the issuance of such a report to the Division of Child Protection and Permanency of the Department of Children and Families in the medical/health record, and serving as a liaison between the facility and the Division of Child Protection and Permanency; and

(3) The provision at least annually of education and/or training programs for all staff and subcontracted personnel who provide direct patient care regarding the identification and reporting of child abuse and/or neglect; sexual abuse; domestic violence; and abuse of the elderly or disabled adult.

(b) The hospice shall make the policy and procedure manual(s) available and accessible to all patients, staff, and the public.

N.J. Admin. Code § 8:42C-3.5

Amended by R.2010 d.106, effective 6/21/2010.
See: 42 N.J.R. 25(a), 42 N.J.R. 1192(b).
Recodified the former last two sentences of (a) as (a)1 and (a)2; recodified former (a)1 through (a)5 as (a)2i through (a)2v; in (a)2v, deleted a comma following "sexual abuse" and "poisonings", substituted "including," for ". These policies and procedures shall include,", and deleted "be" following "not"; recodified former (a)5i through (a)5iii as (a)2v(1) through (a)2v(3); and in (a)2v(2), substituted "Children and Families" for "Human Services".
Amended by R.2021 d.040, effective 5/3/2021.
See: 51 N.J.R. 1312(a), 53 N.J.R. 700(b).
In the introductory paragraph of (a), inserted a comma following "implement"; and rewrote (a)2v(2).