New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 44A - STANDARDS FOR COMMUNITY RESIDENCES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
Subchapter 2 - ORGANIZATION AND ADMINISTRATION
Section 10:44A-2.2 - Development and maintenance of procedure manual
Universal Citation: NJ Admin Code 10:44A-2.2
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The licensee shall develop and implement a manual of written procedures to ensure that the service delivery system complies with State law and rules governing community residences for individuals with developmental disabilities.
1. The procedures shall be reviewed annually
and revised as necessary.
2. Each
procedure shall be designed in accordance with the principles of normalization,
age appropriateness, least restriction, person centered planning and shall be
consistent with the organizational structure and management philosophy of the
licensee.
3. While specific content
for inclusion in a procedure shall be identified on an as-needed basis in these
rules, to ensure consistency, each procedure shall include:
i. A descriptive title which is unique so as
to permit easy reference and retrieval of each document;
ii. An explanation regarding the purpose of
the document;
iii. A description of
sequential steps required to successfully complete a task or action;
iv. Assignment of staff responsibilities at
each step in the implementation; and
v. Reporting and recording requirements for
each person involved.
(b) The licensee shall maintain a procedure manual containing the following documents and/or procedures:
1. A statement of philosophy, values and
goals so as to govern the organization's direction and character;
2. A table of organization that illustrates
lines of authority, responsibility and communication;
3. A procedure for assuring compliance with
the Central Registry;
4. A New
Employee Orientation Checklist, which shall include, at a minimum, all
requirements at
N.J.A.C.
10:44A-2.6(a)1 through
8;
5. A procedure for implementing
a plan to deal with major emergencies requiring evacuation from the residence,
such as a fire or a gas leak.
i. The procedure
shall also address emergencies where evacuation may not be required, such as
when the indoor air temperature is below 68 degrees Fahrenheit or above 82
degrees Fahrenheit for four consecutive hours;
6. A procedure for handling medical
emergencies that includes the requirement to call 9-1-1 in the event of a
life-threatening emergency, in accordance with N.J.S.A 30:6D-5.1 et seq.
(Danielle's Law), and N.J.A.C. 10:42A;
7. Emergency coverage and on-call
procedures;
8. A procedure for
reporting all unusual incidents, including, but not limited to:
i. A written statement expressly prohibiting
abuse, neglect, or exploitation; and
ii. A written statement regarding the
obligation to report each allegation as required at N.J.S.A. 9:68.10 and
52:27G-1 et seq., and Department policy.
9. A procedure for investigations;
10. A procedure to ensure sound fiscal
management of individual's personal funds;
11. A procedure for the safekeeping of
valuable personal possessions;
12.
A list and schedule of all charges and fees for which an individual shall be
held responsible;
13. A procedure
for resolving complaints and grievances of individuals that has a minimum of
two levels at which the grievance shall be heard, the last of which involves
the licensee or the executive director;
14. A procedure, separate from individuals'
records, for internal communication, to include the use of a separate log to
document critical information and the action taken by the licensee to
follow-up:
i. Each log entry shall be dated
and signed with the full name of the staff person making the entry;
15. A procedure for admissions
that complies with the requirements at
N.J.A.C.
10:44A-4;
16. A statement regarding maintaining
confidentiality of individuals receiving services and records, as required at
N.J.A.C.
10:41-2;
17. Written procedures for medication
administration, including procedures for self-medication;
18. Written procedures for assuring
compliance with the requirements for testing employees for controlled dangerous
substances, in accordance with
N.J.S.A.
30:6D-9.5;
19. Written procedures for the exchange of
contact information of parents, family members who are actively involved in
ensuring the individual's welfare, or guardians who choose to, as set forth at
N.J.S.A.
30:6D-9.5 and 9.6;
20. A procedure for assuring that no employee
is included on the Department of Children and Families' Child Abuse Registry,
as set forth at
N.J.S.A.
30:6D-73 et seq., and 9:6-8.10f;
21. A procedure to address the use of
video/audio monitoring in the common areas of the residences, if applicable;
and
22. A continuous quality
improvement system to identify opportunities to improve services and/or
supports and to resolve identified problems. The system shall include, at a
minimum:
i. A written plan to identify how
data is collected, analyzed, and utilized to determine patterns that identify
process or systemic problems requiring further in-depth review;
ii. Input from a variety of sources,
including persons receiving services, family members, and others;
iii. A written summary of satisfaction
surveys;
iv. A written summary of
outcomes assessments; and
v. An
action plan based upon an analysis at (b)22i through iv above.
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