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

(a) Pharmaceutical services shall be available to patients at all times. (b) The hospital shall have in effect a unit dose drug distribution system with individual cassettes or containers that bear the patient's identification. The system shall cover at least the medical/surgical…

Notes N.J. Admin. Code § 8:43G-23.7

(a) The pharmacy shall maintain drugs under proper conditions, as indicated in the United States Pharmacopoeia, product labeling, and/or package inserts. (b) All drugs, needles, and syringes shall be kept in locked storage areas except those drugs exempted by the pharmacy and the…

Requirements for the pharmacy education program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-23.9

(a) There shall be a multidisciplinary safety committee that develops a comprehensive hospital-wide safety program that is reviewed at least once every three years, revised more frequently as needed, and implemented. (b) There shall be a mechanism to report all incidents, injurie…

Notes N.J. Admin. Code § 8:43G-24.10 Repealed by R.1995 d.124, effective 3/20/1995. See: 26 New Jersey Register 4537(a), 27 New Jersey Register 1290(a). Formerly "Physical plant general compliance for construction, alteration or renovation completed during the period of August 1,…

Notes N.J. Admin. Code § 8:43G-24.11 Repealed by R.1995 d.124, effective 3/20/1995. See: 26 New Jersey Register 4537(a), 27 New Jersey Register 1290(a). Formerly "Physical plant general compliance for construction, alteration or renovation completed during the period of September…

Notes N.J. Admin. Code § 8:43G-24.12 Repealed by R.1995 d.124, effective 3/20/1995. See: 26 New Jersey Register 4537(a), 27 New Jersey Register 1290(a). Formerly "Physical plant maintenance general compliance for construction, alteration or renovation completed prior to September…

(a) The hospital shall comply with the National Fire Protection Association publication, NFPA 101(R): Life Safety Code(R), 2012 Edition, specifically, chapter 18 for new construction and chapter 19 for existing construction; National Fire Protection Association (NFPA), and which …

Notes N.J. Admin. Code § 8:43G-24.14

(a) The building maintenance service shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. (b) The building maintenance service shall have a written preventive maintenance program for buil…

(a) The building maintenance service shall be under the supervision of an employee with at least one of the following qualifications: 1. Five years of experience in health care plant maintenance, three of which shall be in a supervisory capacity; 2. A baccalaureate degree in engi…

(a) Records of preventive maintenance inspections and repairs of electrical and mechanical systems shall be maintained for at least one year. (b) The building maintenance service shall be provided with copies of the written instructions for operating and maintaining departmental …

Notes N.J. Admin. Code § 8:43G-24.5

Requirements for the plant maintenance education program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-24.6

Notes N.J. Admin. Code § 8:43G-24.7

(a) The hospital shall comply with the New Jersey Uniform Construction Code ( N.J.A.C. 5:23 under Use Group I-2), standards imposed by the United States Department of Health and Human Services, the New Jersey Departments of Health and Community Affairs and the Guidelines for Desi…

(a) Whenever construction and renovation projects are planned in and around a health care facility, a risk assessment shall be conducted to determine the impact of the project on patient areas, personnel, and mechanical systems. 1. The infection control program shall review areas…

(a) The hospital shall have written policies and procedures for post mortem services that are reviewed at least once every three years, revised more frequently as needed, and implemented. These policies shall delineate the responsibilities of the medical staff, nursing, and post …

The physician who routinely performs or supervises the performance of autopsies shall be Board Certified in Pathology. Notes N.J. Admin. Code § 8:43G-25.2

(a) Bodies and body parts in the morgue shall be kept refrigerated or in chemical fixation in a non-putrescent state. (b) The medical staff shall attempt to secure autopsies in cases of unusual deaths, deaths from unknown causes, and cases of medicolegal and educational interest,…

The morgue shall be equipped with refrigerated space to store at least two bodies. Hospitals with more than 100 beds shall provide additional space using a ratio of one space to every additional 100 beds. Notes N.J. Admin. Code § 8:43G-25.4

Refrigerated spaces in the morgue shall be maintained at temperatures between 32 and 45 degrees Fahrenheit (0 and 7.2 degrees Celsius) and shall have an automatic alarm system that monitors the temperature. Notes N.J. Admin. Code § 8:43G-25.5

The standards in this subchapter shall apply only to hospitals that have a separate, designated unit or service for psychiatry. Notes N.J. Admin. Code § 8:43G-26.1

Notes N.J. Admin. Code § 8:43G-26.10

(a) The restraint equipment needed by the unit shall be immediately available on the unit and accessible to unit staff. (b) The recreation and therapy equipment and supplies needed for psychiatric care shall be available on the unit and stored in locked storage. (c) Locked storag…

(a) Requirements for the psychiatry service education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) The staff of the psychiatric unit shall receive annual training in handling the assaultive patient. (c) The non-medical and non-nursing professional staff shall receive a…

Notes N.J. Admin. Code § 8:43G-26.13

(a) There shall be a program of quality assurance for psychiatric services 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 recommending, implementing…

(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 a…

(a) Psychiatric care services shall be clinically supervised by a physician director who is responsible for the direction and quality of care provided by the medical staff. (b) Any physician currently holding the position of director shall have completed a residence in psychiatry…

Notes N.J. Admin. Code § 8:43G-26.4

(a) A psychiatrist shall be on-site or on call at all times. (b) Nurse staffing shall be based on hospital acuity levels, but in no case shall fewer than two nursing staff members, at least one of whom is a registered professional nurse, be on the unit. Notes N.J. Admin. Code § 8…

Notes N.J. Admin. Code § 8:43G-26.6

(a) Psychiatric patients shall receive, when needed, all medical, surgical, diagnostic, and treatment services as ordered by a physician. If such services are not available within the hospital, qualified consultants and attending physicians shall be available and arrangements est…

Notes N.J. Admin. Code § 8:43G-26.8

(a) Interviews between staff and patients shall be conducted in a private setting. (b) The unit shall have access to at least one acute care/seclusion room. (c) Acute care/seclusion rooms shall be at least 100 square feet and shall be large enough to provide access to the patient…

(a) The governing authority of the hospital (such as the board of trustees) shall have ultimate responsibility for the continuous quality improvement program. (b) The hospital shall have a hospital-wide continuous quality improvement program based on a written continuous quality …

(a) The continuous quality improvement plan shall be reviewed at least annually and revised as necessary. Responsibility for reviewing and revising the plan shall be designated in the plan itself. (b) The continuous quality improvement plan shall delineate lines of communication …

There shall be an individual responsible for coordinating all aspects of the continuous quality improvement program. Notes N.J. Admin. Code § 8:43G-27.3 Amended by R.1999 d.436, effective 12/20/1999. See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey…

Notes N.J. Admin. Code § 8:43G-27.4

(a) There shall be an ongoing process of monitoring patient care. Evaluation of patient care throughout the hospital is criteria-based, so that certain review actions are taken or triggered when specific quantified, predetermined levels of outcomes or potential problems are ident…

(a) The Department shall establish a Quality Improvement Advisory Committee (QIAC), including provider, consumer and individuals with quality of care research expertise representation, to advise the Department in developing a hospital performance measurement and assessment system…

Radiological services shall be provided on-site, except for specialized services that have been approved through the Certificate of Need process to be provided on an off-site regional basis. Notes N.J. Admin. Code § 8:43G-28.1 Amended by R.1992 d.72, effective 2/18/1992. See: 23 …

(a) Radiologists shall supervise and interpret all radiologic procedures, unless performed by clinical practitioners in specialty areas who are trained and experienced in these procedures. (b) All radiologic tests shall be interpreted, on a preliminary basis, within 24 hours of t…

Notes N.J. Admin. Code § 8:43G-28.11

(a) Cardiopulmonary resuscitation technology shall be immediately available to radiology services on all shifts. This technology shall include at least: 1. A patient monitor and defibrillator; 2. Emergency drugs; and 3. Means of maintaining respiration. Notes N.J. Admin. Code § 8…