New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 47 - STANDARDS FOR PRIVATE LICENSED FACILITIES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES
Subchapter 3 - ADMINISTRATION
Section 10:47-3.14 - Pre-admission

Universal Citation: NJ Admin Code 10:47-3.14

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Individual records shall include the following data:

1. The full name and sex of the individual;

2. A copy of the individual's birth certificate or a written statement of the individual's birth date and birth place, including a copy of any guardianship determination made in accordance with 30:4-165.5;

3. Documentation of the current custody and legal guardianship; which shall include the name, address, telephone number of the parent(s) or guardian;

4. Consent forms signed by the parent(s) of a minor or court appointed guardian allowing the facility to authorize all necessary medical care, routine tests, immunization, and emergency medical or surgical treatment;

5. Documentation of the existence of a developmental disability prior to the age of 22 (for example, medical diagnosis, psychological evaluation, social history);

6. A social and developmental history;

7. A previous placement history;

8. Behavioral information, including, if applicable, the most recent psychological evaluation, current behavior plan and history of previous attempts to modify the behavior;

9. A psychiatric evaluation, if applicable;

10. A medication history and immunization history;

11. Documentation for known allergies;

12. Seizure records and/or neurological examination;

13. A history of serious illness, serious injury, or major surgery and all hospitalizations;

14. A certificate which certifies that the person is free from contagious disease within 48 hours prior to admission;

15. A summary of the latest physical examination, including Mantoux testing, Hepatitis B status and lead levels;

16. A current audiological evaluation, if available;

17. Vision testing, if available;

18. Dental information, if available;

19. An IHP from the sending agency indicating the individual's programmatic and service needs and corresponding recommendations; and

20. Education records and reports as required.

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