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

(a) There shall be a program of continuous quality improvement for medical records 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 recom…

(a) There shall be an organized medical staff that is responsible to the governing body of the hospital. Bylaws governing all medical staff members shall be implemented. (b) Applications for membership, privileges, or initial appointment to the medical staff shall be processed un…

(a) The medical staff shall have written policies, procedures, and bylaws that are reviewed at least once every three years; revised more frequently as needed, and implemented. They shall include at least: 1. Policies and procedures addressing the requirements for obtaining writt…

(a) All physicians with clinical privileges shall be licensed or authorized to practice medicine by the New Jersey Board of Medical Examiners. All non-physicians with privileges shall be licensed or authorized to practice in the State of New Jersey, as required by law. (b) In any…

Notes N.J. Admin. Code § 8:43G-16.4

(a) The hospital shall establish policies and procedures for response times for emergencies. (b) There shall be an on-call list of medical and surgical specialists that is available to personnel in all patient care units. Notes N.J. Admin. Code § 8:43G-16.5

(a) Each patient shall have an attending physician who has overall responsibility for the patient's care in the hospital. (b) Each patient admitted to the hospital shall have a medical history and physical examination that includes a provisional diagnosis performed by a clinical …

Requirements for the medical staff education program shall be as provided in N.J.A.C. 8:43G-5.9(a) and (b). Notes N.J. Admin. Code § 8:43G-16.7 Amended by R.1992 d.72, effective 2/18/1992. See: 23 New Jersey Register 2590(a), 24 New Jersey Register 590(a). Stylistic change.

There shall be a medical staff mechanism by which the quality of medical care is monitored, problems identified, solutions recommended and implemented, and follow-up conducted. Summary reports of these activities and problems in the quality of care shall be reviewed by the medica…

(a) The hospital shall have in place a staffing plan that addresses nurse staffing requirements and identifies patient needs, including, at a minimum: 1. A daily staffing schedule that ensures at least one registered professional nurse in charge and assigned exclusively to each p…

Notes N.J. Admin. Code § 8:43G-17.2

(a) The Commissioner promulgates this subchapter pursuant to the authority of N.J.S.A. 26:2H-1 et seq., particularly N.J.S.A. 26:2H-5.h. (b) The provisions of this subchapter apply to general hospitals licensed pursuant to N.J.S.A. 26:2H-1 et seq. (c) The purpose of this subchapt…

The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. "Direct patient care" means clinical care services provided directly to patients by a registered professional nurse, licensed practical nu…

(a) For each inpatient unit, a general hospital shall count the number of patients and the number of staff based on hours worked for each category of direct patient care staff, excluding other licensed health care professionals, one hour before the end of each shift on each day o…

(a) A general hospital shall post direct patient care staffing information described at N.J.A.C. 8:43G-17A.3(a), utilizing the form, "Daily Patient Care Staffing: Inpatient Units," incorporated herein by reference and set forth at Appendix A in a visible location that is accessib…

(a) Each general hospital shall report the following information to the Department once a month on a web-based interface to be developed and communicated by the Department, which will include the use of the information already collected on these forms, "Daily Patient Care Staffin…

If the Commissioner determines that a general hospital has violated any provision of this subchapter, the Department may issue an enforcement action pursuant to P.L. 2005, c. 21, §2(e), N.J.S.A. 26:2H-5g(e), and N.J.A.C. N.J.A.C. 8:43E-3. Notes N.J. Admin. Code § 8:43G-17A.6

(a) A written organizational chart and written plan that delineates lines of authority, accountability, and communication shall be available to all nursing personnel in the hospital at all times. (b) At all times a registered professional nurse with supervisory responsibility sha…

(a) The hospital shall have written policies and procedures for the nursing care service that guide nursing practices in the hospital. These policies shall be reviewed at least once every three years, revised more frequently as needed, and implemented. These policies and procedur…

(a) The nursing care service shall be directed on a full-time basis by a chief nursing executive who has at least one of the following qualifications: 1. Is a registered professional nurse with a baccalaureate degree from an accredited college or university, and five years combin…

(a) The standards in this section shall apply to the use of physical restraints in all patient care areas of the hospital. Physical restraints are defined as devices, materials, or equipment that are attached or adjacent to a person and that prevent free bodily movement to a posi…

(a) Registered professional nurses and licensed practical nurses shall provide patient care commensurate with their scope of practice, as delineated in the Nurse Practice Act. 1. Patient care may be provided by certified nurse practitioners/clinical nurse specialists in accordanc…

(a) All medications administered by nursing personnel shall be administered in accordance with prescriber orders, medical staff policy, and all Federal and State laws and regulations. (b) Medications for individual patients shall not be removed from their original prescription co…

(a) Requirements for the nursing care education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) All nursing staff shall receive orientation and annual training regarding the use of restraints, including at least: 1. Policies and procedures in accordance with N.J.A.C. 8:43…

Notes N.J. Admin. Code § 8:43G-18.8

There shall be a program of continuous quality improvement for nursing care 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 recommending…

(a) The standards in this subchapter shall apply only to hospitals that have a separate, designated unit or service for obstetrics. (b) The following terms, when used in this subchapter, shall have the following meanings: "Advanced practice nurse" means a licensed registered prof…

(a) There shall be a continuous quality improvement program for obstetrics 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 recommending,…

(a) There shall be at least one registered professional nurse present whenever a patient is in a labor area. Nurse staffing assignments for patients in active labor shall be determined by patient acuity levels. (b) All deliveries shall be attended by an obstetrician, a physician …

(a) A registry of all births shall be maintained through either the electronic certificate or a maternity log book located in the obstetrics area and shall include the minimum data set required by the Department in accordance with N.J.S.A. 26:8-30 and N.J.A.C. 8:2. (b) Obstetrics…

(a) At least one registered professional nurse shall be on duty in the postpartum area whenever a patient is present. (b) Nurse staffing assignments for postpartum patients shall be determined by patient acuity levels. (c) There shall be written policies and procedures for the ca…

(a) The hospital shall provide or arrange for an organized program of education in self-care and newborn care. (b) The hospital shall provide each mother a comprehensive evaluation of infant feeding (that is breastfeeding and/or formula feeding, as appropriate) and follow-up asse…

(a) A current roster of physicians, their specific pediatric privileges, and an on-call schedule shall be kept in each nursing unit in newborn care. (b) A physician or an advanced practice nurse skilled in neonatal assessment shall perform a complete physical examination of the n…

(a) Hospitals designated as a CPC-Basic may provide care to neonates born greater than 2,499 grams or at least 36 weeks gestation. The only exception to this criteria is if it has been documented in the medical record that the neonate was expected to meet the weight and age crite…

(a) Hospitals designated as a CPC-Intermediate may provide care to neonates born greater than 1,499 grams or at least 32 weeks gestation. The only exception to this criteria is if it has been documented in the medical record that the neonate was expected to meet the weight and ag…

(a) A CPC-Intensive may provide care to neonates greater than 999 grams and at least 28 weeks gestation. A CPC-Intensive may provide care to neonates born in the facility who are below the specified weight and age criteria only if the infant does not require a higher level of car…

(a) The newborn service shall provide for immediate resuscitation of the newborn, including at least: 1. Short-term ventilation with laryngoscope, endotracheal tube, and bag-valve-mask; 2. Oxygen administration; 3. Intravenous therapy; 4. Temperature control; and 5. Infusion equi…

(a) The hospital shall develop and implement written policies and procedures, review them every three years and make revisions at any time as necessary, make current copies available to obstetrics staff in all areas of the obstetrics service, and address: 1. Criteria for the iden…

(a) Each room used as a nursery accessory room shall be equipped with at least three foot-controlled, covered, and labeled receptacles: one for the disposal of wet or soiled diapers, one for the disposal of trash, and one for the sanitary disposal of linens other than wet or soil…

The standards in N.J.A.C. 8:43G-19.22 through 19.26 shall apply only to hospitals that have a separate, designated service or unit for nurse-midwifery. Hospitals which do not have a separate, designated service or unit for nurse-midwifery but grant obstetrical privileges to nurse…

Nurse-midwifery services shall be organized as part of the obstetric service. The physician director of obstetrics shall be responsible for assuring that nurse-midwifery services conform with applicable rules and hospital policies and procedures. Notes N.J. Admin. Code § 8:43G-19…

(a) Nurse-midwifery services shall be based on written policies and procedures that are reviewed annually, revised as needed, and implemented. These policies and procedures shall include mechanisms by which medical staff in the obstetric and newborn services consult with and assi…

(a) There shall be a certified nurse-midwife who serves as director of nurse-midwifery services, coordinates and is responsible for all nurse midwifery services provided in the hospital, and monitors the quality of nurse-midwifery care. (b) All nurse-midwives practicing in the ho…

Requirements for the nurse-midwifery education program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-19.25 Recodified from N.J.A.C. 8:43G-19.27 by R.1999 d.436, effective 12/20/1999. See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 3…

The quality assurance program for nurse-midwifery services shall include physicians and nurse-midwives and shall monitor at least high-risk screening, transfers and return transfers, and mortality and morbidity by birth weight. Notes N.J. Admin. Code § 8:43G-19.26 Recodified from…

(a) If the hospital places non-obstetric patients on the obstetric unit, it shall establish written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. These policies shall include: 1. Criteria and procedu…

(a) A non-obstetric patient shall not be admitted to the obstetric service if she has any of the following conditions:1. An oral temperature of 100.4 degrees Fahrenheit or higher upon admission; 2. Substance abuse or misuse; 3. A history of household contacts with staphylococcal …