N.J. Admin. Code § 8:111-1.7

Current through Register Vol. 56, No. 12, June 17, 2024

Section 8:111-1.7 - Qualifications and responsibilities of the administrator of the facility

(a) Each facility shall hire an administrator who has, at a minimum, a Master's degree and two years of full-time, or full-time equivalent, administrative or supervisory experience in a licensed substance use disorders treatment facility.

(b) Individuals who do not meet the qualifications in (a) above must have a Bachelor's degree and five years of full-time, or full-time equivalent, administrative or supervisory experience in a licensed substance use disorders treatment facility.

(c) The administrator's responsibilities shall include, but need not be limited to, the following:

1. Providing administrative oversight of the facility;

2. Ensuring the development, implementation and enforcement of all policies and procedures as required under this chapter, including client rights;

3. Planning and administration of all operational functions including managerial, personnel, fiscal and reporting requirements of the facility;

4. Developing an organizational plan and ensuring that facilities and services are consistent with the organization's mission, while monitoring their effectiveness;

5. Establishing and implementing a formal quality assurance program that is comprehensive and integrated with the facility's programmatic quality assurance plans and programs; address all levels of treatment programming and client care; ensure that all personnel are assigned duties based upon their education, training, competencies and job description; while utilizing written, job-relevant criteria to make evaluation, hiring and promotional decisions;

6. Selecting and hiring responsibility for all staff, as well as participating in the determination of staffing issues including, but not limited to, establishing and maintaining policies ensuring references, credentials and criminal history background checks of all prospective staff and making certain that they have been reviewed and verified; developing written policies regarding the employment of family members, past and present governing body members and volunteers; developing written policies regarding hiring staff with past criminal convictions and/or ethical violations that ensure that the convictions/violations do not impact staff ability to perform duties; and developing policies for assessing staff performance, determining employment and termination decisions;

i. The administrator shall advise candidates and staff members that candidates and staff members must disclose to the administrator any disciplinary outcome imposed as a result of an investigation by any State licensing agency, law enforcement agency or professional disciplinary review board, such as disciplinary probation, suspension of license, revocation of license or criminal conviction at the time of initial employment and/or during employment if the action occurs after hire.

7. Ensuring the provision of timely staff orientation, education and supervision;

8. Establishing and maintaining liaison relationships and communication with facility staff, service providers, support service providers, community resources and clients;

9. Overseeing the development and implementation of policies and procedures, in conjunction with designated staff members, for the various services provided for in this chapter.

i. Ensuring that appropriate policies and procedures developed and implemented under this paragraph are shared with the governing authority;

10. Ensuring that admission interviews with clients are conducted in accordance with the facility's policies and procedures.

i. Admissions interviews with adolescent clients shall include the client's family, guardian or legally authorized representative;

11. Implementing and monitoring the quality of all services provided at the facility, including the review of program outcomes available through NJSAMS;

i. When appropriate, share facility outcome data with relevant staff, DMHAS, the Department and, when necessary, the governing authority;

12. Ensuring maintenance of the physical plant as necessary to ensure client and staff safety, and otherwise keeping the facility in compliance with all applicable building, fire and safety codes;

13. Establishing policies and procedures for provision of emergency services to clients, including policies and procedures for broader-based emergency situations resulting from either internal incidents, external incidents, or natural disasters.

i. Such policies shall include guidelines for the immediate notification to the Department of such situations, a contingency plan with a minimum of explanation of timeframes for service interruption to clients, closure and reopening of a facility and procedures governing the dispensing and, when necessary, monitoring of client treatment medications;

14. Establishing written policies and procedures for non-emergency closures.

i. Policies established under this paragraph shall include the timely notification to the Department of such closures, the timeframes for service interruption, closures and reopening, and procedures governing the dispensing and, where clinically necessary, monitoring of medications administered to clients.

ii. Facilities shall submit a written request to the Department at least 48 hours before closing for non-emergency reasons.

iii. Facilities shall not close for non-emergency reasons without receiving written approval from the Department to do so;

15. Identifying priority populations (for example, pregnant, intravenous drug users, women with children, HIV, etc.) for admission and treatment as evidenced by protocols, policies, and procedures to provide such treatment services, or where appropriate, referral procedures with interim services available until transfer is completed;

16. Ensuring that plans of correction, licensing deficiencies, and complaint reports are addressed as specified by the Department.

i. Ensure that such reports are shared with the governing authority in a timely manner;

17. Developing and implementing an infection prevention and control program;

18. Developing and implementing client safety policies and procedures that include, but are not limited to, forbidding staff to engage in client coercion, sexual harassment and sexual relationships with clients; and

19. Developing, implementing and providing administrative oversight of a volunteer services program, if the facility along with the governing authority elects to utilize such a program.

N.J. Admin. Code § 8:111-1.7

Amended and recodified from 10:161A-1.7 53 N.J.R. 2208(a), effective 12/20/2021