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

(a) There shall be a physician director who is clinically responsible for surgical services and is board certified. (b) There shall be a person with administrative responsibility for the surgical service. (c) Each surgical suite shall have available a roster of physicians with de…

(a) A registered professional nurse shall be assigned to circulating nurse duties in each room where surgery is being performed. (b) All registered professional nurses in the unit shall maintain certification in Basic Cardiac Life Support. (c) During scheduled hours of operation,…

(a) A patient identification system shall be implemented and patient identification shall be verified prior to any surgical procedure. (b) There shall be a policy and procedure to verify the site and side of any and all surgical procedures. The procedure site and side shall be do…

(a) The surgical suite shall be maintained as a closed unit. Access to the surgical suite shall be restricted in accordance with hospital policies and procedures. (b) All staff in the surgical suite shall be attired in scrub attire. Individuals who are permitted limited access sh…

(a) Emergency equipment available in the surgical suite shall include at least the following: 1. An emergency call system to include at least an emergency communication system that connects each operating room and postanesthesia care unit with the control center of the suite. 2. …

Requirements for the surgery staff education program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-34.9

(a) The postanesthesia care unit shall have written policies and procedures that are reviewed at least every three years, revised more frequently as needed, and implemented. They shall include at least:1. Criteria for admission to and discharge from the unit; 2. Delineation of th…

(a) There shall be a physician director with overall responsibility for postanesthesia care. The physician director may also be the director of anesthesia services. (b) There shall be a registered professional nurse with administrative responsibility for nursing care in the posta…

(a) There shall be at least two health care personnel, one of whom is a registered professional nurse and the other of whom is either a licensed practical nurse, a registered professional nurse, or a physician, present whenever a patient is in the postanesthesia care unit. (b) Th…

(a) The patient shall be accompanied to the postanesthesia care unit by two individuals, one of whom, stationed at the patient's head, shall be responsible for the patient's airway. (b) An oral report on the patient's condition shall be given to postanesthesia care unit nursing s…

Notes N.J. Admin. Code § 8:43G-35.5

(a) Postanesthesia care units shall be adjacent to or within the operating suite and the obstetrics suite. (b) The postanesthesia care unit shall be maintained as a closed unit. Access to the postanesthesia care unit shall be in accordance with hospital policies and procedures. (…

Requirements for the postanesthesia education program shall conform to the standards set forth in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-35.7 Amended by R.2003 d.57, effective 2/3/2003. See: 34 New Jersey Register 232(a), 35 New Jersey Register 865(a). Substituted "co…

Notes N.J. Admin. Code § 8:43G-35.8

(a) The hospital's quality improvement program shall include a systematic review and evaluation of patient care, anesthesia practices and anesthesia techniques. The surgical staff shall identify problem-prone processes which manifest undesirable patterns. The hospital shall devel…

(a) All satellite emergency departments shall be owned and operated by an acute care general hospital and shall comply with the rules in this subchapter and all applicable requirements of this chapter. All satellite emergency departments shall provide emergency treatment and care…

The satellite emergency departments shall comply with the requirements of N.J.A.C. 8:43G-5.7 and 5.9. Notes N.J. Admin. Code § 8:43G-36.10

The satellite emergency department shall comply with the requirements of N.J.A.C. 8:43G-5.11, 5.12, 5.13, 5.14 and 5.15. Notes N.J. Admin. Code § 8:43G-36.11

The satellite emergency department shall comply with N.J.A.C. 8:43G-5.16. Notes N.J. Admin. Code § 8:43G-36.12

(a) The following equipment shall be located within the satellite emergency department at all times: 1. Basic and stat laboratory equipment/supplies, with at least the capability to perform the following laboratory testing and evaluation: i. Arterial blood gases; ii. Creatinine; …

(a) The satellite emergency department shall comply with N.J.A.C. 8:43G-5.15. (b) On a quarterly basis, beginning with the closest calendar quarter after commencing operation, the satellite emergency department shall submit the following information to the Department's Licensing …

A building or structure being considered for use as a satellite emergency department, located independent from an acute care hospital shall comply with all the requirements of Use Group B in chapter 20 of the NFPA 101: Life Safet. National Fire Protection Association (NFPA). This…

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. "Advanced life support" means an advanced level of pre-hospital, inter-hospital, and emergency service care which includes basic life suppo…

(a) All laboratory services provided in the satellite emergency department shall comply with the requirements of N.J.A.C. 8:45, Standards for Clinical Laboratory Services, and all radiology services shall comply with applicable requirements of N.J.A.C. 7:28-19, Medical Exposure t…

Satellite emergency departments shall comply with N.J.A.C. 8:43G-2.13. Notes N.J. Admin. Code § 8:43G-36.4

Every New Jersey satellite emergency department patient has the same rights as required in N.J.A.C. 8:43G-4, with the exception of N.J.A.C. 8:43G-4.1(a) 14. None of the patient rights shall be abridged by the satellite emergency department or the hospital that owns and operates t…

(a) A satellite emergency department may be licensed as a free-standing ambulatory care facility owned and operated by a hospital or as part of the hospital. If licensed as an ambulatory care facility, it must comply with the general ambulatory care facility requirements set fort…

The satellite emergency department shall comply with the requirements of N.J.A.C. 8:43G-5.6. Notes N.J. Admin. Code § 8:43G-36.7

(a) Physician qualifications for satellite emergency departments are as follows: 1. There shall be a physician director of the satellite emergency department, who may also be the director of the hospital's emergency department, who is board certified in emergency medicine or who …

(a) The satellite emergency department shall have all personnel identified in N.J.A.C. 8:43G-36.8(a) onsite at all times during hours of operation. (b) No patient who comes to the satellite emergency department shall be discharged to home or another facility without being seen an…

All general hospitals providing extracorporeal shock wave lithotripsy services shall conform to the applicable criteria set forth in this chapter as well as the provisions set forth in N.J.A.C. 8:43A-29. Notes N.J. Admin. Code § 8:43G-37.1

(a) Special hospitals providing long term acute care services shall comply with all standards set forth in this subchapter and all applicable provisions of this chapter. (b) The rules in this subchapter apply to special hospitals providing long term acute care services either as …

(a) All special hospitals providing long term acute care services (LTAC) shall be licensed by the Department and comply with the licensing procedures set forth at N.J.A.C. 8:43G-2. (b) All beds maintained by a special hospital providing long term acute care services shall be lice…

(a) Special hospitals shall have written policies and procedures that are reviewed at least once every three years, revised more frequently as needed, and implemented. They shall include at least:1. Criteria for admission to, and discharge and transfer from, the hospital; 2. A vi…

(a) There shall be a physician director with clinical responsibility for the care rendered throughout the facility. (b) The physician director shall be board certified in internal medicine and licensed or authorized to practice medicine by the New Jersey Board of Medical Examiner…

(a) Nursing staff shall be determined by the acuity of illness of the patient. The hospital shall develop written policies and procedures for determining and relating patient acuity to nursing staff levels. (b) There shall be a full-time director of nursing or nursing administrat…

(a) There shall be a program of continuous quality improvement which includes regularly collecting and analyzing data to help identify health-service problems and their extent, and for recommending, implementing, and monitoring corrective actions on the basis of these data. (b) T…

(a) Every New Jersey hospital patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questio…

Notes N.J. Admin. Code § 8:43G-4.2

(a) There shall be an organizational chart of the hospital and each service that shows lines of authority, responsibility, and communication between and within services. (b) The hospital shall have an established and functioning governing body responsible for establishing hospita…

(a) All hospitals providing emergency room services shall be members in good standing of the New Jersey Poison Information and Education System established pursuant to N.J.S.A. 26:2-119 et seq. (b) All hospitals with licensed obstetric or pediatric beds or designated as a Communi…

(a) There shall be an employee-management occupational health and safety committee that: 1. Meets a minimum of six times a year; 2. Establishes a procedure for receiving and responding to employees' occupational health and safety complaints and concerns; 3. Receives, investigates…

(a) The hospital shall develop and implement a written policy to assure that staff have the right to voice occupational health and safety complaints or problems without reprisals. (b) The hospital shall have available the most current version of standards and guidelines for: 1. C…

The hospital shall designate an individual to provide clinical guidance on occupational health and safety issues who is a physician with occupational medicine background, an industrial hygienist, or a health professional with two years of experience in occupational health. Notes …

(a) The hospital shall develop, revise as necessary, and implement a written plan of staff education. The plan shall address the education needs of different categories of employees with potential exposure to hazardous substances, including at least cytotoxic drugs, waste anesthe…

There shall be a program of continuous quality improvement for occupational health that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify occupational health problems and their extent, and …

(a) The hospital shall have a written, comprehensive disaster plan. The disaster plan, and any updates or changes to it, shall be submitted to the Inspection Service Program within the Department and shall include the following: 1. Identification of potential hazards that could n…