N.J. Admin. Code § 8:111-6.2

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

Section 8:111-6.2 - Client continuity of care and client safety

(a) Client care policies shall facilitate continuity of care and client safety, and shall include, but need not be limited to, the following:

1. Admissions and exclusionary criteria that include identification of the conditions or diagnoses eligible and ineligible for admission;

2. Orientation process for new clients;

3. Services offered including, but not limited to, screening, assessment, diagnosis, counseling, education, and case management;

4. Client rights, that include the acknowledgement that the client is made aware of, and has approved, receiving counseling services from a substance abuse counselor-intern;

5. Staffing patterns;

6. Referral of clients to health care providers outside of the facility, including referrals to other treatment facilities along the continuum of care;

7. Procedures governing client search and seizure that ensures protection of staff and clients, doesn't violate client rights and preserves the dignity of clients;

8. Emergency care of clients;

9. Care of clients during an episode of communicable disease;

10. Care of clients with tuberculosis that is no longer communicable or is not transmissible;

11. Informed consent requirements and methodology, including provisions for obtaining informed consent from parents or guardians of adolescents and the identification of staff designated to obtain informed consent from clients, or in the case of an adolescent, the parents or guardians of the adolescent;

12. Initiation, implementation, review, and revision of a written treatment plan of care to include DSM-IV-TR diagnosis, ASAM level of care assessment, measurable goals, objectives and treatment outcomes;

13. Health education of clients through various media, including written materials that are presented multi-lingually on the basis of client composition of the facility;

14. Criteria for discharge, transfer and re-admission of clients from the facility;

15. Screening clients for substance use through random urinalysis or other approved methods of drug screening on grounds that are reasonable and not unfairly discriminatory;

16. Criteria and procedures for conducting of research activities;

17. Reporting of critical incidents, complaints and threats;

18. Conflict resolution process;

19. Responsibility of the facility with respect to client care and supervision off-site, including staff who may accompany clients and the identification of destinations for clients or classes of clients;

20. The facility shall develop policies and procedures governing the permitting of pets at the facility;

21. When clothing for clients is provided by the facility, such clothing shall be suitable for the season, client size and compatible with the clothes worn by the client's peers;

22. Policies governing which on-site activities, work and/or vocational activities are to be performed by the client.

i. Such activities, that are appropriate to the facility include, but are not limited to, clerical functions, housekeeping and light manual labor.

ii. The therapeutic benefit, along with the client's voluntary written consent to participate in such activities, shall be documented in the client's treatment plan.

iii. The client shall sign a client consent form verifying their voluntary participation in the activities described in this paragraph; and

23. Care and documentation of deceased clients, including notification of local law enforcement and the Department, pronouncement of death, recording of death in the client's clinical record, immediate notification of the deceased client's family, guardian, or legal representative, if not present at the time of death, and person responsible for the deceased.

(b) The facility shall establish policies and procedures regarding financial arrangements established between clients and the facility, including:

1. The method and timeframes for retention of records of financial arrangements and transactions.

i. The facility shall provide clients with copies of all financial arrangements and transactions relevant to the client;

2. Clients shall be advised in writing at admission of all fees and payments charged by the facility, including any services, such as physician or nursing visits, that are billed separately.

i. Descriptions of any sliding fee scales or special payment plans shall be provided to clients;

3. The facility shall not assess charges, expenses or other financial liabilities in excess of those established in the fee schedule without the written approval of the client, except in the event of an emergency, which requires that the client be provided with special services or supplies.

i. The facility shall provide the client written copies of all of his or her approvals of additional expenses, or expenses incurred in rendering services to the client during an emergency;

4. The method for notifying clients regarding the facility's agreements with insurance companies, health maintenance organizations (HMOs) and other third-party payers; and

5. The method for notifying clients regarding sources of financial assistance available to clients, and the method for referring clients directly to the source(s) of financial assistance, when appropriate.

(c) If the facility provides medical and/or nursing service, the facility shall establish policies and procedures regarding verbal and telephone orders from physicians or other licensed practitioners authorized under New Jersey statute, to include the following:

1. Specifications of the circumstances under which verbal and telephone orders may be given and received;

2. Limitations on verbal and telephone orders to emergency situations; and

3. Written documentation of verbal and telephone orders shall be entered into the client's clinical record by medical staff authorized medical to receive such orders, and countersigned within 72 hours of the original order by the physician or medical staff issuing the verbal or telephone order.

(d) The facility shall establish policies and procedures for providing documented written notifications to families of clients including, but not limited to, the following situations:

1. Client injury requiring medical care;

2. Accidents or incidents involving the client;

3. Client transfer; and

4. Client death.

N.J. Admin. Code § 8:111-6.2

Amended and recodified from 10:161A-6.2 53 N.J.R. 2208(a), effective 12/20/2021