N.J. Admin. Code § 8:121-1.7

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

Section 8:121-1.7 - Site reviews

(a) Site reviews shall be conducted for each separate site location, including the location where medications and/or service records are maintained, for every mental health program.

1. Licensing reviews shall minimally occur every three years.

2. Site reviews shall occur prior to licensing any new mental health program and/or site.

3. Site reviews may occur on an announced or unannounced basis at any time. The purpose of the site review may include, but not be limited to, investigation of a complaint or incident, assessment of the facility or facility improvement, or review of policies, procedures and/or clinical records.

(b) The site review is designed to determine that the mental health program(s) and program location(s) meet all relevant standards.

(c) The site review is designed as a collaborative process to promote learning, program improvement, high quality services, protection of consumer's rights, and ensure compliance with standards.

(d) Site reviews shall be conducted by individual staff of the Department or by a team coordinated and led by staff of the Department.

1. Teams may include: mental health consumers and family members, staff from similar mental health programs (peers), and county mental health administrators.

(e) Team composition, the amount of time scheduled for each site review and the level of intensity of each site review may vary to reflect the characteristics of the mental health program and the populations served.

(f) Site reviews may include, but not be limited to, consumer, family/guardian, direct care and administrative staff interviews; record reviews; reviews of policies and procedures; program observations; onsite inspection of the physical plant; review of internal documents, including financial records; and review of the quality assurance program. The review of each of these items shall be based on applicable State rules.

(g) Site review of programs granted deemed status shall primarily focus on, but may not be limited to, staffing and clinical records, and any Level 1 standard not otherwise addressed by the recognized accrediting body.

(h) Following the site review, an official report of findings shall be issued by the Department within 60 to 90 days.

(i) Within 40 calendar days of receipt of the official report, the mental health program shall send a written response to the official report, including a plan for improvement with specific time frames. This response shall be attached to the report and together shall constitute a public document.

(j) The mental health program shall be notified in writing whether the improvement plan, or portions thereof, are approved for implementation and whether there are any areas that need to be addressed further.

(k) The mental health program shall, upon request, make available for review a copy of the report and response.

N.J. Admin. Code § 8:121-1.7

Adopted and Recodified from 10:190-1.7 53 N.J.R. 2008(a), effective 12/6/2021