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

(a) The following words and terms, when used in this subchapter, shall have the meanings established at N.J.S.A. 26:2H-12.6b. "Division on Women" "Emergency care to sexual assault victims" "Emergency contraception" "Medically and factually accurate and objective" "Sexual assault …

(a) Each emergency health care facility shall provide emergency care to a sexual assault victim, including:1. Medically and factually accurate and objective verbal and written information about emergency contraception and sexually transmitted diseases, as set forth at N.J.A.C. 8:…

(a) Each emergency health care facility shall establish written policies and procedures to ensure that all personnel who provide care or information to a sexual assault victim: 1. Complete mandatory training to provide medically and factually accurate and objective verbal and wri…

(a) Each emergency health care facility shall provide each sexual assault victim a copy of the brochure entitled "For People Who Have Been Sexually Assaulted . . . What You Need To Know about STDs and Emergency Contraception." (b) The Department shall make a copy of the brochure …

The Department shall investigate every complaint of an emergency health care facility's noncompliance with the provisions of the Act, in accordance with N.J.S.A. 26:2H-12.6f(a), including the failure of a facility to provide the services required by the Act. Notes N.J. Admin. Cod…

(a) If the Department determines that an emergency health care facility has violated any provision of the Act, the Department may assess the penalty established at N.J.A.C. 8:43E-3.4(a)16. 1. All penalties assessed pursuant to (a) above shall be allocated on a quarterly basis to …

(a) The housekeeping service 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 a minimum, scope of responsibility, assignment by designated unit, and responsibil…

There shall be a designated director or supervisor of laundry with a minimum of two years of experience in institutional laundry service. Notes N.J. Admin. Code § 8:43G-13.10 Amended by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register …

(a) All laundry from patient rooms and other service areas shall be transported in such a way that no leakage occurs. (b) Laundry carts shall be in good repair, kept clean, and identified for use with either clean linen or soiled laundry. (c) Clean linen shall be transported in c…

(a) Soiled laundry shall be stored in containers provided for it in a clean, ventilated, vermin-proof and vermin-free area, separate from other supplies. It shall be collected from the storage area regularly so that it does not overflow or accumulate beyond the capacity of the st…

(a) The hospital shall have on-site an adequate supply, in good repair, of sheets, pillowcases, drawsheets, blankets, towels, washcloths, and scrub suits. 1. All hospitals shall provide laundered scrub suits in the following areas: surgical suites, obstetrical surgical suites, po…

(a) Requirements for the laundry staff education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) Orientation for new laundry employees shall include protocols for handling and receiving soiled laundry and clean linen. Notes N.J. Admin. Code § 8:43G-13.14

(a) There shall be a program of continuous quality improvement for the laundry service that is coordinated with the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help identify problems and their extent, and recommending, i…

The sanitation service shall have written policies and procedures that are reviewed every three years, revised as needed, and implemented. They include, at least, scope of responsibility, assignment by designated unit, and responsibility for all sanitation tasks. Notes N.J. Admin…

There shall be a designated director or supervisor of sanitation with specialized training or education in institutional sanitation service. A consultant may be used to fulfill this role. Notes N.J. Admin. Code § 8:43G-13.17 New Rule, R.2004 d.302, effective 8/2/2004. See: 35 New…

(a) The water supply shall be adequate in quantity, of a safe sanitary quality, and from a water system that is constructed, protected, operated, and maintained in conformance with the New Jersey Safe Drinking Water Act, N.J.S.A. 58:12A-1 et seq., and N.J.A.C. 7:10 and other appl…

(a) Water piping carrying non-potable water shall be clearly labeled as such. (b) The sewage disposal system shall be maintained in good repair and operated in compliance with State and local laws, ordinances, and regulations. (c) There shall be no direct physical connections bet…

There shall be a housekeeping or environmental service with a designated director who has at least two years of experience in institutional housekeeping or environmental services. Notes N.J. Admin. Code § 8:43G-13.2

The hospital shall adhere to the water sampling schedule and the chemical and biological monitoring requirements of the water supply system set by the New Jersey Department of Environmental Protection. Records of the sampling and monitoring shall be maintained. Notes N.J. Admin. …

(a) The hospital shall develop and implement and the Infection Control Program shall review, approve, and audit written policies and procedures for collection, storage, handling, transport and disposal transport of medical waste, in conformance with applicable Federal and State l…

(a) Policies and procedures for solid waste and recyclables shall be established and enforced to ensure appropriate collection, storage and disposal and to maintain them clean and odor-free and to prevent the breeding of insects or vermin. (b) Solid waste shall be stored within t…

Notes N.J. Admin. Code § 8:43G-13.3

(a) All areas, including areas with limited access such as cabinets, drawers, locked medication rooms, and storage areas, shall be kept clean to sight and touch. (b) All toilets and bathrooms shall be kept clean to sight and touch, in good repair, and free of odors that reflect p…

(a) Toilet tissue and proper waste receptacles shall be provided in all toilet areas. (b) Hand cleanser, sanitary towels, and waste receptacles or hand-drying machines shall be provided at each handwashing unit. Hand cleanser and hand-drying machines shall be approved by the infe…

Notes N.J. Admin. Code § 8:43G-13.6

(a) Requirements for the housekeeping education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) Orientation for new housekeeping employees shall include training in cleaning and infection control techniques. (c) For specialty units, including at least the newborn nursery,…

(a) There shall be a program of quality improvement for housekeeping that is coordinated with the hospital quality improvement program and includes collecting and analyzing data to help identify problems and their extent, and recommending, implementing, and monitoring corrective …

(a) The laundry service shall have written policies and procedures, which are reviewed every three years or more frequently as needed, revised as needed, implemented, and followed, and which include at least a policy that identifies special handling practices for soiled laundry. …

(a) A hospital epidemiologist shall direct and oversee the hospital Infection Control Program. A hospital epidemiologist is defined as a physician who is board certified in a medical specialty, preferably Infectious Diseases, and has training (such as a Centers for Disease Contro…

Notes N.J. Admin. Code § 8:43G-14.10 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Sanitation space and environment".

Notes N.J. Admin. Code § 8:43G-14.11 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Sanitation quality assurance methods".

Notes N.J. Admin. Code § 8:43G-14.12 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Regulated medical waste policies and procedures".

Notes N.J. Admin. Code § 8:43G-14.13 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Solid waste policies and procedures".

Notes N.J. Admin. Code § 8:43G-14.14 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Solid waste patient services".

Notes N.J. Admin. Code § 8:43G-14.15 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Solid waste space and environment".

Notes N.J. Admin. Code § 8:43G-14.16 Repealed by R.2004 d.302, effective 8/2/2004. See: 35 New Jersey Register 2847(a), 35 New Jersey Register 3782(a), 36 New Jersey Register 3538(a). Section was "Solid waste supplies and equipment".

Notes N.J. Admin. Code § 8:43G-14.2

The infection control professional shall have education or training in surveillance, prevention, and control of nosocomial infections. The infection control professional shall be certified in infection control within five years of beginning practice of infection control and shall…

Notes N.J. Admin. Code § 8:43G-14.4

(a) There shall be a hospital epidemiologist and infection control professional(s) who are responsible for coordination of the infection control program. (b) There shall be a ratio of the equivalent of at least one full-time infection control professional to every 200 adjusted oc…

(a) Between October 1, or earlier if the vaccination is available, and February 1 of every year, provided a patient's medical condition permits, every patient aged 65 or older shall be provided the opportunity to receive vaccination against influenza, in accordance with the recom…

(a) Requirements for the infection control staff education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) The infection control professional shall coordinate educational programs to address specific problems, as recommended by the Centers for Disease Control and Preventi…

The infection control professional shall develop and implement a program of continuous quality improvement that is integrated into the hospital continuous quality improvement program and includes regularly collecting and analyzing data to help determine the effectiveness of infec…

(a) A hospital shall establish, implement, and periodically update, evidence-based protocols for the early identification and treatment of patients with sepsis and septic shock (sepsis protocols). (b) The sepsis protocols shall address, at a minimum:1. Screening patients for, and…

(a) There shall be a medical record department with the primary responsibility of maintaining medical records for all inpatients treated at the hospital. (b) There shall be a system for identifying medical records to facilitate their retrieval by patient identifier. (c) If the ho…

(a) The medical record department 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. Procedures for record completion, including chart analysis; 2. Condi…

(a) Health care practitioners who provide clinical services to the patient shall enter clinical/progress notes in the patient's medical record, when the services are rendered. (b) Notes that provide a full and accurate description of the care provided to the patient shall be made…