New Jersey Administrative Code
Title 8 - HEALTH
Chapter 43 - STANDARDS FOR LICENSURE OF RESIDENTIAL HEALTH CARE FACILITIES LOCATED WITH, AND OPERATED BY, LICENSED HEALTH CARE FACILITIES
Subchapter 4 - GENERAL REQUIREMENTS
Section 8:43-4.6 - Policy and procedure manual

Universal Citation: NJ Admin Code 8:43-4.6

Current through Register Vol. 56, No. 6, March 18, 2024

(a) A policy and procedure manual(s) for the organization and operation of the facility shall be developed, implemented, and reviewed at intervals specified in the manual(s). Each review of the manual(s) shall be documented, and the manual(s) shall be available in the facility to representatives of the Department at all times. The manual(s) shall include at least the following:

1. An organizational chart delineating the lines of authority, responsibility, and accountability for the administration and resident care services of the facility;

2. A description of the services provided;

3. Specification of business hours and visiting hours;

4. Policies and procedures for reporting all diagnosed and/or suspected cases of resident abuse or exploitation, as follows:
i. All county welfare agencies shall be notified, in accordance with N.J.S.A. 55:13B-1et seq., the Rooming and Boarding Act of 1979, as amended; and

ii. In accordance with NJ.S.A. 52:27G-7.1 et seq., if the resident is 60 years of age or older, the Office of the State Long-Term Care Ombudsman shall also be notified, at (877) 582-6995;

5. Policies and procedures for maintaining confidentiality of resident records, including policies and procedures for examination of resident records by the resident and other authorized persons and for release of the resident's records to any individual outside the facility, as consented to by the resident or as required by law or third party payor;

6. Policies and procedures for the maintenance and confidentiality of personnel records for each employee, including at least the employee's name, previous employment, educational background, credentials, license number with effective date and date of expiration (if applicable), certification (if applicable), verification of credentials, prior criminal records, records of physical examinations, job description, and evaluations of job performance; and

7. Policies and procedures, including content and frequency, for physical examinations upon employment and subsequently for employees and persons providing direct resident care services in the facility through contractual arrangements or written agreement.

(b) The facility shall make all policy and procedure manuals available to residents, guardians, designated responsible persons, prospective applicants, and referring agencies during normal business hours or by prior arrangement.

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