N.J. Admin. Code § 8:43E-10.5

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:43E-10.5 - Patient or resident safety plan

(a) Each facility shall develop, implement, and comply with a patient or resident safety plan that includes the following elements:

1. A process for facility staff to follow in reporting preventable adverse events and near-misses to the patient or resident safety committee.

i. The reporting system established by the facility shall be accessible to facility staff at all times the facility is operating;

2. A process for conducting ongoing review and application of evidence-based patient or resident safety practices in order to reduce the probability of preventable adverse events;

3. Except for Medicare and/or Medicaid nursing homes, policies and procedures for the patient or resident safety committee to conduct root cause analyses of all serious preventable adverse events and annually at least one other preventable adverse event not subject to mandatory reporting, or a near-miss reported to the Committee.

i. In selecting a case for root cause analysis of a near-miss or a preventable adverse event not subject to mandatory reporting, the patient or resident safety committee shall consider the seriousness of the resulting potential disability, observed trends or patterns, and the likelihood that a particular event would be repeated;

4. A process for monitoring the impact of changes recommended by the patient or resident safety committee and implemented by the facility; and

5. Policies and procedures for providing on-going training for facility personnel, including professional and direct patient or resident care employees and medical staff, as to the requirements of this subchapter and the facility's policies and procedures for assuring patient or resident safety.

i. Current employees and staff shall undergo such training no later than one year following the operative date of this subchapter applicable to the particular type of facility as set forth at N.J.A.C. 8:43E-10.2(a).

ii. New employees and staff shall undergo such training during the employee orientation.

iii. The policies and procedures shall include a method for the facility to document that personnel have completed the required training.

(b) The processes, policies, and procedures established pursuant to (a) above shall not eliminate or lessen a facility's obligation under applicable State licensure standards at Title 8 of the New Jersey Administrative Code or Federal Medicare Conditions of Participation to implement and maintain a continuous quality improvement program.

1. Investigation and analysis, as well as the recommendation and monitoring of the implementation of related corrective actions, of preventable adverse events and near-misses shall fall within the jurisdiction of the patient or resident safety program rather than the continuous quality improvement program.

N.J. Admin. Code § 8:43E-10.5