Current through Register Vol. 56, No. 6, March 18, 2024
(a) The facility's quality assurance program shall provide for an ongoing process, including documentation, that monitors and evaluates 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 practice 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. 8:111-1.3;
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 actions by the facility 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 facility;
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 that includes core functions addressing ASAM criteria (ASAM PPC), medication-assisted treatment, and professional ethics.
(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 the Division;
2. Deficiencies jeopardizing client or staff safety shall be verbally reported to the governing authority and to the Division immediately, with written correspondence provided to the governing authority and the Division within five working days.
(c) The facility shall identify and establish indicators of quality care and outcome objectives specific to the facility and in response to those emerging issues related to client care and/or deficiencies.
1. The indicators shall be consistent with and include, but not be limited to, the Federal SAMHSA National Outcome Measures (NOMs), as defined at
http://www.samhsa.gov/dataOutcomes/.
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 the Division.
(d) The facility 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.
