N.J. Admin. Code § 8:43G-26.2

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

Section 8:43G-26.2 - Psychiatry policies and procedures

(a) The psychiatric service shall have written policies and procedures that are reviewed annually, revised as needed, and implemented. These policies and procedures shall be readily available on the inpatient unit and include at least the following:

1. Criteria for admission to and discharge from each component of the psychiatric unit. Admissions criteria shall be based solely on the patient's needs and the ability of the unit to meet these needs, and discharge policies shall preclude punitive discharge;

2. Safety and security precautions for the prevention of suicide, assault, elopement, and patient injury;

3. Emergency procedures for medical emergencies;

4. Infection control practices for the day/dining room, equipment, and rooms used by more than one patient. If these special practices are included in the hospital-wide infection control policies and procedures manual, which is available on the unit, then additional policies and procedures do not have to be developed by the psychiatric service for infection control;

5. Patient privileges;

6. Patient rights as delineated at N.J.A.C. 8:43G-4;

7. Family interviews for assessment and treatment purposes;

8. A clinical services plan describing the services provided;

9. Content of patient evaluations, including the components of care, time frames for goals, and staff assigned to the patient;

10. Release of information, in conformance with applicable statutes and the policies of the medical records department;

11. Informed consent, with special policies for patients undergoing electro-convulsive therapy;

12. Patient grievance procedures;

13. Criteria for use of seclusion in accordance with procedures delineated in the current or revised or later edition, if in effect, of the American Psychiatric Association Task Force Report No. 22 on Restraint and Seclusion, incorporated herein by reference, available from the American Psychiatric Association, 1400 K Street NW, Washington, D.C. 20005;

14. Review by physician director or designee of restraints or seclusion used in excess of 72 consecutive hours for a patient; and

15. Criteria for physician monitoring of patients in restraints more frequently than every 24 hours based on patient acuity.

(b) The psychiatric service shall develop and implement written policies and procedures for use of restraints in accordance with 8:43G-18.4.

(c) The psychiatric service shall develop and implement written policies and procedures for use of electroconvulsive therapy (ECT), in accordance with the recommendations of the current or revised or later edition, if in effect, of the American Psychiatric Task Force on ECT: "The Practice of ECT: Recommendations for Treatment, Training, and Privileging" and the New Jersey Patient's Bill of Rights at 30:4-24.2(d)(2), incorporated herein by reference, including at least:

1. Criteria specifying when ECT may be used;

2. The use of written informed consent;

3. The requirement that an anesthesiologist, a certified registered nurse anesthetist, or a physician granted privileges by the medical staff to administer anesthesia be present at the procedure;

4. Administration in an appropriately equipped area, with emergency equipment available;

5. Full documentation of the administration of ECT in the medical record; and

6. Observation of the patient's recovery immediately after the procedure is performed.

(d) There shall be a written affiliation or referral agreement with the community mental health agency or agencies designated within the hospital's service area by the Department's Division of Mental Health and Addiction Services, for referral, case management, and discharge planning.

(e) The hospital shall comply with the provisions of the New Jersey Screening and Commitment Law of 1988, 30:4-27.1 et seq., specifically 30:4-27.1 0(f), and all rules promulgated pursuant to the aforementioned Act in regards to the transfer of a patient to a psychiatric facility.

N.J. Admin. Code § 8:43G-26.2

Amended by 50 N.J.R. 552(b), effective 1/16/2018