N.J. Admin. Code § 8:43G-2.11

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:43G-2.11 - Hospital satellite facilities and off-site ambulatory care service facilities

(a) A satellite hospital facility may be operated under the effective supervision of an existing hospital.

(b) Individual licenses shall not be required for separate hospital buildings and services located on the same or adjoining grounds, if these are operated under one management.

(c) All off-site ambulatory care service facilities, including mobile units, must be licensed to operate by the Department. A hospital may seek licensure and classification of off-site ambulatory care service facilities as either "free-standing" or "hospital-based" facilities. Both "free-standing" and "hospital-based" off-site ambulatory care service facilities shall be separately inspected and separately licensed in accordance with the provisions set forth at N.J.A.C. 8:43A, Standards for Licensure of Ambulatory Care Facilities. All off-site ambulatory care service facilities ar

1. The hospital-based off-site ambulatory care service facility is integrated with and subordinate and accountable to the hospital. Services provided at the off-site location are clinically integrated with other departments of the hospital and staff members are employees of the hospital. Where applicable, credentialing of hospital-based ambulatory care service facility staff is performed by the hospital credentialing committee. Where applicable, the hospital-based ambulatory care service facility is required to comply with the provisions set forth at 8:43G-4.1, Patient rights.

2. The hospital-based ambulatory care service facility administrator is subordinate to and reports to an identified administrator at the hospital. The hospital Chief Medical Officer (or similar official) is also responsible for the medical direction of the hospital-based ambulatory care service facility.

3. If the hospital is accredited, the hospital-based ambulatory care service facility is included in the accreditation and the accrediting body recognizes the hospital-based ambulatory care service facility as part of the hospital.

4. The hospital-based off-site ambulatory care service facility is operated under common ownership and control and by the same governing body as the hospital. The factors considered in evaluating this criterion are one or more of the following:

i. The hospital-based ambulatory care service facility and the hospital are subject to common by-laws and operating decisions of the governing body;

ii. Final responsibility for administrative decisions, personnel actions and approval of hospital-based ambulatory care service facility medical staff appointments rests with the hospital;

iii. The hospital-based ambulatory care service facility functions as a department of the hospital; and/or

iv. The hospital has written policies, procedures and protocol applicable to the hospital-based ambulatory care service facility, assuring that the requirements of this section are followed.

5. The director of the hospital-based ambulatory care service facility must function under the day-to-day supervision of the hospital. The factors considered in evaluating this criterion are one or more of the following:

i. The hospital-based ambulatory care service facility director (or the individual responsible for the day-to-day operation of the hospital-based ambulatory care service facility) reports daily and is accountable to the chief executive officer of the hospital and also reports to the hospital governing body through the chief executive officer;

ii. Medical records, billing, laundry, housekeeping, purchasing and all other administrative functions of the hospital-based ambulatory care service facility are integrated with those of the hospital; and/or

iii. The hospital has written policies, procedures and protocol applicable to the hospital-based ambulatory care service facility, assuring that the requirements of this section are followed.

6. All hospital-based ambulatory care service facility clinical services are integrated with those of the hospital. The factors considered in evaluating this criterion are one or more of the following:

i. Hospital-based ambulatory care service facility professional staff have clinical privileges in the hospital;

ii. Where applicable, the hospital-based ambulatory care service facility medical director reports to the chief medical officer (or similar official) of the hospital on a daily basis;

iii. All hospital medical staff and other professional committees are responsible for all medical activities at the hospital-based ambulatory care service facility;

iv. Medical records for patients treated in the hospital-based ambulatory care service facility are integrated into the unified records system of the hospital;

v. Patients treated at the hospital-based ambulatory care service facility are considered patients of the hospital and have full access to all hospital services;

vi. Patient services provided at the hospital-based ambulatory care service facility are integrated with corresponding hospital inpatient and/or outpatient services, as appropriate; and/or

vii. The hospital has written policies, procedures and protocol applicable to the hospital-based ambulatory care service facility, assuring that the requirements of this section are followed.

7. The hospital-based ambulatory care service facility is held out to the public as part of the hospital such that patients know they are entering the hospital and will be billed accordingly.

8. The hospital and the hospital-based ambulatory care service facility are financially integrated. The factors considered in evaluating this criterion are one or more of the following:

i. The hospital and the hospital-based ambulatory care service facility have a written agreement for the sharing of income and expenses; and/or

ii. The hospital-based ambulatory care service facility reports its costs, including total revenues and total expenses, as part of the hospital's audited financial statements and uses the same accounting system for the same cost reporting period as the hospital.

9. The hospital-based ambulatory care service facility accepts and provides care to patients in accordance with the provisions as set forth in 8:43G-5.2(c) and, accordingly, shall not deny admission to patients on the basis of their inability to pay.

N.J. Admin. Code § 8:43G-2.11

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