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

(a) The hospital 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 on the admission of patients, transfer of patients to another facil…

The hospital shall provide at least one room designated for electrocardiography. Sufficient space shall be provided for the maintenance of essential records and such office space as may be required. Notes N.J. Admin. Code § 8:43G-5.20

(a) All hospitals shall provide, on a regular and continuing basis, out-patient and preventive services, including clinic services for medically indigent patients, in those services provided on an in-patient basis. (b) In no instance shall a hospital provide less than out-patient…

(a) In addition to any general orientation, a general hospital shall ensure that all members of the hospital's governing body complete a trustee training program as set forth in (b) below conducted by an approved training provider within six months of the member's appointment. (b…

(a) In accordance with N.J.S.A. 26:2H-12.3 4b, the Department approves the following as trustee training providers: 1. Accredited academic institutions that do not have a direct interest, corporate relationship, or primary mission in the support or development of the hospital off…

(a) The administrator or chief executive officer of the hospital shall have at least one of the following qualifications:1. A master's degree and at least three years of full-time experience in progressively responsible management positions; 2. A baccalaureate degree and at least…

(a) The hospital shall develop and implement written protocols for organ and tissue donation in accordance with N.J.S.A. 26:6-57 et seq., and the Uniform Anatomical Gift Act, P.L. 1969, c.161, as amended. (b) For the purposes of this rule, the following words shall have the follo…

(a) To meet the needs of pediatric patients, the hospital shall have available medical and nursing staff with specialized pediatric training and shall have equipment adaptable to the needs of pediatric patients on-site. (b) The hospital shall ensure the safe transport of patients…

(a) A general hospital shall post, in a conspicuous place in each of its waiting rooms for members of the general public, the notice about the Independent Health Care Appeals Program (IHCAP notice) entitled, "An Explanation of an Individual's Right to Appeal Health Insurance Dete…

(a) There shall be a formal orientation program for all new permanent staff that includes at least training in patient rights as found at N.J.A.C. 8:43G-4, a tour of the hospital, orientation to the hospital's security system and disaster plan, and review of procedures to follow …

Notes N.J. Admin. Code § 8:43G-5.8

(a) Each department in the hospital shall develop, revise as necessary, and implement a written plan of staff education. The plan shall address the education needs, relevant to the service, of different categories of staff on all work shifts. The plan shall include education prog…

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: "Accreditation Council of Graduate Medical Education" means the Accreditation Council of Graduate Medical Education, for which the conta…

(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) Anesthesia services shall be administered in accordance with written policies and procedures that are reviewed at least annually, and revised as needed to ensure the safety of patients during the administration and conduct of, and emergence from, anesthesia and shall include …

(a) There shall be a physician director of anesthesia services who is a diplomate of either the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology, or who was made a fellow of the American College of Anesthesiology before 1982. (b) The physician …

At all times, an anesthesiologist shall be on-site or on-call and available to reach the hospital within 30 minutes under normal transportation conditions. Notes N.J. Admin. Code § 8:43G-6.4 Amended by R.1991 d.451, effective 8/19/1991, operative October 15, 1991. See: 22 New Jer…

(a) A preanesthesia note, reflecting evaluation of the patient and review of the patient record prior to administration of anesthesia, shall be made or certified by the APN/anesthesia or the physician administering or supervising, as applicable, the administration of anesthesia a…

(a) Diameter index safety systems or equivalent shall be used on all large cylinders of medical gases and wall and ceiling outlets of medical gases. (b) Pin index safety systems with a single washer shall be used on all small cylinders to prevent interchangeability of medical gas…

(a) A record shall be maintained of all service and maintenance performed on all anesthesia machines, ventilators, and vaporizers. The record shall include machine identification; name of servicing agent; work performed; and date of work. This maintenance shall conform with maint…

(a) An in-circuit oxygen analyzer shall monitor the oxygen concentration within the breathing circuit, displaying the percent oxygen of the total mixture, for all patients receiving general anesthesia. (b) A respirometer (volumeter) measuring exhaled tidal volume shall be used wh…

Requirements for the anesthesia education program shall be as set forth in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-6.9 Amended by R.1991 d.451, effective 8/19/1991, operative October 15, 1991. See: 22 New Jersey Register 3470(a), 23 New Jersey Register 2527(a). Recodif…

(a) The standards set forth in this subchapter shall apply only to separate, designated units or services for adult and/or pediatric cardiac surgery, cardiac catheterization, and interventional cardiac procedures. All hospitals licensed to provide any of these services shall also…

Requirements for the cardiac service staff education program shall be as provided at N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-7.10

Notes N.J. Admin. Code § 8:43G-7.11

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

Notes N.J. Admin. Code § 8:43G-7.13

(a) Cardiac catheterization services shall be promptly accessible in a hospital setting, either on-site or by immediate transfer, in which case there shall be a written transfer agreement. (b) The cardiac catheterization laboratory shall perform a minimum of 500 catheterizations,…

(a) There shall be a director of cardiac catheterization who is board certified in internal medicine in the subspecialty of cardio-vascular disease, and who has completed at least one year of additional training in cardiac catheterization and has performed at least 200 cardiac pr…

(a) The following staff shall be present for all cardiac catheterization procedures: 1. A physician who meets the requirements in N.J.A.C. 8:43G-7.15(b); 2. A registered professional nurse, trained and experienced in assisting in cardiac catheterization procedures, who acts as th…

Handwashing between contacts with patients shall be performed using an antimicrobial agent by all personnel involved in patient care in the cardiac catheterization laboratory. Notes N.J. Admin. Code § 8:43G-7.17

(a) All persons entering the cardiac catheterization laboratory shall be attired in scrub suits. Limited access people may wear cover gowns or jumpsuits as substitutes. (b) The procedure room in the cardiac catheterization laboratory shall have a minimum clear area of 400 square …

(a) All cardiac catheterization laboratory linens and apparel shall be laundered in the laundry services provided by the hospital. (b) The cardiac catheterization laboratory shall be equipped with radiological equipment strong enough to produce an image and in accordance with N.J…

(a) At least 350 open-heart operations shall be performed at each licensed cardiac surgical center by the end of the third year of operation and annually thereafter as referenced at N.J.A.C. 8:33E-2.3(a)1 and 2. (b) The hospital shall have in effect policies and procedures which …

Requirements for the cardiac catheterization staff education program shall be as provided at N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-7.20

(a) The quality assurance program for cardiac catheterization shall include at least: 1. Monitoring the volume of procedures; 2. Infection and complication rates; 3. The incidence of mortality, morbidity, and other adverse occurrences; 4. Patient factors that affect risk of compl…

In addition to meeting all applicable standards in N.J.A.C. 8:43G-7.1 through 7.21, a pilot catheterization program established in accordance with N.J.A.C. 8:33E shall comply with all standards in N.J.A.C. 8:43G-7.23 through 7.27. Notes N.J. Admin. Code § 8:43G-7.22 New Rule, R.1…

(a) Initial licenses granted to pilot catheterization program facilities shall be valid for a period not to exceed 30 months from the month in which the facility initiates low risk invasive cardiac diagnostic services under the program and shall expire automatically without the n…

The pilot catheterization program shall perform a minimum of 350 left-heart catheterizations annually by the end of the second year of operation. In accordance with N.J.A.C. 8:33E-1.14, the program shall demonstrate and verify its ability to provide at least this level of service…

(a) There shall be a physician director of the program who is board certified in internal medicine in the subspecialty of cardiovascular disease. The director shall have completed at least one year of additional training and performed at least 200 cardiac procedures as the primar…

(a) There shall be at least one physician trained and experienced in cardiac catheterization present in the room during all catheterization and angiographic procedures. (b) There shall be at least one registered professional nurse with appropriate training and experience, in acco…

(a) The pilot catheterization program shall include at least the following quality improvement indicators:1. Low-risk patient mortality and morbidity rate; 2. Physician-specific and overall pilot laboratory percentage of normal studies (not to exceed 25 percent of total annual ca…

(a) Elective percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary interventions (PCI) shall be performed only in cardiac surgical centers approved by the Department unless a certificate of need has been granted in accordance with N.J.A.C. 8:33-3.11. (b) …

(a) Any physician performing PTCA as primary operator shall meet one of the following qualifications: 1. Is board certified in both internal medicine and the subspecialty of cardiovascular disease, or is board eligible in the subspecialty of cardiovascular disease and shall be ex…

(a) There shall be a director of the cardiac surgery service who is board certified in thoracic surgery. (b) The primary surgeon shall be board certified in thoracic surgery, or shall meet current requirements to be examined and shall be examined within two years of eligibility. …

(a) The following staff shall be present for all PTCA procedures: 1. A physician who meets the requirements in N.J.A.C. 8:43G-7.23(a); 2. A registered professional nurse certified in basic cardiac life support, and trained and experienced in cardiac catheterization and PTCA who a…

There shall be an operating room available for immediate use on-site that complies with criteria established in the hospital's surgery policies and procedures and meets the minimal physical requirements of N.J.A.C. 5:23-3.2(b), any time a PTCA procedure is performed on an electiv…