N.J. Admin. Code § 8:36-5.7

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:36-5.7 - Policy and procedure manual

(a) A policy and procedure manual(s) for the organization and operation of the facility or program shall be developed, implemented, and reviewed at least annually. Each review of the manual(s) shall be documented, and the manual(s) shall be available in the facility or program 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 or program;

2. A description of the services which the assisted living residence, comprehensive personal care home or assisted living program is capable of providing;

3. Policies and procedures for maintaining security;

4. Policies and procedures for reporting all alleged and/or suspected cases of resident abuse or exploitation to the Complaints Program of the Division of Health Facility Survey and Field Operations at 1-800-792-9770. If the resident is 60 years of age or older, the State Long-Term Care Ombudsman shall also be notified, in compliance with N.J.S.A. 52:27G-7.1et seq., at 1-877-582-6995;

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 resident records to any individual outside the facility or program, as consented to by the resident or as required by law or third-party payor;

6. Policies and procedures for the maintenance of personnel records for each employee, including at least his or her name, previous employment, educational background, credentials, license number with effective date and date of expiration (if applicable), certification (if applicable), verification of credentials, records of physical examinations, job description, records of orientation and inservice education, and evaluation of job performance;

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

8. Policies and procedures delineating the responsibilities of the facility's staff in making prompt notification regarding the death of a resident as required by N.J.S.A. 26:2H-5e and N.J.A.C. 8:36-15.7(a).

(b) The facility shall have a policy and procedure that addresses how policy and procedure manuals will be made available to residents, guardians, designated responsible individuals, prospective applicants, and referring agencies.

N.J. Admin. Code § 8:36-5.7

Amended by 54 N.J.R. 54(a), effective 1/3/2022