N.J. Admin. Code § 8:43J-3.4

Current through Register Vol. 56, No. 11, June 3, 2024

Section 8:43J-3.4 - Administrative policies and procedures

(a) If a health care facility licensed by the Department provides pediatric medical day care in addition to other heath care services, the facility shall adhere to this chapter and to the applicable rules for licensure of facilities providing the other health care services.

(b) The facility shall adhere to applicable Federal, State and local laws.

(c) The facility shall develop, implement and review, at intervals specified therein, a policy and procedure manual for the organization and operation of the facility.

(d) Each review of the manual shall be documented and the manual(s) shall be available in the facility to representatives of the Department at all times.

(e) The manual shall address at least the following:

1. The program's philosophy and objectives and the services provided by the facility;

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

3. Specifications for each therapeutic intervention for use by all staff involved in the care of the children;

i. With respect to this requirement, the facility shall review the manual every six months to assure that the facilities procedures conform to prevailing and acceptable treatment practices.

4. The maintenance of an admission register listing children admitted by name with identifying information about each, the referral source, family contacts and emergency contacts;

5. The maintenance of a discharge register with final disposition and the discharge date;

6. The maintenance of a daily census record;

7. The maintenance of an accident and incident record;

8. The maintenance of an individual record for each child that contains:

i. Identifying data;

ii. All details of the referral and admission;

iii. Correspondence;

iv. Payer status; and

v. Medical history, signed and dated in ink by the health professional providing the service, which contains allergies, special precautions, an immunization record, the initial plan for care and updates, physician's orders, progress notes and medications dispensed;

9. Referral procedure to other health care providers in a manner that ensures the provision of a continuum of care for the child;

10. The conduct of an interdisciplinary review of each child's interdisciplinary plan of care every two months, which requires, at a minimum, that the facility share the interdisciplinary plan of care summary and recommendations with the primary health care provider, who shall approve or modify any changes in writing, and which requires the facility to give a copy of the interdisciplinary plan of care summary and recommendations to the child's parent;

11. Discharge procedures that require, at a minimum, that the facility conduct a conference involving pediatric medical day care facility staff, the child's parent and staff of other agencies involved in the child's care to discuss post-discharge care and follow-up and which require the facility to develop a written discharge summary and to enter it in the child's record within 10 business days following discharge;

12. A quality improvement program for child-care and staff performance;

13. Facility operation hours and days on which services are provided;

14. The maintenance of personnel records for each employee, which require, at a minimum, the employee's name, address, previous employment, educational background, credentials, license and/or certification and/or registration number, as applicable, with the effective date and date of expiration, and the results of the criminal background investigation;

15. The content and frequency of physical examinations, upon employment and subsequently, for employees and for other persons providing direct care services to children;

16. Procedures for follow-up of a child in the event that a child does not appear for services on scheduled days and for documentation of the follow-up in the child's medical record; and

17. Procedures for compliance with applicable statutes and protocols to report abuse or mistreatment of children, elopement, sexual abuse, specified communicable diseases, poisonings, birth defects, and unattended or suspicious deaths, which shall address, at a minimum, the following:

i. The notification of any suspected case of child abuse or exploitation to the New Jersey Department of Children and Families, Division of Child Protection and Permanency;

ii. The development of written protocols for the identification and the treatment of children who are abused and/or neglected;

iii. The provision at least annually of education and/or training programs to appropriate persons regarding the identification and reporting of diagnosed and/or suspected cases of sexual abuse, domestic violence, child abuse and the facility's policies and procedures;

iv. Communicable disease reporting, in accordance with N.J.A.C. 8:57; and

v. Birth defect reporting, in accordance with N.J.A.C. 8:20.

(f) The policy and procedure manual shall be available and accessible to children's parents, staff and the public.

(g) The facility shall have a written agreement for services not directly provided by the facility.

1. The written agreement, or its equivalent, shall specify that the facility retain administrative responsibility for services rendered and shall require that services be provided in accordance with this chapter.

(h) Each facility shall maintain at least one bulletin board in a conspicuous location in the facility in an area accessible to the public upon which the facility shall place all notices this chapter requires to be posted.

N.J. Admin. Code § 8:43J-3.4

Notice of readoption with technical change.
See: 48 N.J.R. 2354(a).