N.J.A.C. 8:43G — HOSPITAL LICENSING STANDARDS (Subchapter 1 to 38)

(a) Questions regarding hospital licensure may be addressed to the Licensing Office. (b) To make a complaint about any New Jersey licensed health care facility, call: 1-800-792-9770 (toll-free hotline). Notes N.J. Admin. Code § 8:43G-1.4 Amended by R.2005 d.279, effective 9/6/200…

(a) The dietary service shall have written policies and procedures for all dietary services that are reviewed at least once every three years, revised more frequently as needed, and implemented. (b) A diet manual detailing nutritional and therapeutic standards for meals and snack…

(a) There shall be a program of continuous quality improvement for dietary services that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, and reco…

Notes N.J. Admin. Code § 8:43G-10.2

(a) There shall be a food service director who has a baccalaureate degree from an accredited college or university in food, nutrition, food services management, or a related area, or has at least four years of experience in food services management in a health care facility and s…

(a) A dietitian shall be on duty in the hospital for a specified period, as determined by the hospital, during every 48-hour weekend or holiday period. (b) Dietary service members shall be assigned duties based upon their education, training and competencies and in accordance wit…

Notes N.J. Admin. Code § 8:43G-10.5

(a) All new admissions shall be listed with the dietary service by the first pre-meal deadline following admission, as specified in the dietary service's policies and procedures. (b) Each patient's diet shall be documented in the medical record. (c) A physician shall write a spec…

Notes N.J. Admin. Code § 8:43G-10.7

Requirements for the dietary education program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-10.8

Notes N.J. Admin. Code § 8:43G-10.9

(a) Each hospital shall have a discharge planning program with formal mechanisms in place which include criteria by which every patient is screened for post-discharge needs. (b) The hospital shall maintain an organizational chart or alternative documentation that clearly delineat…

Notes N.J. Admin. Code § 8:43G-11.2

Hospital staff working in the discharge planning program shall have open access to relevant patient records. Notes N.J. Admin. Code § 8:43G-11.3

(a) A team that includes at least a social worker and a registered professional nurse shall have responsibility for and guide multidisciplinary discharge planning for patients who, upon screening, are determined to require coordinated discharge planning. This team shall receive i…

(a) Patients who require post-discharge continuity of care shall be linked to needed resources, such as: 1. Placement in a nursing home; 2. Enrollment with a home care program; 3. Transfer to another health care facility; 4. Referral to community resources; or 5. Information rega…

(a) There shall be a program of continuous quality improvement for discharge planning that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, and re…

The rules in this subchapter apply to general acute care hospitals in accordance with N.J.S.A. 26:2H-5.24 through 5.32. Notes N.J. Admin. Code § 8:43G-11A.1 Adopted by 50 N.J.R. 528(a), effective 1/16/2018

The rules in this subchapter implement N.J.S.A. 26:2H-5.24 through 5.32, by requiring hospitals to offer patients who are able to return to their place of residence after discharge an opportunity to designate caregivers to perform after-care assistance tasks and to train these ca…

(a) The following words and terms are defined at N.J.S.A. 26:2H-5.25 and are used in this subchapter as defined therein: "After-care assistance"; "Caregiver"; "Discharge"; "Entry"; "Hospital";and "Residence." (b) The following words and terms, when used in this subchapter, have t…

(a) Following entry into a hospital and prior to discharge, a hospital's discharge planning team shall offer every patient, or the patient's legally authorized decision maker, an opportunity to designate a caregiver for after-care assistance tasks, in accordance with the patient'…

The discharge planning team shall disclose to the designated caregiver, the patient's discharge plan only after providing notice of, and obtaining written consent for, the intended disclosure from the patient or the patient's legally authorized decision maker. Notes N.J. Admin. C…

(a) The discharge planning team shall schedule after-care assistance training at a time convenient for the caregiver in accordance with N.J.A.C. 8:43G-11A.7. (b) The discharge planning team shall meet with the caregiver at a time that takes into consideration: 1. The severity of …

(a) A hospital shall ensure that after-care assistance training offered to the caregiver includes instructions on performing each after-care assistance task set forth in the patient's discharge plan. (b) A hospital shall ensure that the caregiver has opportunities to: 1. Choose w…

(a) The discharge planning team shall notify the caregiver in advance of the patient's discharge or transfer to another facility. (b) The discharge planning team shall document promptly in the patient's medical record all attempts to contact the caregiver. 1. If required, the dis…

The hospital shall provide emergency services on a 24 hour basis, unless it is a licensed special or psychiatric hospital. Special and psychiatric hospitals shall have a written plan and a system to meet medical emergencies based on the types of patients and cases that are typica…

(a) Requirements for the emergency department education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) Regularly assigned emergency department staff shall attend training or educational programs related to the identification and reporting of child abuse and/or neglect in…

(a) There shall be a program of continuous quality improvement for the emergency department that is integrated into the hospital continuous quality assurance program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, an…

(a) The requirements of N.J.A.C. 8:43G-12.13 through 12.23 and this section apply to all hospitals that the Department designates as Level I or Level II trauma centers, pursuant to Certificate of Need designation criteria at N.J.A.C. 8:33. (b) The purpose of the rules designated …

The following words and terms, when used in N.J.A.C. 8:43G-12.12 through 12.23, shall have the following meanings, unless the context clearly indicates otherwise: "Advanced life support" means an advanced level of prehospital, interhospital, and emergency service care which inclu…

(a) Hospitals designated as Level I or Level II trauma centers shall have organized departments or services for the following specialties: 1. General surgery; 2. Neurologic surgery; 3. Orthopedic surgery; 4. Emergency services; and 5. Anesthesia. (b) Hospitals designated as Level…

(a) The trauma service shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. These policies and procedures shall ensure a systematic and comprehensive approach to the care of trauma patien…

(a) There shall be a physician director of trauma services who is board certified in surgery, and who has also completed the following post-residency clinical experience in trauma services (which may include experience in a trauma or surgical critical care fellowship program) at …

(a) For Level I and Level II trauma centers there shall be present in-hospital at all times personnel who meet the following qualifications: 1. At least one general surgeon who is credentialed to provide trauma care and, in consultation with the chief of neurosurgery, credentiale…

(a) The trauma service is required to provide on-site specialized services, including, at a minimum: 1. Acute hemodialysis; 2. Radiological services as follows: i. Angiography; ii. Computerized tomography, with a technician present in the hospital 24 hours a day; and iii. Nuclear…

There shall be an immediately available and adequately staffed operating room in-hospital 24 hours a day, for any emergency operative procedures needed by trauma center patients. Notes N.J. Admin. Code § 8:43G-12.19 New Rule, R.1999 d.436, effective 12/20/1999. See: 31 New Jersey…

(a) The emergency department shall have written policies and procedures for medical, trauma, and pediatric patients, that are reviewed at least once every three years, revised more frequently as needed, and implemented. (b) Each hospital shall develop and implement policies and p…

(a) There shall be an organized quality improvement program at Level I and Level II trauma centers that is integrated into the hospital quality assurance program and includes regularly collecting and analyzing data to help identify health-service problems and their extent, and re…

(a) Each Level I and Level II trauma center shall maintain a trauma registry enumerating demographic, injury scene, prehospital, emergency department, inpatient, and discharge/outcome data for all patients treated or evaluated by the trauma center. The trauma registry shall inclu…

(a) After designation, Level I and Level II trauma centers shall demonstrate continuing compliance with the applicable requirements of this subchapter according to the following process: 1. Trauma centers shall maintain current verification at Level I or Level II in accordance wi…

(a) In addition to meeting the requirements in N.J.A.C. 8:43G-12.12 through 12.22, each Level I and Level II trauma center shall continuously maintain verification by the Committee on Trauma of the American College of Surgeons (ACS) as an adult trauma center for caring for injure…

(a) There shall be a physician director of the emergency department who is board certified in emergency medicine or who has five years of full-time experience in emergency medicine, which may include three years residency in emergency medicine, within the past seven years. (b) Ea…

(a) Each emergency department shall have a designated pediatric liaison physician and a designated pediatric liaison nurse, who shall be responsible for review and approval of the emergency department's pediatric activities, including: 1. Policies and procedures for pediatric car…

(a) At all times at least one licensed physician who meets at least one of the qualifications in N.J.A.C. 8:43G-12.3(b) shall be present in the emergency department to attend to all emergencies. (b) There shall be a physician specialist on call to the emergency department for eac…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Comes to the emergency department" means, with respect to an individual requesting examination or treatment by him or herself or with a…

(a) When an individual comes to the emergency department requesting examination or treatment for a medical condition, or if a request is made on the individual's behalf, clinical priority for treatment shall be assigned by a registered professional nurse or qualified medical pers…

Notes N.J. Admin. Code § 8:43G-12.8