N.J. Admin. Code § 8:43G-36.6

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

Section 8:43G-36.6 - Administrative and structural organization

(a) A satellite emergency department may be licensed as a free-standing ambulatory care facility owned and operated by a hospital or as part of the hospital. If licensed as an ambulatory care facility, it must comply with the general ambulatory care facility requirements set forth in N.J.A.C. 8:43A as well as this subchapter. If the satellite emergency department is licensed as part of the hospital, it shall comply with the requirements set forth in 8:43G-2.5 and the criteria set forth in 8:43G-2.11, as well as this subchapter.

(b) An administrator of the satellite emergency department shall be designated in writing.

(c) The satellite emergency department shall have policies and procedures which pertain to:

1. All staff;

2. Admission and discharge of patients;

3. Procedures for obtaining patient's written consent for all medical treatment;

4. Patient advance directives;

5. Elder abuse;

6. Domestic violence;

7. The ability of family members and significant others to remain with patients during treatment;

8. Referrals to primary care physicians and specialists, to assure access to all appropriate clinical services and specialties even though immediate consultation is not necessary;

9. Transfer protocol;

i. Written transfer agreements must be in place assuring timely response to accomplish basic and advanced level transfers from a satellite emergency department to an acute care facility;

ii. Transfers requiring basic life support services shall be accomplished by a licensed ambulance in accordance with N.J.A.C. 8:40;

iii. Transfers requiring advanced life support care shall be accomplished with a critical care transport team including a registered nurse and a licensed ambulance in accordance with N.J.A.C. 8:40-6.22; and

iv. Transfers may be by other means as deemed appropriate by the physician;

10. Pharmacy services, including controlled substances;

11. Procedural sedation;

12. Infection control;

13. Dietary;

14. Linens;

15. Housekeeping;

16. Lab services;

17. Payment source;

18. Policies and procedures for handling an unexpected influx of patients; and

19. Policies and procedures for maintaining a record of hospital employees, medical staff members, and volunteers who can speak languages other than English or know sign language for the hearing impaired and can provide interpretive services to patients. This record shall include the work shifts of hospital employees.

(d) The satellite emergency department shall maintain a copy of all policies and procedures which apply to the facility onsite.

N.J. Admin. Code § 8:43G-36.6