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

In addition to the standards in N.J.A.C. 8:43G-7.1 through 7.34 for adult cardiac services, the following standards in N.J.A.C. 8:43G-7.36 through 7.46 shall apply to separate, designated units or services for pediatric cardiac diagnostic services and pediatric surgical centers. …

(a) At least 150 open and closed heart operations shall be performed in the hospital per year with at least 75 open heart operations performed per year, excluding the first three years following initiation of services as referenced at N.J.A.C. 8:33E-2.3(b)1. (b) The hospital shal…

(a) There shall be a director of the pediatric cardiac surgery service who is board certified in thoracic surgery and has five years prior experience in pediatric cardiac surgery. (b) Effective July 1, 1990, the surgeon in charge of a pediatric cardiac operation shall be board ce…

(a) All staff providing clinical services to the pediatric cardiac surgical patient shall be trained and experienced in pediatric cardiac surgical care. (b) There shall be at least a ratio of one registered nurse to one patient at all times during the first 24 hours of the patien…

The hospital shall designate beds in the cardiac surgical intensive care service, the pediatric surgical intensive care service or the pediatric medical intensive care service for patients from the pediatric cardiac surgical service. Notes N.J. Admin. Code § 8:43G-7.39 Amended by…

Notes N.J. Admin. Code § 8:43G-7.4

(a) There shall be monitoring and treatment equipment available that is appropriate for the pediatric cardiac surgical patient. (b) The pediatric cardiac surgical intensive care service shall have equipment and staff for at least the following: 1. Hemodynamic and electrocardiogra…

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

Notes N.J. Admin. Code § 8:43G-7.42 Recodified from N.J.A.C. 8:43G-7.36 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 Register 4293(c).

(a) Pediatric invasive cardiac diagnostic procedures shall be performed only at pediatric cardiac surgery centers. (b) The pediatric cardiac catheterization service may share the catheterization laboratory with the adult cardiac catheterization program. However, the staff who par…

(a) There shall be a director of the pediatric cardiac catheterization service who is board certified in pediatrics, in the subspecialty of pediatric cardiology, and who has completed at least one year of additional training in an accredited program for interventional pediatric c…

There shall be a peer review committee for the pediatric cardiac catheterization service that includes at least the director of the pediatric catheterization laboratory, the director of pediatric cardiology, a pediatric catheterization cardiologist, and a non-catheterizing cardio…

(a) Exceptions for physicians with hospital privileges to these minimum board certification and training requirements may be granted by the Commissioner or his or her designee upon application by an institution providing acceptable documentation which assures that the physician's…

(a) There shall be at least a ratio of one registered professional nurse to one patient during the patient's stay in the cardiovascular surgical intensive care service or recovery room until the patient is stabilized. (b) For patients who remain in the cardiovascular surgical int…

Notes N.J. Admin. Code § 8:43G-7.6

(a) Reports of diagnostic and operative procedures performed by cardiac services shall be dictated for inclusion in the medical record not later than 48 hours after completion of the procedure. (b) A note by the physician performing the procedure shall be included in the patient'…

There shall be a cardiac surgical intensive care service or recovery room dedicated specifically to patients from the cardiac surgical service. Notes N.J. Admin. Code § 8:43G-7.8

(a) The cardiac surgical intensive care service or recovery room shall have equipment and staff for the following:1. Hemodynamic and electrocardiogram monitoring; 2. Pacemaker usage; 3. Cardiopulmonary resuscitation; 4. Arrhythmia detection and treatment; and 5. Intra-aortic ball…

This subchapter sets forth the standards for designation as a primary or comprehensive stroke center with which all applicants for the respective designations shall comply. Notes N.J. Admin. Code § 8:43G-7A.1

(a) General hospitals seeking designation as a primary stroke center or a comprehensive stroke center shall meet the applicable minimum criteria and standards contained in this subchapter and file a licensing amendment in accordance with N.J.A.C. 8:43G-2.2. (b) Existing designate…

The following words and terms, when used in this subchapter, shall have the following meanings: "Acute care rehabilitation" means the provision of occupational therapy, physical therapy and speech-language pathology, as medically necessary, during the acute phase of a stroke pati…

(a) To be designated as a primary stroke center, a hospital shall, at a minimum, provide: 1. An acute stroke team available to see a patient identified as a potential acute stroke patient within 15 minutes following the patient's arrival at the hospital's emergency department or …

(a) There shall be a physician director of a primary stroke center, who may also serve as a physician member of a stroke team, who is board certified in neurology or neurosurgery and who shall meet two or more of the following qualifications: 1. Completion of a stroke fellowship;…

(a) A hospital designated as a primary stroke center shall, under the direction of a stroke center physician director, provide education regarding acute stroke to both the hospital's personnel and the public. 1. The hospital shall provide to personnel engaged in direct patient ca…

(a) A hospital designated as a primary stroke center shall collect patient-level data to support evaluation of outcomes and quality improvement activities. 1. Data shall be collected on each patient evaluated for stroke and each patient receiving acute stroke interventional thera…

(a) In addition to meeting the requirements of N.J.A.C. 8:43G-7A.3 and 7A.4, a hospital designated as a comprehensive stroke center shall: 1. Satisfy the following staff qualifications, consistent with the on-call criteria set forth at N.J.A.C. 8:43G-5.1 (l)2: i. A neurosurgical …

(a) In addition to satisfying the requirements of N.J.A.C. 8:43G-7A.5, a hospital designated as a comprehensive stroke center shall:1. Provide guidance and continuing medical education to hospitals designated as primary stroke centers with which they have transfer agreements; 2. …

A hospital designated as a comprehensive stroke center shall, in addition to satisfying the requirements of N.J.A.C. 8:43G-7A.6, develop and maintain de-identified outcomes data from affiliated primary stroke centers and shall integrate this data and its own patient-level data wi…

(a) The hospital's central service shall have written policies and procedures that are reviewed at least once every three years or as needed, revised as needed, and implemented. These policies and procedures shall be approved by the hospital's infection control committee. (b) Pol…

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

(a) All hinged instruments shall be sterilizer processed in an open position. (b) All instruments and equipment shall be visually inspected for cracks, pitting, rust, or any condition that would impede cleaning/sterilization. Defective instruments and equipment shall not be used.…

Notes N.J. Admin. Code § 8:43G-8.12 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 "Sterilizer space and environment".

Notes N.J. Admin. Code § 8:43G-8.13 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 "Sterilizer supplies and equipment".

(a) There shall be a full-time director or supervisor of central service. (b) The director or supervisor of central services shall have two years of supervisory experience and shall be certified through a national sterile processing program recognized by the Department. (c) All p…

(a) Requirements for the central service education program shall be as provided in N.J.A.C. 8:43G-5.9. (b) All new central service employees shall receive on-the-job training on practices and equipment unique to the hospital. (c) Competency for processing tasks shall be documente…

(a) Entrance to the central service processing and decontamination area shall be restricted to persons attired in hospital-laundered or protective attire, in relation to the purpose and scope of their duties. 1. All personnel performing decontamination, preparation, and assembly …

(a) Single use patient care items shall not be reprocessed except under the following conditions: 1. The manufacturer provides written instruction for cleaning and sterilization of the item and the facility has the resources to meet those specifications; and/or 2. Methods for pro…

(a) Each sterilizer processing area shall have exhaust ventilation to remove heat, moisture and odors without recirculating the exhaust to other areas of the hospital. (b) Exterior shipment cartons shall not be brought into sterile supply storage or processing areas. (c) Soiled o…

(a) Patient care items shall be scrupulously cleaned to sterilization or disinfection. The selection and use of disinfection and/or sterilization methods for patient care items or equipment shall be divided into the following three categories: 1. Critical items are objects that e…

(a) Biological monitoring with live spores, or an FDA approved equivalent, shall be performed as follows:1. Ethylene oxide--in each load; 2. Peracetic acid--weekly; 3. Low temperature gas plasma--daily in the working load; and 4. Steam sterilizers--weekly. (b) The biological indi…

Notes N.J. Admin. Code § 8:43G-8.9 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 "Central supply staff education and training".

The standards set forth in this chapter shall apply to licensed critical and intensive care beds inclusive of medical, surgical, coronary, pulmonary, cardiovascular, and neurological critical care, but not pediatric or neonatal intensive care. Notes N.J. Admin. Code § 8:43G-9.1

Notes N.J. Admin. Code § 8:43G-9.10

There shall be a handwashing sink that is easily accessible to each patient's bedside. Notes N.J. Admin. Code § 8:43G-9.11

Notes N.J. Admin. Code § 8:43G-9.12

(a) Each critical care unit shall be equipped to provide at least: 1. Cardiopulmonary resuscitation, including a defibrillator/monitor and emergency drugs; 2. Airway management, including endotracheal and assisted ventilation; 3. Oxygen delivery systems; 4. Continual electrocardi…

Requirements for the critical and intermediate care staff education and training program shall be as provided in N.J.A.C. 8:43G-5.9. Notes N.J. Admin. Code § 8:43G-9.14