Current through Register Vol. 56, No. 6, March 18, 2024
(a) A personal, primary physician or medical group/clinic or advanced practice nurse shall be identified for each person served.
(b) Each person served shall, at a minimum, have an annual medical examination.
1. The examining physician or advanced practice nurse shall sign, date and document the results of the examination.
2. A copy of the results of the annual examination shall be maintained in the file of the person served. The confidentiality of this document shall be maintained in accordance with N.J.A.C. 10:41-2.
3. Should a competent person served refuse such an examination, documentation signed and dated by the person served rejecting the service, as well as the name of the staff offering the service, shall be filed in the record of the person served.
4. Additional documentation shall be provided whenever the refusal of treatment is considered to be necessary, but not life threatening. The document shall identify steps taken to counsel the person served regarding the risks and consequences of refusal.
(c) Each person served shall, at a minimum, have an annual dental or oral examination.
1. A record documenting the results of the dental examination, signed and dated by the dentist, shall be maintained in the record of the person served.
2. Should a competent person served refuse such an examination, documentation signed and dated by the person served rejecting the service, as well as the name of the staff offering the service, shall be filed in the person's record.
3. Additional documentation shall be provided whenever the refusal of any medical exam or treatment is considered necessary, but not life threatening. The document shall identify steps taken to counsel the person served regarding the risks and consequences of refusal.
(d) Upon any known or suspected exposure to a confirmed case of M. Tuberculosis by a person served, the agency shall consult with the local health department and maintain documentation that all requirements for follow up testing were met.
(e) The licensee shall follow-up on all health needs including medical treatment, pharmaceutical, dental or other needed services.
1. Documentation shall be maintained in the record of the person served.
(f) The licensee shall assure that the community residence has access to emergency medical services.
(g) Each licensed program site shall have a first aid kit to include:
1. Antiseptic;
2. Rolled gauze bandages;
3. Sterile gauze bandages;
4. Adhesive paper or ribbon tape;
5. Scissors;
6. Adhesive bandage (for example, Band-Aids);
7. Either a standard type or a digital thermometer;
8. CPR Mask; and
9. Protective gloves.
(h) Upon confirmation that a person served has contracted a communicable disease as specified at N.J.A.C. 8:57, the licensee shall assure exposed persons served are placed under a physician's or advanced practice nurse's care.
1. The physician or advanced practice nurse of the person served shall determine treatment and precautions to be taken.
i. Documentation of treatment and precautions shall be maintained in the person's file.
2. If the person served does not live alone, the licensee shall contact the primary physician or advanced practice nurse for all other persons served in the residence.
(i) The agency shall assure that all adaptive and assistive devices are available for each person served who requires them.
