N.J. Admin. Code § 8:43G-12.22

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

Section 8:43G-12.22 - Trauma services compliance

(a) After designation, Level I and Level II trauma centers shall demonstrate continuing compliance with the applicable requirements of this subchapter according to the following process:

1. Trauma centers shall maintain current verification at Level I or Level II in accordance with the verification review program conducted by the American College of Surgeons (ACS), 633 N. Saint Clair Street, Chicago, IL 60611-3211, Phone (800) 621-4111; (312) 202-5000. Fax: (312) 202-5001. Website: http://www.facs.org. E-mail: postmaster@facs.org.

2. Trauma centers shall undergo ACS reverification reviews, at the hospital's expense, prior to expiration of current verification. The trauma center shall arrange for staff of the OEMS within the Department to be present at such reviews;

3. The trauma center shall submit a copy of the written report of the ACS Verification Review Committee site visit to OEMS, and shall certify that it has corrected "criteria" deficiencies and addressed "non-criteria" recommendations contained in the ACS report within six months of receiving the report. However, individual patient chart reviews shall be considered confidential information, are not required to be submitted, and shall not be disclosed to the public;

4. The Department may use information from ACS verification reviews in the conjunction with other survey methods to determine whether licensure deficiencies have occurred, in accordance with the provisions of N.J.A.C. 8:43E; and

5. The Department may terminate the Level I or Level II designation of a trauma center for failure to maintain ACS verification or other licensure deficiencies if a continuing pattern of substandard care is demonstrated which adversely affects patient outcomes and which has not been corrected within six months. Proposed termination shall follow the process for enforcement remedies and hearings set forth in N.J.A.C. 8:43E.

N.J. Admin. Code § 8:43G-12.22

Amended by 50 N.J.R. 552(b), effective 1/16/2018