N.J. Admin. Code § 8:111-3.6

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

Section 8:111-3.6 - Policy and procedure manual

(a) The administrator shall develop, implement, and ensure the review, at least annually, of a policy and procedure manual(s) about the organization and operation of the facility.

1. The administrator shall ensure that the governing authority shall participate in the review of the facility's policy and procedure manual at least annually.

2. The policy and procedure manual shall be signed and dated by the administrator and governing authority presiding officer, attesting that the policy and procedure manual was reviewed.

3. The policy and procedure manual shall be maintained on-site at the facility and available for review at all times by clients, staff, the Department, and the public.

(b) The facility shall ensure that, at a minimum, the following is contained in the policy and procedure manual(s):

1. A written statement describing the facility's vision and mission, staffing patterns and the services provided by the facility;

2. An organizational chart delineating the lines of authority, responsibility and accountability for the administration and client care services;

3. Policies regarding the facility's definition of "business hours," "full-time" and "shift";

4. A description of the facility's quality assurance program, including, but not limited to, client care (including medical and nursing services) and its documentation; staff performance and supervision, at least annual review of staff performance, staff qualifications and credentials, staff orientation and education and documentation of these staff-related functions;

5. Adherence to privacy and confidentiality policies and procedures ensuring the confidential maintenance of client records while the facility is in operation and in the event that it ceases to operate, as required by Federal confidentiality regulations at 42 CFR Part 2 and Federal HIPAA requirements at 45 CFR Part 160 ;

6. A description of the modalities of treatment provided, including a listing of services and procedures, which must be performed and ASAM (ASAM PPC 2R) designations that may be offered in the facility;

7. A written plan for informing persons in need of substance use disorders treatment services, their friends and family members, the public and health care providers of the availability of the facility's services, all facility fees and available financial arrangements, including a description of referral mechanisms and linkages with consultants, other health care facilities, law enforcement, social and community agencies that will provide continuity of care, including designation of staff responsible for implementation of the plan;

8. Policies and procedures for making information about alcohol, tobacco and other drug use prevention and treatment available to the public;

9. Policies and procedures that ensure the accessibility of and use of telephone(s) by clients.

i. Such policies and procedures shall include written descriptions of situations that may preclude the use of telephones by clients.

ii. Such policies and procedures shall comply with the facility's client care policies and procedures and shall not violate client rights, nor be used as a tool to punish or coerce clients.

iii. Such policies and procedures shall not prevent clients from contacting the local police in the event of an emergency or from contacting the Department to issue a complaint regarding the facility;

10. Policies and procedures for answering and responding to incoming telephone calls for clients at times other than the facility's designated business hours.

i. The facility must use an answering service, assign a designated on-call staff, or provide an alternative method approved by the Division, to ensure that clients have access to emergency incoming telephone calls on a 24-hour-a-day basis, seven days a week.

11. Policies and procedures addressing the use of sanctions in the facility.

i. The following practices are expressly forbidden in facilities serving adolescents:

(1) Corporal punishment;

(2) Use of restraints of any sort;

(3) Use of a behavior management room, unless such a room is permitted and regulated under the auspices of the Department of Children and Families (DCF) or the Division; and

(4) Sanctions that include verbal, mental or physical abuse;

12. Policies and procedures to provide for the assessment, diagnosis, identification and treatment of persons with co-occurring substance abuse mental health disorders; or to coordinate the care and/or referral to appropriate mental health providers, so that services are provided in a integrated fashion.

i. Clients who have been clinically assessed as being unable to participate in, or benefit from, the facility's services will be referred to an appropriate treatment provider, and the referral documented in the clinical record;

13. Policies addressing the confiscation and disposition of illicit substances, alcohol, weapons and other prohibited items or materials within the facility.

i. Procedures governing client search and seizure that ensures protection of staff and clients, do not violate client rights and preserve the dignity of clients.

ii. The policy shall include notification of appropriate parties for clients referred from the criminal justice system;

14. Policies and procedures for complying with applicable statutes and rules to report child abuse and/or neglect, abuse, or mistreatment of elderly clients and disabled adults, sexual abuse, sexual assault, specified communicable diseases, including HIV infection, poisonings, and unattended or suspicious deaths. Such policies and procedures shall include the following:

i. The designation of a staff member(s) responsible for coordinating the reporting of identified and/or suspected cases of child abuse and/or neglect in compliance with N.J.S.A. 9:6-8.11 et seq., documenting the notification to DCF in the clinical record and serving as a liaison between the facility and DCF;

ii. If the client is 60 years of age or older, the protocols for notification of any suspected case of client abuse or exploitation to the Office of the Ombudsman for the Institutionalized Elderly, which is in, but not of, the Department of the Treasury, 1-877-582-6995, pursuant to 52:27G-7.1 et seq.;

iii. The protocols for the identification and treatment of children and elderly and disabled adults who are abused and/or neglected; and

iv. The provision, at least annually, of educational and/or training facilities to staff on the identification and reporting of identified and/or suspected cases of child abuse and/or neglect, sexual assault or abuse, domestic violence, abuse of the elderly and/or disabled adults and related agency policies and procedures;

15. Policies and procedures governing the delivery of services that include, at a minimum, the following:

i. The frequency of counseling interventions and didactic sessions, including a weekly and monthly posted written schedule of all program activities; and

ii. The content of didactic sessions, including a written description or curriculum of didactic sessions offered in the facility; and

16. Policies and procedures pertaining to P.L 100-336, the Americans with Disabilities Act (ADA) that include at a minimum:

i. Assessing and referring clients with disabilities; and

ii. Staff training for ADA compliance.

N.J. Admin. Code § 8:111-3.6

Amended and recodified from 10:161A-3.6 53 N.J.R. 2208(a), effective 12/20/2021