New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 44C - STANDARDS FOR COMMUNITY RESIDENCES FOR PERSONS WITH HEAD INJURIES
Subchapter 2 - ORGANIZATION AND ADMINISTRATION
Section 10:44C-2.2 - Development and maintenance of procedure manual

Universal Citation: NJ Admin Code 10:44C-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 persons with head injuries.

1. The procedures shall be reviewed annually and revised as necessary.

2. Each procedure shall be designed in accordance with the principles of affirming and protecting rights of persons served within a rehabilitative treatment environment, 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 this chapter, 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. Administrative policies and procedures identified at N.J.A.C. 10:44C-2.1 including:
i. Procedures for the orientation of new board members to the operations of the organization;

ii. Policies to guard against the development of a conflict of interest between a member of the board and organization;

iii. A policy on the investment of funds; and

iv. A policy that prohibits fee splitting with other agencies or persons as consideration for referral of the person served;

4. A procedure for implementing a plan to deal with major emergencies requiring evacuation from the residence, including, but not limited to, 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;

5. A procedure for handling medical emergencies that contains provisions that conform to the requirements of N.J.S.A. 30:6D-5.1 et seq. (Danielle's Law);

6. Emergency coverage and on-call procedures;

7. 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 pursuant to N.J.S.A. 9:6-8.10 and 52:27G-1 et seq., and Department policy;

8. A procedure for investigations;

9. A procedure to ensure sound fiscal management of the funds of a person served;

10. A New Employee Orientation Checklist, which shall include, at a minimum, all requirements at N.J.A.C. 10:44C-2.6(a)1 through 8.

11. A procedure for the safekeeping of valuable personal possessions;

12. A list and schedule of all charges and fees for which a person served shall be held responsible;

13. A procedure for resolving complaints and grievances of persons served or decisions of the TDT, which shall have the following:
i. A minimum of two levels of appeal, the last of which shall involve the executive leadership or the licensee;

ii. Time frames for decision-making at each step;

iii. Written notification procedures;

iv. The rights and responsibilities of each party; and

v. The opportunity for the person served, his or her guardian or his or her personal advocate to obtain assistance from any of the individuals or organizations at N.J.A.C. 10:44C-3.1(b)2;

14. A procedure for an internal communication log to document only critical information and the necessary follow-up action taken, which shall be dated and shall include the full name and title of the person making the entry.

15. A procedure for admissions, including admission criteria, changes in supports or services, the development, implementation, review and evaluation of each person's treatment plan and transfers and discharges, that complies with the requirements of N.J.A.C. 10:44C-4;

16. A statement regarding maintaining confidentiality of persons served and records as required by N.J.A.C. 10:41-2;

17. Written procedures for medication administration, including procedures for self-medication;

18. A written policy governing the use of psychotropic medication that complies with the requirements at N.J.A.C. 10:44C-5.3;

19. A procedure for assuring compliance with the requirements for testing employees for controlled dangerous substances, as set forth at N.J.S.A. 30:6D-9.5 and 9.6;

20. Written procedures for the exchange of contact information of parents, family members who are actively involved in ensuring the person's welfare, or guardians, as applicable, as set forth at N.J.S.A. 30:6D-9.5 and 9.6;

21. A procedure for assuring that no employee is included on the Department of Children and Families' child abuse registry, as set forth pursuant to N.J.S.A. 30:6D-73 et seq., and 9:6-8.10f;

22. A procedure to address the use of surveillance cameras in the common areas of the residences, if applicable; and

23. 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 served, 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)23i through iv above.

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