Current through Register Vol. 56, No. 18, September 16, 2024
(a) The facility's quality assurance program
shall provide for an ongoing process for monitoring and evaluating client care services, staffing, infection
prevention and control, housekeeping, sanitation, safety, maintenance of physical plant and equipment, client
care statistics, discharge planning services, volunteer services and shall include, but not be limited to:
1. Evaluation of the behavioral and pharmacological approaches to treatment
to ensure that treatment practices are evidence-based or based on best objective information to provide
treatment services consistent with recognized treatment principles and practices for each level of care and
type of client served, as defined at N.J.A.C. 10:161B-6.2(a)11;
2. Review of policies, procedures, and practices relating to the provision
of clinical supervision of staff, including the methods and frequency by which staff receive clinical
supervision;
3. Evaluation of client care shall be
criteria-based, and trigger certain review actions when specific, quantified, predetermined levels of
outcomes or potential problems are identified;
4. Periodic
reviews of client clinical records;
5. Evaluation by clients of
care and services provided by the program;
6. If the families of
clients are routinely involved in the care and services provided by the facility, the quality assurance plan
shall include a means for obtaining their input; and
7. The
quality assurance plan shall include at a minimum an annual review of staff qualifications and credentials,
and staff orientation and education.
(b) The
administrator shall follow-up on the findings of the quality assurance program to ensure that effective
corrective actions have been taken, or that additional corrective actions are no longer indicated or needed.
The following shall apply:
1. The administrator shall follow-up on all
recommendations resulting from findings of the quality assurance program or DCN&L.
2. Deficiencies jeopardizing client or staff safety shall be verbally
reported to the governing authority and to DMHAS immediately, with written correspondence provided to the
governing authority and DMHAS within five working days.
(c) The facility shall identify and establish indicators of quality care
and outcome objectives specific to the program.
1. The indicators shall be
consistent with the Federal SAMHSA National Outcome Measures (NOMs), as defined and accessible at
http://integratedrecovery.org/wp-content/uploads/2010/08/SAMHSA-National-Outcome-Measures.pdf, incorporated
herein by reference.
2. The facility shall monitor and evaluate
each of the specific indicators at least annually, and develop reports as required by the facility, governing
authority and DHS.
(d) The program shall submit
results of the quality assurance program to its governing authority at least annually, including reporting of
deficiencies found and recommendations for corrections or improvements.
