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26:2H-12a. . Requirements for licensure of mental health programs
5. A license issued to a mental health program by the Commissioner of Human Services pursuant to P.L.1995, c.321 (C.30:9A-18 et al.) shall be deemed to satisfy the requirements for licensure of a health care facility by the Department of Health pursuant to section 12 of P.L.1971, c.136 (C.26:2H-12) for those mental health programs, and for payment by a purchaser of health care services pursuant to section 18 of P.L.1971, c.136 (C.26:2H-18).
L.1995,c.321,s.5.
26:2H-12.1. Health care facility to provide privileges for podiatrists, psychologists
1. a. Any health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), which provides medical or surgical care, shall provide for the use of the facility by, and appropriate privileges for, duly licensed podiatrists and psychologists. Use of the facility and privileges of a podiatrist or psychologist shall be subject to nondiscriminatory rules and regulations governing such use or privileges established by the governing body of the facility for persons licensed as physicians and surgeons pursuant to R.S.45:9-6 and dentists pursuant to R.S.45:6-19.
b. Nothing in this act shall be construed to require a hospital to grant admitting privileges to a psychologist or to permit the exercise of those privileges granted by the hospital without appropriate collaboration with the attending physician of the patient who is receiving or will receive care or treatment from the psychologist.
L.1983,c.28,s.1; amended 1995,c.310.
26:2H-12.2. Repealed by L.2005,c.83,s.20, amended by L.2005,c.259,s.34 to change ~podiatry~ to ~podiatric medicine.~
26:2H-12.2a Maintenance of records of complaints, disciplinary actions.
3. a. A health care entity shall maintain all records of all documented complaints of events related to patient care about, and disciplinary proceedings or actions against, a health care professional who is employed by or has an affiliation with the health care entity. The health care entity shall retain the information for a period of seven years and make the records, including any information the health care entity has pertaining to records maintained on the health care professional prior to the effective date of P.L.1989, c.300 (C.45:9-19.4 et al.), available to the division, the board which licenses or otherwise authorizes the health care professional to practice, the Medical Practitioner Review Panel established pursuant to section 8 of P.L.1989, c.300 (C.45:9-19.8) and the Department of Health and Senior Services, as applicable, upon request.
b. A health care entity shall maintain for a period of four years all records and source data relating to its mortality, morbidity, complication, infection and readmission and shall make the records available to the division, the board which licenses or otherwise authorizes the health care professional, the review panel and the Department of Health and Senior Services, as applicable, upon request.
c. A health care entity which fails to maintain the records required pursuant to this section shall be subject to such penalties as the Department of Health and Senior Services shall determine pursuant to sections 13 and 14 of P.L.1971, c.136 (C.26:2H-13 and 26:2H-14) and section 16 of P.L.1997, c.192 (C.26:2S-16), or the director shall determine pursuant to P.L.1989, c.331 (C.34:8-43 et seq.), as applicable.
L.1989,c.300,s.3; amended 2005, c.83, s.3.
26:2H-12.2b Notification relative to certain impairments of health care professionals; definitions.
2. a. A health care entity shall notify the division in writing if a health care professional who is employed by, under contract to render professional services to, or has privileges granted by, that health care entity, or who provides such services pursuant to an agreement with a health care services firm or staffing registry:
(1) for reasons relating to the health care professional@s impairment, incompetency or professional misconduct, which incompetency or professional misconduct relates adversely to patient care or safety: (a) has full or partial privileges summarily or temporarily revoked or suspended, or permanently reduced, suspended or revoked; (b) has been removed from the list of eligible employees of a health services firm or staffing registry; (c) has been discharged from the staff; or (d) has had a contract to render professional services terminated or rescinded;
(2) has conditions or limitations placed on the exercise of clinical privileges or practice within the health care entity for reasons relating to the health care professional@s impairment, incompetency or professional misconduct or, which incompetency or professional misconduct relates adversely to patient care or safety, including, but not limited to, second opinion requirements, non-routine concurrent or retrospective review of admissions or care, non-routine supervision by one or more members of the staff, or the completion of remedial education or training;
(3) voluntarily resigns from the staff if: (a)the health care entity is reviewing the health care professional@s patient care or reviewing whether, based upon its reasonable belief, the health care professional@s conduct demonstrates an impairment or incompetence or is unprofessional, which incompetence or unprofessional conduct relates adversely to patient care or safety; or (b)the health care entity, through any member of the medical or administrative staff, has expressed an intention to do such a review;
(4) voluntarily relinquishes any partial privilege or authorization to perform a specific procedure if:(a)the health care entity is reviewing the health care professional@s patient care or reviewing whether, based upon its reasonable belief, the health care professional@s conduct demonstrates an impairment or incompetence or is unprofessional , which incompetence or unprofessional conduct relates adversely to patient care or safety; or(b)the health care entity, through any member of the medical or administrative staff, has expressed an intention to do such a review;
(5) while under, or subsequent to, a review by the health care entity of the health care professional@s patient care or professional conduct is granted a leave of absence for reasons relating to a physical, mental or emotional condition or drug or alcohol use which impairs the health care professional@s ability to practice with reasonable skill and safety, except that no report is required for pregnancy-related leaves of absence or if the health care professional has sought assistance from a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the health care professional and is following the treatment regimen or monitoring as that program requires; or
(6) is a party to a medical malpractice liability suit, to which the health care entity is also a party, and in which there is a settlement, judgment or arbitration award.
As used in this subsection, incompetence, professional misconduct and unprofessional conduct shall not include personal conduct, such as tardiness, insubordination or other similar behavior, which does not relate to patient care or safety.
b. A health care entity shall notify the division in writing if it is in possession of information that indicates that a health care professional has failed to comply with a request to seek assistance from a professional assistance or intervention program approved or designated by the division or a board to provide confidential oversight of the health care professional, or has failed to follow the treatment regimen or monitoring program required by that program to assure that the health care professional@s physical, mental or emotional condition or drug or alcohol use does not impair the health care professional@s ability to practice with reasonable skill and safety.
c. A health care entity shall notify the division in writing if any health care professional who has been the subject of a report pursuant to this section, has had conditions or limitations on the exercise of clinical privileges or practice within the health care entity altered, or privileges restored, or has resumed exercising clinical privileges that had been voluntarily relinquished.
d. In the case of a health care professional who is providing services at a health care entity pursuant to an agreement with a health care services firm or staffing agency and is the subject of a notice pursuant to this section, the health care entity shall, when it submits a notice to the division concerning that health care professional, provide a copy of the notice to the health care services firm or staffing agency.
e. The form of notification shall be prescribed by the Commissioner or Health and Senior Services, in consultation with the Commissioner of Human Services in the case of psychiatric facilities and developmental centers, and shall contain such information as may be required by the division and shall be made within seven days of the date of the action, settlement, judgment or award.
f. A health care entity which fails to provide such notice to the division or fails to cooperate with a request for information by the division, the board or the Medical Practitioner Review Panel established pursuant to section 8 of P.L.1989, c.300 (C.45:9-19.8) shall be subject to such penalties as the Department of Health and Senior Services may determine pursuant to sections 13 and 14 of P.L.1971, c.136 (C.26:2H-13 and 26:2H-14).
g. A health care entity, or any employee thereof, which provides information to the division, the board, the Medical Practitioner Review Panel, a health care services firm or staffing agency, or the Department of Health and Senior Services, in good faith and without malice, regarding a health care professional pursuant to the provisions of this section or section 3 of P.L.1989, c.300 (C.26:2H-12.2a), is not liable for civil damages in any cause of action arising out of the provision or reporting of the information.
h. A health care entity shall provide the health care professional who is the subject of a notice pursuant to paragraphs (1), (2), (4) and (5) of subsection a. of this section and subsection c. of this section with a copy of the notice provided to the division, when the health care entity submits the notice to the division.
i. For the purposes of this section, section 3 of P.L.1989, c.300 (C.26:2H-12.2a) and section 15 of P.L.2005, c.83 (C.26:2H-12.2c):
~Board~ means a professional and occupational licensing board within the Division of Consumer Affairs in the Department of Law and Public Safety which licenses or otherwise authorizes a health care professional to practice a health care profession.
~Division~ means the Division of Consumer Affairs in the Department of Law and Public Safety.
~Health care entity~ means a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), a health maintenance organization authorized to operate pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), a carrier which offers a managed care plan regulated pursuant to P.L.1997, c.192 (C.26:2S-1 et seq.), a State or county psychiatric hospital, a State developmental center, a staffing registry, and a home care services agency as defined in section 1 of P.L.1947, c.262 (C.45:11-23).
~Health care professional~ means a person licensed or otherwise authorized pursuant to Title 45 or Title 52 of the Revised Statutes to practice a health care profession that is regulated by the Director of the Division of Consumer Affairs or by one of the following boards: the State Board of Medical Examiners, the New Jersey Board of Nursing, the New Jersey State Board of Dentistry, the New Jersey State Board of Optometrists, the New Jersey State Board of Pharmacy, the State Board of Chiropractic Examiners, the Acupuncture Examining Board, the State Board of Physical Therapy, the State Board of Respiratory Care, the Orthotics and Prosthetics Board of Examiners, the State Board of Psychological Examiners, the State Board of Social Work Examiners, the State Board of Veterinary Medical Examiners, the State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians, the Audiology and Speech-Language Pathology Advisory Committee, the State Board of Marriage and Family Therapy Examiners, the Occupational Therapy Advisory Council and the Certified Psychoanalysts Advisory Committee. ~Health care professional~ also includes a nurse aide and a personal care assistant certified by the Department of Health and Senior Services.
L.2005,c.83,s.2.
26:2H-12.2c Disclosure of information by health care entity.
15. a. A health care entity, upon the inquiry of another health care entity, shall truthfully:
(1) disclose whether, within the seven years preceding the inquiry, it provided any notice to the division pursuant to section 2 of P.L.2005, c.83 (C.26:2H-12.2b), or to the review panel, as required by section 3 of P.L.1989, c.300 (C.26:2H-12.2a), with respect to the health care professional about whom the inquiry has been made, providing a copy of the form of notification and any supporting documentation that was provided to the division, a professional or occupational licensing board in the Division of Consumer Affairs in the Department of Law and Public Safety, or the review panel; and
(2) provide information about a current or former employee@s job performance as it relates to patient care, as provided in this section, and, in the case of a former employee, the reason for the employee@s separation.
b. For the purposes of this section, ~job performance~ shall relate to the suitability of the employee for re-employment at a health care entity, and the employee@s skills and abilities as they relate to suitability for future employment at a health care entity. Information about a current or former employee@s job performance pursuant to this paragraph shall be based on the employee@s performance evaluation, and provided to another health care entity only if: (1) the evaluation has been signed by the evaluator and shared with the employee; (2) the employee has had the opportunity to respond; and (3) the employee@s response, if any, has been taken into consideration when providing the information to another health care entity.
Job performance as it relates to patient care shall not include the current or former employee@s participation in labor activities pursuant to the ~National Labor Relations Act,~ 29 U.S.C. s.151 et seq.
c. A health care entity, or any employee designated by the entity, which, pursuant to this section, provides information in good faith and without malice to another health care entity concerning a health care professional, including information about a current or former employee@s job performance as it relates to patient care, is not liable for civil damages in any cause of action arising out of the provision or reporting of the information.
d. health care entity which fails to truthfully disclose information to another health care entity making an inquiry pursuant to this section or fails to cooperate with such request for information by the other health care entity shall be subject to such penalties as the Department of Health and Senior Services may determine pursuant to sections 13 and 14 of P.L.1971, c.136 (C.26:2H-13 and 26:2H-14) and section 16 of P.L.1997, c.192 (C.26:2S-16), or the director shall determine pursuant to P.L.1989, c.331 (C.34:8-43 et seq.), as applicable.
L.2005,c.83,s.15.
26:2H-12.2d Provision of information by health care professional, immunity from civil liability.
16. a. A health care professional employed by or practicing at a health care entity shall promptly notify the person at the entity, who is designated by that entity, if the health care professional is in possession of information which reasonably indicates that another health care professional who is employed by or practicing at the entity has demonstrated an impairment, gross incompetence or unprofessional conduct which would present an imminent danger to an individual patient or to the public health, safety or welfare.
b. A health care professional who provides information pursuant to this section, in good faith and without malice, shall not be liable for civil damages in any cause of action arising out of the provision of such information.
c. The reporting requirement in this section shall be in addition to the reporting requirement for health care professionals established in section 12 of P.L.2005, c.83 (C.45:1-37).
L.2005,c.83,s.16.
26:2H-12.3. Hospital respite care program
A general hospital which has had an average of 20% or more of its beds vacant on weekends over a six month period may apply to the Commissioner of Health for permission to establish a hospital respite care program for senior citizens. Under such a program, otherwise empty hospital facilities, in a section separate from medical and surgical patients, shall be used to provide shelter, food, recreation and supervision to senior citizens age 65 or older who are ordinarily dependent upon family members or others for their care. The purpose of the hospital respite care program is to provide quality care to the elderly while enabling those who ordinarily care for an elderly person to be temporarily relieved of the stress of this responsibility. A hospital having an overall vacancy rate in excess of 20% over a six month period may also apply to the commissioner for permission to offer this service on weekdays for periods determined by the commissioner.
L. 1986, c. 11, s. 1.
26:2H-12.4 Application procedure for hospital respite care program.
2. A hospital applying for permission to establish a hospital respite care program is not required to apply for a certificate of need pursuant to section 7 of P.L.1971, c.136 (C.26:2H-7) and is required to demonstrate only that it has the vacancy rate required by this act and adequate staff to serve the number of senior citizens it proposes to accept.
L.1986,c.11,s.2; amended 1998, c.43, s.13.
26:2H-12.5. Rules, regulations
The Commissioner of Health shall, pursuant to the ~Administrative Procedure Act,~ P.L. 1968, c. 410 (C. 52:14B-1 et seq.), promulgate such rules and regulations as may be necessary to effectuate the purposes of this act.
L. 1986, c. 11, s. 3.
26:2H-12.6. Care of newborn children
The governing body of a health care facility licensed in this State pursuant to P.L. 1971, c. 136 (C. 26:2H-1 et seq.) which provides health care services to newborn children shall adopt policies and procedures which ensure that newborn children, including newborn handicapped children, receive a level of nourishment and medical care consistent with accepted medical standards.
If a federal statute or regulation requires that the State submit its regulations and policy to the federal government for approval in order to qualify for federal funding, then the State Department of Health shall so comply.
L. 1987, c. 49, s. 1.
26:2H-12.6a Preparation, distribution of pamphlet providing information on child abuse, neglect.
1. a. The Department of Human Services, in consultation with the Department of Health and Senior Services, shall prepare a pamphlet which provides information on child abuse and neglect to all parents of newborn infants born in this State. The pamphlet shall be distributed to each parent present during the infant@s birth, by the personnel at a hospital or birthing facility at the time of the mother@s discharge, as part of the hospital or birthing facility@s discharge procedures.
b. The pamphlet shall include information on the signs of child abuse and neglect, the services provided by the State which help in preventing child abuse and neglect and the legal ramifications of abusing or neglecting a child.
c. The department shall distribute the pamphlet, at no charge, to all the hospitals and birthing facilities in the State. The department shall update the pamphlet as necessary, and shall make additional copies of the pamphlet available to health care providers upon request.
L.1998,c.136,s.1.
26:2H-12.6b Definitions relative to emergency contraception for sexual assault victims.
1. As used in this act:
~Commissioner~ means the Commissioner of Health and Senior Services.
~Division on Women~ means the Division on Women in the Department of Community Affairs.
~Emergency care to sexual assault victims~ means a medical examination, procedure or service provided by an emergency health care facility to a sexual assault victim following an alleged sexual offense.
~Emergency contraception~ means one or more prescription drugs to prevent pregnancy, used separately or in combination, administered to or self-administered by a patient within a medically recommended time after sexual intercourse, dispensed for that purpose in accordance with professional standards of practice and determined to be safe by the United States Food and Drug Administration.
~Emergency health care facility~ means a general hospital or satellite emergency department licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).
~Medically and factually accurate and objective~ means verified or supported by the weight of research conducted in compliance with accepted scientific methods and standards, published in peer-reviewed journals and recognized as accurate and objective by leading professional organizations and agencies with relevant expertise in the field of obstetrics and gynecology.
~Sexual Assault Nurse Examiner program~ means the Statewide Sexual Assault Nurse Examiner program in the Division of Criminal Justice in the Department of Law and Public Safety, established pursuant to P.L.2001, c.81 (C.52:4B-50 et seq.).
~Sexual assault victim~ means a female who alleges or is alleged to have suffered a personal, physical or psychological injury as a result of a sexual offense.
~Sexual offense~ means sexual assault and aggravated sexual assault as set forth in N.J.S.2C:14-2, criminal sexual contact and aggravated criminal sexual contact as set forth in N.J.S.2C:14-3, fourth degree lewdness as set forth in subsection b. of N.J.S.2C:14-4 and endangering the welfare of a child by engaging in sexual conduct which would impair or debauch the morals of the child as set forth in N.J.S.2C:24-4.
L.2005,c.50,s.1.
26:2H-12.6c Provision of emergency care to sexual assault victim.
2. An emergency health care facility shall provide emergency care to a sexual assault victim. It shall be the standard of care for an emergency health care facility to:
a. provide each sexual assault victim with medically and factually accurate and objective oral and written information about emergency contraception and sexually transmitted diseases, as provided for in section 4 of this act;
b. orally inform each sexual assault victim of her option to be provided emergency contraception at the health care facility; and
c. provide emergency contraception to the sexual assault victim, upon her request, unless contraindicated. If the emergency contraceptive is in the form of pills, the provision of the emergency contraception shall include the initial dose that the victim may take at the emergency health care facility, as well as the follow-up dose that the victim can self-administer later.
An emergency health care facility shall not be required to provide emergency contraception to a sexual assault victim who is pregnant.
L.2005,c.50,s.2.
26:2H-12.6d Policies, procedures concerning personnel training.
3. An emergency health care facility shall have written policies and procedures to ensure that all personnel who provide care or information to a sexual assault victim:
a. are trained to provide medically and factually accurate and objective information about emergency contraception and sexually transmitted diseases to a sexual assault victim; and
b. provide that information to a sexual assault victim.
L.2005,c.50,s.3.
26:2H-12.6e Written information relative to emergency contraception for sexual assault victims.
4. a. The commissioner, in collaboration with the Director of the Division on Women, the New Jersey Coalition Against Sexual Assault and the Sexual Assault Nurse Examiner program, shall develop, prepare and produce, in quantities sufficient to comply with the purposes of this act, written information relating to: emergency contraception for the prevention of pregnancy in sexual assault victims; and sexually transmitted diseases.
b. The information shall be clearly written and readily comprehensible in a culturally competent manner, as the commissioner, in collaboration with the Division on Women, the New Jersey Coalition Against Sexual Assault and the Sexual Assault Nurse Examiner program, deems necessary to inform a sexual assault victim. The information shall explain:
(1) the nature of emergency contraception, the effectiveness of emergency contraception in preventing pregnancy, where emergency contraception can be obtained, and treatment options; and
(2) the symptoms and effects of sexually transmitted diseases, and treatment options.
c. The information shall be distributed to all hospital and satellite emergency departments in the State for use in those facilities pursuant to this act.
L.2005,c.50,s.4.
26:2H-12.6f Responsibilities of commissioner concerning compliance.
5. a. The commissioner shall:
(1) investigate every complaint of noncompliance with the provisions of this act by an emergency health care facility, including the failure of a facility to provide the services required by this act;
(2) determine whether the complaint is substantiated, and if so, what action shall be taken by the emergency health care facility or commissioner to address the complaint;
(3) notify the Sexual Assault Nurse Examiner program of all substantiated complaints;
(4) compile the substantiated complaints;
(5) analyze the substantiated complaints, at least annually, to determine if there is any pattern of failure to provide services pursuant to this act; and
(6) determine, at least annually, whether an emergency health care facility is complying with the provisions of this act. The commissioner may utilize all means within his regulatory authority concerning health care facilities to verify a facility@s compliance with this act.
b. If the commissioner determines that an emergency health care facility is not in compliance with the provisions of this act, the commissioner may assess such penalties and take other actions against the facility, as provided in P.L.1971, c.136 (C.26:2H-1 et seq.). Any such penalties assessed for noncompliance shall be paid to the Department of the Treasury and allocated, on a quarterly basis, to the Division on Women for supplemental funding for designated rape crisis centers.
c. The commissioner shall prepare an annual report, which shall be available to the public, summarizing the substantiated complaints, the actions taken by an emergency health care facility or the commissioner to address the complaints, and the commissioner@s findings concerning any pattern of failure to provide services under, or noncompliance with, the provisions of this act.
L.2005,c.50,s.5.
26:2H-12.6g Rules, regulations.
7. Pursuant to the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.), the commissioner, in consultation with the Director of the Division on Women and the Sexual Assault Nurse Examiner program, shall adopt rules and regulations to effectuate the purposes of this act; except that, notwithstanding any provision of P.L.1968, c.410 to the contrary, the commissioner may adopt, immediately upon filing with the Office of Administrative Law, such regulations as the commissioner deems necessary to implement the provisions of this act, which shall be effective for a period not to exceed six months and may thereafter be amended, adopted or readopted by the commissioner in accordance with the requirements of P.L.1968, c.410.
L.2005,c.50,s.7.
26:2H-12.7. Legislative findings and declarations
The Legislature finds and declares that a person admitted to a general hospital often feels overwhelmed and uncertain as to his condition and course of treatment, and that the declaration of a bill of rights for hospital patients may lead to fuller understanding and greater security on the part of patients as well as greater sensitivity by the providers of medical care.
L.1989,c.170,s.1.
26:2H-12.8 Rights of persons admitted to a general hospital.
2. Every person admitted to a general hospital as licensed by the State Department of Health and Senior Services pursuant to P.L.1971, c.136 (C.26:2H-1 et al.) shall have the right:
a. To considerate and respectful care consistent with sound nursing and medical practices, which shall include being informed of the name and licensure status of a student nurse or facility staff member who examines, observes or treats the patient and the right to expect and receive appropriate assessment, management and treatment of pain as an integral component of that person@s care;
b. To be informed of the name of the physician responsible for coordinating his care;
c. To obtain from the physician complete, current information concerning his diagnosis, treatment, and prognosis in terms he can reasonably be expected to understand. When it is not medically advisable to give this information to the patient, it shall be made available to another person designated by the patient on his behalf;
d. To receive from the physician information necessary to give informed consent prior to the start of any procedure or treatment and which, except for those emergency situations not requiring an informed consent, shall include as a minimum the specific procedure or treatment, the medically significant risks involved, and the possible duration of incapacitation, if any, as well as an explanation of the significance of the patient@s informed consent. The patient shall be advised of any medically significant alternatives for care or treatment, however, this does not include experimental treatments that are not yet accepted by the medical establishment;
e. To refuse treatment to the extent permitted by law and to be informed of the medical consequences of this act;
f. To privacy to the extent consistent with providing adequate medical care to the patient. This shall not preclude discussion of a patient@s case or examination of a patient by appropriate health care personnel;
g. To privacy and confidentiality of all records pertaining to his treatment, except as otherwise provided by law or third party payment contract, and to access to those records, including receipt of a copy thereof at reasonable cost, upon request, unless his physician states in writing that access by the patient is not medically advisable;
h. To expect that within its capacity, the hospital will make reasonable response to his request for services, including the services of an interpreter in a language other than English if 10% or more of the population in the hospital@s service area speaks that language;
i. To be informed by his physician of any continuing health care requirements which may follow discharge and to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge;
j. To be informed by the hospital of the necessity of transfer to another facility prior to the transfer and of any alternatives to it which may exist, which transfer shall not be effected unless it is determined by the physician to be medically necessary;
k. To be informed, upon request, of other health care and educational institutions that the hospital has authorized to participate in his treatment;
l. To be advised if the hospital proposes to engage in or perform human research or experimentation and to refuse to participate in these projects. For the purposes of this subsection ~human research~ does not include the mere collecting of statistical data;
m. To examine and receive an explanation of his bill, regardless of source of payment, and to receive information or be advised on the availability of sources of financial assistance to help pay for the patient@s care, as necessary;
n. To expect reasonable continuity of care;
o. To be advised of the hospital rules and regulations that apply to his conduct as a patient;
p. To treatment without discrimination as to race, age, religion, sex, national origin, or source of payment; and
q. To contract directly with a New Jersey licensed registered professional nurse of the patient@s choosing for private professional nursing care during his hospitalization. A registered professional nurse so contracted shall adhere to hospital policies and procedures in regard to treatment protocols and policies and procedures so long as those policies and procedures are the same for private duty and regularly employed nurses. The registered professional nurse shall not be considered an agent or employee of the hospital for purposes of any financial liabilities, including, but not limited to, State or federal employee taxes, worker@s compensation payments or coverage for professional liability.
The hospital, upon a patient@s or his designee@s request for private professional nursing care, shall provide the patient or his designee with a list of local nonprofit professional nurses association registries that refer nurses for private professional nursing care.
L.1989,c.170,s.2; amended 1994, c.22; 1997, c.76, s.1. 2000, c.65, s.1.
26:2H-12.8a. Identification of staff member to patient
3. A general hospital, licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et al.), shall require a student nurse or facility staff member to wear an identifying badge that includes the person@s name and licensure status, and, if appropriate, to verbally identify himself by name and licensure status to the patient and to any guardian or other responsible party when necessary, prior to examining, observing or treating the patient.
L.1997,c.76,s.3.
26:2H-12.9. Summary of rights given to all patients, posted in general hospital rooms
The administrator of a general hospital shall insure that a written summary of the rights set forth in this act be given to the patient or his guardian upon admittance to the hospital and to each individual already in residence, and that a written notice listing these rights is posted in a conspicuous place in the patient@s room. The administrator shall also post this notice in a conspicuous public place in the hospital.
L.1989,c.170,s.3.
26:2H-12.9a. Revision of written summary, notice
2. A general hospital shall revise the written summary and written notice required pursuant to section 3 of P.L.1989, c.170 (C.26:2H-12.9) within 180 days of the effective date of this act to reflect the amendments made to section 2 of P.L.1989, c.170 (C.26:2H-12.8) pursuant to this act.
L.1997,c.76,s.2.
26:2H-12.9b. Short title
1. This act shall be known and may be cited as ~Leonard Cohen@s Law.~
L.2001,c.207,s.1.
26:2H-12.9c. Discharge summary required for transfer of patients
2. A general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall not transfer a patient to another health care facility unless the patient is accompanied by a complete discharge summary from the transferring hospital at the time of the transfer.
L.2001,c.207,s.2.
26:2H-12.9d. Noncompliance, penalties
3. A hospital that fails to comply with the provisions of section 2 of this act shall be subject to such penalties as the Commissioner of Health and Senior Services shall determine pursuant to sections 13 and 14 of P.L.1971, c.136 (C.26:2H-13 and 26:2H-14).
L.2001,c.207,s.3.
26:2H-12.10. Filing of complaint
A patient may file a written complaint against a hospital for a failure to comply with the provisions of this act, or any rule or regulation adopted pursuant to this act, either with the hospital or the Department of Health. The hospital or the Department of Health, as appropriate, shall respond promptly in writing to the complaint. The Department of Health shall investigate a written complaint filed with the department and report its findings to the hospital and the patient.
L.1989,c.170,s.4.
26:2H-12.11. Rules, regulations
The Commissioner of Health is authorized to adopt rules and regulations in accordance with the provisions of the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the purposes of this act.
L.1989,c.170,s.5.
26:2H-12.12 Responsibility of health care facilities for filing claims.
14. Effective 12 months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) is responsible for filing all claims for third party payment, including claims filed on behalf of the health care facility@s patient for any health care service provided by the health care facility that is eligible for third party payment, except that at the patient@s option, the patient may file the claim for third party payment.
a. In the case of a claim filed on behalf of the health care facility@s patient, the health care facility shall file the claim within 60 days of the last date of service for a course of treatment, on the standard claim form adopted by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23).
b. In the case of a claim in which the patient has assigned his benefits to the health care facility, the health care facility shall file the claim within 180 days of the last date of service for a course of treatment, on the standard claim form adopted by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23). If the health care facility does not file the claim within 180 days of the last date of service for a course of treatment, the third party payer shall reserve the right to deny payment of the claim, in accordance with regulations established by the Commissioner of Banking and Insurance, and the health care facility shall be prohibited from seeking any payment directly from the patient.
(1) In establishing the standards for denial of payment, the Commissioner of Banking and Insurance shall consider the length of delay in filing the claim, the good faith use of information provided by the patient to the health care facility with respect to the identity of the patient@s third party payer, delays in filing a claim related to coordination of benefits between third party payers and any other factors the commissioner deems appropriate, and, accordingly, shall define specific instances where the sanctions permitted pursuant to this subsection shall not apply.
(2) A health care facility which fails to file a claim within 180 days and whose claim for payment has been denied by the third party payer in accordance with this subsection may, in the discretion of a judge of the Superior Court, be permitted to refile the claim if the third party payer has not been substantially prejudiced thereby. Application to the court for permission to refile a claim shall be made within 14 days of notification of denial of payment and shall be made upon motion based upon affidavits showing sufficient reasons for the failure to file the claim with the third party payer within 180 days.
c. The provisions of this section shall not apply to any claims filed pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.).
d. A health care facility which violates the provisions of subsection a. of this section may be subject to a civil penalty of $250 for each violation plus $50 for each day after the 60th day that the health care facility fails to submit a claim. The penalty shall be sued for and collected by the Department of Health and Senior Services pursuant to ~the penalty enforcement law,~ N.J.S.2A:58-1 et seq.
L.1999,c.154,s.14.
26:2H-12.13 Posting of drinking water test reports by general hospitals.
3. a. The owner or operator of a general hospital who is required to prepare a Consumer Confidence Report pursuant to the ~Safe Drinking Water Act Amendments of 1996,~42 U.S.C.s.300f et al., or who receives a Consumer Confidence Report from the owner or operator of a public community water system, shall post each Consumer Confidence Report it prepares or receives in the area of each major entrance and in each admitting room in the hospital.
b. The owner or operator of a general hospital who is a supplier of water but is not required to prepare a Consumer Confidence Report pursuant to the ~Safe Drinking Water Act Amendments of 1996,~ and who is required to conduct tests of its drinking water by the Department of Environmental Protection, shall post a chart setting forth the results of the water tests, including the level of detection and, as appropriate for each contaminant, the maximum contaminant level, highest level allowed, action level, treatment technique, or other expression of an acceptable level, for each contaminant, in the area of each major entrance and in each admitting room in the general hospital. The chart also shall include in bold print the statement required to be included in a Consumer Confidence Report pursuant to 40 CFR s.141.154(a). The chart shall not include contaminants that are not detected.
c. As used in this section, ~general hospital~ shall mean any general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).
d. The provisions of this section shall be enforced by the Department of Health and Senior Services. The Department of Health and Senior Services shall not be required to conduct on-site inspections to determine compliance with this section more frequently than any on-site inspections of general hospitals are conducted by the department pursuant to any other law.
L.1999,c.362,s.3.
26:2H-12.14 Posting of drinking water test reports by rehabilitation centers, extended care facilities, nursing homes.
4. a. The owner or operator of a rehabilitation center, extended care facility, skilled nursing home, or nursing home who is required to prepare a Consumer Confidence Report pursuant to the ~Safe Drinking Water Act Amendments of 1996,~42 U.S.C.s.300f et al., or who receives a Consumer Confidence Report from the owner or operator of a public community water system, shall post each Consumer Confidence Report it prepares or receives in at least one conspicuous location in the rehabilitation center, extended care facility, skilled nursing home, or nursing home.
b. The owner or operator of a rehabilitation center, extended care facility, skilled nursing home, or nursing home who is a supplier of water but is not required to prepare a Consumer Confidence Report pursuant to the ~Safe Drinking Water Act Amendments of 1996,~ and who is required to conduct tests of its drinking water by the Department of Environmental Protection, shall post a chart setting forth the results of the water tests, including the level of detection and, as appropriate for each contaminant, the maximum contaminant level, highest level allowed, action level, treatment technique, or other expression of an acceptable level, for each contaminant, in at least one conspicuous location in the rehabilitation center, extended care facility, skilled nursing home, or nursing home. The chart also shall include in bold print the statement required to be included in a Consumer Confidence Report pursuant to 40 CFR s.141.154(a). The chart shall not include contaminants that are not detected.
c. As used in this section, ~rehabilitation center,~ ~extended care facility,~ skilled nursing home,~ and ~nursing home~ shall mean a rehabilitation center, extended care facility, skilled nursing home, or nursing home licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).
d. The provisions of this section shall be enforced by the Department of Health and Senior Services. The Department of Health and Senior Services shall not be required to conduct on-site inspections to determine compliance with this section more frequently than any on-site inspections of rehabilitation centers, extended care facilities, skilled nursing homes, or nursing homes are conducted by the department pursuant to any other law.
L.1999,c.362,s.4.
26:2H-12.15 Regulations on use of unlicensed assistive personnel.
2. a. The Commissioner of Health and Senior Services, pursuant to the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt regulations governing the use of unlicensed assistive personnel in licensed health care facilities, in consultation with at least the following: the Director of the Division of Consumer Affairs in the Department of Law and Public Safety, the New Jersey Hospital Association, the New Jersey Association of Health Care Facilities, the Medical Society of New Jersey, and the New Jersey State Nurses Association.
As used in this section, ~unlicensed assistive personnel~ means any unlicensed or uncertified personnel employed by a licensed health care facility that perform nursing tasks which do not require the skill or judgment of a registered professional nurse and which are assigned to them by, and carried out under the supervision of, a registered professional nurse.
b. The regulations adopted pursuant to subsection a. of this section, shall require, at a minimum, that:
(1) unlicensed assistive personnel employed by a health care facility meet the standards and requirements for education and competency evaluation prescribed by the New Jersey Board of Nursing pursuant to paragraph (26) of subsection d. of section 2 of P.L.1947, c.262 (C.45:11-24); and
(2) a health care facility, prior to implementing the use of unlicensed assistive personnel, establish a multidisciplinary committee, including representation from registered professional nurses, physicians, administrative staff, and unlicensed assistive personnel, to evaluate the need for using these personnel, formulate and adopt a plan to implement their use, and monitor the implementation of the plan.
c. The plan for implementing the use of unlicensed assistive personnel pursuant to paragraph (2) of subsection b. of this section shall, at a minimum:
(1) require the use and specify the composition of multidisciplinary patient care teams operating under the plan;
(2) prescribe materials and protocols for the orientation and training of health care facility staff with respect to implementing the plan;
(3) provide for the periodic monitoring and evaluation of the use of unlicensed assistive personnel by the multidisciplinary committee established pursuant to subsection b. of this section; and
(4) require in-service training and educational programming for both registered professional nurses and unlicensed assistive personnel which include subject matter relating to the delegation of nursing tasks to unlicensed assistive personnel and the supervision of these personnel by registered professional nurses.
L.1999,c.436,s.2.
26:2H-12.16 Definitions relative to residential facilities for Medicaid recipients; 10 percent utilization requirement.
1. a. For the purposes of this act, ~Medicaid~ means the program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and ~Medicaid-eligible~ means that a person is determined to meet the financial eligibility standards for medical assistance under the State Medicaid program and is approved by the Department of Health and Senior Services for participation in a federally approved 1915(c) waiver program that provides assisted living services.
b. A new facility that is licensed to operate an assisted living residence or comprehensive personal care home after the effective date of this act shall reserve 10% of its total bed compliment for use by Medicaid-eligible persons. The 10% utilization by Medicaid-eligible persons shall be met through Medicaid conversion of persons who enter the assisted living residence or comprehensive personal care home as private paying persons and subsequently become eligible for Medicaid, or through direct admission of Medicaid-eligible persons. An assisted living residence or comprehensive personal care home shall achieve this 10% utilization within three years of licensure to operate and shall maintain this level of utilization thereafter.
c. Existing assisted living residences and comprehensive personal care homes that add additional assisted living beds shall be required, as a condition of licensure approval, to maintain 10% of the additional beds for Medicaid-eligible persons through Medicaid conversion of persons who enter the assisted living residence or comprehensive personal care home as private paying persons and subsequently become eligible for Medicaid, or through direct admission of Medicaid-eligible persons. If the total number of additional beds is less than 10, at least one of the additional beds shall be reserved for a Medicaid-eligible person.
L.2001,c.234,s.1.
26:2H-12.17 Waiver of utilization requirement.
2. The Commissioner of Health and Senior Services may waive the 10% utilization requirement or reduce the required percentage by regulation for specific regions of the State or Statewide if he determines that sufficient numbers of assisted living beds are available in the State to meet the needs of Medicaid-eligible persons within the limits of the federal waiver to provide assisted living services through the Medicaid program.
L.2001,c.234,s.2.
26:2H-12.18 Reserve requirement as fulfillment of utilization requirements.
3. The 10% reserve requirement of this act shall be recognized to fulfill all or a portion, as applicable, of low and moderate income or Medicaid utilization requirements contained in municipal ordinances and shall satisfy all or a portion, as applicable, of low income housing requirements for assisted living residences or comprehensive personal care homes that are financed by bonds mandating low income housing as a condition of financing.
L.2001,c.234,s.3.
26:2H-12.19 Construction of act.
4. Nothing in this act shall be construed to: prohibit an existing assisted living residence, comprehensive personal care home or assisted living program, which is not affected by this act, from participating in the Medicaid program; or create an entitlement to financing under the Medicaid program for services provided at assisted living residences or comprehensive personal care homes.
L.2001,c.234,s.4.
26:2H-12.20 Applicability of act.
5. This act shall not apply to an assisted living residence or comprehensive personal care home operated by a continuing care retirement community operating under a certificate of authority issued by the Department of Community Affairs pursuant to P.L.1986, c.103 (C.52:27D-330 et seq.).
L.2001,c.234,s.5.
26:2H-12.21 Regulations.
6. The Commissioner of Health and Senior Services shall adopt regulations pursuant to the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to carry out the purposes of this act.
L.2001,c.234,s.6.
26:2H-12.22 Domestic partner permitted visitation in health care facility.
13. a. A health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall allow a patient@s domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3), the children of the patient@s domestic partner, and the domestic partner of the patient@s parent or child to visit, unless one of the following conditions is met:
(1) No visitors are allowed;
(2) The health care facility reasonably determines that the presence of a particular visitor would endanger the health or safety of a patient, a member of the staff of the facility, or another visitor to the facility, or would significantly disrupt the operations of the facility; or
(3) The patient has indicated to health care facility staff that the patient does not want the person to visit.
b. The provisions of subsection a. of this section shall not be construed as prohibiting a health care facility from otherwise establishing reasonable restrictions upon visitations, including restrictions upon the hours of visitation and number of visitors.
L.2003,c.246,s.13.
26:2H-12.23. Short title
1. This act shall be known and may be cited as the ~Patient Safety Act.~
L.2004,c.9,s.1.
26:2H-12.24. Findings, declarations relative to patient safety
2. The Legislature finds and declares that:
a. Adverse events, some of which are the result of preventable errors, are inherent in all systems, and the health care literature demonstrates that the great majority of medical errors result from systems problems, not individual incompetence;
b. Well-designed systems have processes built in to minimize the occurrence of errors, as well as to detect those that do occur; they incorporate mechanisms to continually improve their performance;
c. To enhance patient safety, the goal is to craft a health care delivery system that minimizes, to the greatest extent feasible, the harm to patients that results from the delivery system itself;
d. An important component of a successful patient safety strategy is a feedback mechanism that allows detection and analysis not only of adverse events, but also of ~near-misses~;
e. To encourage disclosure of these events so that they can be analyzed and used for improvement, it is critical to create a non-punitive culture that focuses on improving processes rather than assigning blame. Health care facilities and professionals must be held accountable for serious preventable adverse events; however, punitive environments are not particularly effective in promoting accountability and increasing patient safety, and may be a deterrent to the exchange of information required to reduce the opportunity for errors to occur in the complex systems of care delivery. Fear of sanctions induces health care professionals and organizations to be silent about adverse events, resulting in serious under-reporting; and
f. By establishing an environment that both mandates the confidential disclosure of the most serious, preventable adverse events, and also encourages the voluntary, anonymous and confidential disclosure of less serious adverse events, as well as preventable events and near misses, the State seeks to increase the amount of information on systems failures, analyze the sources of these failures and disseminate information on effective practices for reducing systems failures and improving the safety of patients.
L.2004,c.9,s.2.
26:2H-12.25. Definitions relative to patient safety; plans; reports; documentation, notification of adverse events, etc.
3. a. As used in this act:
~Adverse event~ means an event that is a negative consequence of care that results in unintended injury or illness, which may or may not have been preventable.
~Anonymous~ means that information is presented in a form and manner that prevents the identification of the person filing the report.
~Commissioner~ means the Commissioner of Health and Senior Services.
~Department~ means the Department of Health and Senior Services.
~Event~ means a discrete, auditable and clearly defined occurrence.
~Health care facility~ or ~facility~ means a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) and a State psychiatric hospital operated by the Department of Human Services and listed in R.S.30:1-7.
~Health care professional~ means an individual who, acting within the scope of his licensure or certification, provides health care services, and includes, but is not limited to, a physician, dentist, nurse, pharmacist or other health care professional whose professional practice is regulated pursuant to Title 45 of the Revised Statutes.
~Near-miss~ means an occurrence that could have resulted in an adverse event but the adverse event was prevented.
~Preventable event~ means an event that could have been anticipated and prepared against, but occurs because of an error or other system failure.
~Serious preventable adverse event~ means an adverse event that is a preventable event and results in death or loss of a body part, or disability or loss of bodily function lasting more than seven days or still present at the time of discharge from a health care facility.
b. In accordance with the requirements established by the commissioner by regulation, pursuant to this act, a health care facility shall develop and implement a patient safety plan for the purpose of improving the health and safety of patients at the facility.
The patient safety plan shall, at a minimum, include:
(1) a patient safety committee, as prescribed by regulation;
(2) a process for teams of facility staff, which teams are comprised of personnel who are representative of the facility@s various disciplines and have appropriate competencies, to conduct ongoing analysis and application of evidence-based patient safety practices in order to reduce the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures;
(3) a process for teams of facility staff, which teams are comprised of personnel who are representative of the facility@s various disciplines and have appropriate competencies, to conduct analyses of near-misses, with particular attention to serious preventable adverse events and adverse events; and
(4) a process for the provision of ongoing patient safety training for facility personnel.
The provisions of this subsection shall not be construed to eliminate or lessen a hospital@s obligation under current law or regulation to have a continuous quality improvement program.
c. A health care facility shall report to the department or, in the case of a State psychiatric hospital, to the Department of Human Services, in a form and manner established by the commissioner, every serious preventable adverse event that occurs in that facility.
d. A health care facility shall assure that the patient affected by a serious preventable adverse event or an adverse event specifically related to an allergic reaction, or, in the case of a minor or a patient who is incapacitated, the patient@s parent or guardian or other family member, as appropriate, is informed of the serious preventable adverse event or adverse event specifically related to an allergic reaction, no later than the end of the episode of care, or, if discovery occurs after the end of the episode of care, in a timely fashion as established by the commissioner by regulation. The time, date, participants and content of the notification shall be documented in the patient@s medical record in accordance with rules and regulations adopted by the commissioner. The content of the documentation shall be determined in accordance with the rules and regulations of the commissioner. If the patient@s physician determines that the disclosure would seriously and adversely affect the patient@s health, then the facility shall assure that the family member, if available, is notified in accordance with rules and regulations adopted by the commissioner. In the event that an adult patient is not informed of the serious preventable adverse event or adverse event specifically related to an allergic reaction, the facility shall assure that the physician includes a statement in the patient@s medical record that provides the reason for not informing the patient pursuant to this section.
e. (1) A health care professional or other employee of a health care facility is encouraged to make anonymous reports to the department or, in the case of a State psychiatric hospital, to the Department of Human Services, in a form and manner established by the commissioner, regarding near-misses, preventable events and adverse events that are otherwise not subject to mandatory reporting pursuant to subsection c. of this section.
(2) The commissioner shall establish procedures for and a system to collect, store and analyze information voluntarily reported to the department pursuant to this subsection. The repository shall function as a clearinghouse for trend analysis of the information collected pursuant to this subsection.
f. Any documents, materials or information received by the department, or the Department of Human Services, as applicable, pursuant to the provisions of subsections c. and e. of this section concerning serious preventable adverse events, near-misses, preventable events and adverse events that are otherwise not subject to mandatory reporting pursuant to subsection c. of this section, shall not be:
(1) subject to discovery or admissible as evidence or otherwise disclosed in any civil, criminal or administrative action or proceeding;
(2) considered a public record under P.L.1963, c.73 (C.47:1A-1 et seq.) or P.L.2001, c.404 (C.47:1A-5 et al.); or
(3) used in an adverse employment action or in the evaluation of decisions made in relation to accreditation, certification, credentialing or licensing of an individual, which is based on the individual@s participation in the development, collection, reporting or storage of information in accordance with this section. The provisions of this paragraph shall not be construed to limit a health care facility from taking disciplinary action against a health care professional in a case in which the professional has displayed recklessness, gross negligence or willful misconduct, or in which there is evidence, based on other similar cases known to the facility, of a pattern of significant substandard performance that resulted in serious preventable adverse events.
The information received by the department, or the Department of Human Services, as applicable, shall be shared with the Attorney General in accordance with rules and regulations adopted pursuant to subsection j. of this section, and may be used by the department, the Department of Human Services and the Attorney General for the purposes of this act and for oversight of facilities and health care professionals; however, the departments and the Attorney General shall not use the information for any other purpose.
In using the information to exercise oversight, the department, Department of Human Services and Attorney General, as applicable, shall place primary emphasis on assuring effective corrective action by the facility or health care professional, reserving punitive enforcement or disciplinary action for those cases in which the facility or the professional has displayed recklessness, gross negligence or willful misconduct, or in which there is evidence, based on other similar cases known to the department, Department of Human Services or the Attorney General, of a pattern of significant substandard performance that has the potential for or actually results in harm to patients.
g. Any documents, materials or information developed by a health care facility as part of a process of self-critical analysis conducted pursuant to subsection b. of this section concerning preventable events, near-misses and adverse events, including serious preventable adverse events, and any document or oral statement that constitutes the disclosure provided to a patient or the patient@s family member or guardian pursuant to subsection d. of this section, shall not be:
(1) subject to discovery or admissible as evidence or otherwise disclosed in any civil, criminal or administrative action or proceeding; or
(2) used in an adverse employment action or in the evaluation of decisions made in relation to accreditation, certification, credentialing or licensing of an individual, which is based on the individual@s participation in the development, collection, reporting or storage of information in accordance with subsection b. of this section. The provisions of this paragraph shall not be construed to limit a health care facility from taking disciplinary action against a health care professional in a case in which the professional has displayed recklessness, gross negligence or wilful misconduct, or in which there is evidence, based on other similar cases known to the facility, of a pattern of significant substandard performance that resulted in serious preventable adverse events.
h. Notwithstanding the fact that documents, materials or information may have been considered in the process of self-critical analysis conducted pursuant to subsection b. of this section, or received by the department or the Department of Human Services pursuant to the provisions of subsection c. or e. of this section, the provisions of this act shall not be construed to increase or decrease, in any way, the availability, discoverability, admissibility or use of any such documents, materials or information if obtained from any source or context other than those specified in this act.
i. The investigative and disciplinary powers conferred on the boards and commissions established pursuant to Title 45 of the Revised Statutes, the Director of the Division of Consumer Affairs in the Department of Law and Public Safety and the Attorney General under the provisions of P.L.1978, c.73 (C.45:1-14 et seq.) or any other law, rule or regulation, as well as the investigative and enforcement powers conferred on the department and the commissioner under the provisions of Title 26 of the Revised Statutes or any other law, rule or regulation, shall not be exercised in such a manner so as to unduly interfere with a health care facility@s implementation of its patient safety plan established pursuant to this section. However, this act shall not be construed to otherwise affect, in any way, the exercise of such investigative, disciplinary and enforcement powers.
j. The commissioner shall, pursuant to the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.), adopt such rules and regulations necessary to carry out the provisions of this act. The regulations shall establish: criteria for a health care facility@s patient safety plan and patient safety committee; the time frame and format for mandatory reporting of serious preventable adverse events at a health care facility; the types of events that qualify as serious preventable adverse events and adverse events specifically related to an allergic reaction; the circumstances under which a health care facility is not required to inform a patient or the patient@s family about a serious preventable adverse event or adverse event specifically related to an allergic reaction; and a system for the sharing of information received by the department and the Department of Human Services pursuant to subsections c. and e. of this section with the Attorney General. In establishing the criteria for reporting serious preventable adverse events, the commissioner shall, to the extent feasible, use criteria for these events that have been or are developed by organizations engaged in the development of nationally recognized standards.
The commissioner shall consult with the Commissioner of Human Services with respect to rules and regulations affecting the State psychiatric hospitals and with the Attorney General with respect to rules and regulations regarding the establishment of a system for the sharing of information received by the department and the Department of Human Services pursuant to subsections c. and e. of this section with the Attorney General.
k. Nothing in this act shall be construed to increase or decrease the discoverability, in accordance with Christy v. Salem, No. A-6448-02T3 (Superior Court of New Jersey, Appellate Division, February 17, 2004)(2004 WL291160), of any documents, materials or information if obtained from any source or context other than those specified in this act.
L.2004,c.9,s.3.
26:2H-12.26 Nursing homes, defibrillator, trained personnel; required.
1. A nursing home that is licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall, no later than one year after the effective date of this act:
a. acquire at least one defibrillator as defined in section 2 of P.L.1999, c.34 (C.2A:62A-24), which shall be maintained in a central location within the nursing home that shall be made known and available to the employees of the nursing home for the purposes of this act;
b. ensure that the defibrillator is tested and maintained, and provide notification to the appropriate first aid, ambulance or rescue squad or other appropriate emergency medical services provider regarding the defibrillator, the type acquired and its location, pursuant to section 3 of P.L.1999, c.34 (C.2A:62A-25);
c. arrange and pay for training in cardio-pulmonary resuscitation and the use of a defibrillator for employees of the nursing home in accordance with the provisions of section 3 of P.L.1999, c.34 (C.2A:62A-25); and
d. ensure that the employees of the nursing home comply with the provisions of section 4 of P.L.1999, c.34 (C.2A:62A-26) concerning the use of the defibrillator.
L.2004,c.93.
26:2H-12.27 Findings, declarations relative to designation of stroke centers.
1. The Legislature finds and declares that:
a. Despite significant advances in diagnosis, treatment and prevention, stroke remains a common disorder; an estimated 700,000 to 750,000 new and recurrent strokes occur each year in this country; and with the aging of the population, the number of persons who have strokes is projected to increase;
b. Although new treatments are available to improve the clinical outcomes of stroke, many acute care hospitals lack the necessary staff and equipment to optimally triage and treat stroke patients, including the provision of optimal, safe and effective emergency care for these patients;
c. Two levels of stroke centers should be established for the treatment of acute stroke. Primary stroke centers should be established in as many acute care hospitals as possible. These centers would evaluate, stabilize and provide emergency care to patients with acute stroke and then, depending on the patient@s needs and the center@s capabilities, either admit the patient and provide inpatient care or transfer the patient to a comprehensive stroke center. Comprehensive stroke centers should be established in hospitals that meet the criteria set forth in this act, to ensure coverage for all patients throughout the State who require this level of care. These centers would provide complete and specialized care to patients who experience the most complex strokes, which require specialized testing, highly technical procedures and other interventions. Also, these centers would provide education and guidance to affiliated primary stroke centers;
d. There is a public health need for acute care hospitals in this State to establish stroke centers to ensure the rapid triage, diagnostic evaluation and treatment of patients suffering a stroke. This should result in increased survival and a decrease in the disabilities associated with stroke; and
e. Therefore, it is in the best interest of the residents of this State to establish a program to designate stroke centers throughout the State, to provide specific patient care and support services criteria that stroke centers must meet in order to ensure that stroke patients receive safe and effective care, and to provide financial support to acute care hospitals to encourage them to develop stroke centers in all areas of the State.
L.2004,c.136,s.1.
26:2H-12.28 Designation of hospitals as stroke centers.
2. The Commissioner of Health and Senior Services shall designate hospitals that meet the criteria set forth in this act as primary or comprehensive stroke centers.
a. A hospital shall apply to the commissioner for designation and shall demonstrate to the satisfaction of the commissioner that the hospital meets the criteria set forth in section 3 or 4 of this act for a primary or comprehensive stroke center, respectively.
b. The commissioner shall designate as many hospitals as primary stroke centers as apply for the designation, provided that the hospital meets the criteria set forth in section 3 of this act. In addition to the criteria set forth in section 3 of this act, the commissioner is encouraged to take into consideration whether the hospital contracts with carriers that provide coverage through the State Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), the Children@s Health Care Coverage Program, established pursuant to P.L.1997, c.272 (C.30:4I-1 et seq.), and the FamilyCare Health Coverage Program, established pursuant to P.L.2000, c.71 (C.30:4J-1 et seq.).
c. The commissioner shall designate as many hospitals as comprehensive stroke centers as apply for the designation, provided that the hospital meets the criteria set forth in section 4 of this act.
d. The commissioner may suspend or revoke a hospital@s designation as a stroke center, after notice and hearing, if the commissioner determines that the hospital is not in compliance with the requirements of this act.
L.2004,c.136,s.2.
26:2H-12.29 Minimum criteria for primary stroke centers.
3. A hospital designated as a primary stroke center shall, at a minimum, meet the following criteria:
a. With respect to patient care, the hospital shall:
(1) maintain acute stroke team availability to see an emergency department patient within 15 minutes of arrival at the emergency department, 24 hours a day, seven days a week;
(2) maintain written care protocols and standing orders for emergency care of stroke patients;
(3) maintain neurology and emergency department personnel trained in the diagnosis and treatment of acute stroke;
(4) maintain telemetry or critical care beds staffed by physicians and nurses who are trained and experienced in caring for acute stroke patients;
(5) provide for neurosurgical services, including operating room availability either at the hospital or under agreement with a comprehensive stroke center, within two hours, 24 hours a day, seven days a week;
(6) provide acute care rehabilitation services; and
(7) enter into and maintain a written transfer agreement with a comprehensive stroke center so that patients with complex strokes can be transported to the comprehensive center for care when clinically warranted.
b. With respect to support services, the hospital shall:
(1) demonstrate an institutional commitment and support of a stroke center, including having a designated physician stroke center director with special training and experience in caring for patients with stroke;
(2) maintain neuro-imaging services capability, which shall include computerized tomography scanning or magnetic resonance imaging and interpretation of the image, that is available 24 hours a day, seven days a week, within 25 minutes of order entry;
(3) maintain laboratory services capability, which shall include blood testing, electrocardiography and X-ray services that are available 24 hours a day, seven days a week, within 45 minutes of order entry;
(4) develop and maintain outcomes and quality improvement activities, which include a database or registry to track patient outcomes. These data shall include, at a minimum: (a) the number of patients evaluated; (b) the number of patients receiving acute interventional therapy; (c) the amount of time from patient presentation to delivery of acute interventional therapy; (d) patient length of stay; (e) patient functional outcome; and (f) patient morbidity. A primary stroke center may share these data with its affiliated comprehensive stroke center for the purposes of quality improvement and research;
(5) provide annual continuing education on stroke to support and emergency services personnel regarding stroke diagnosis and treatment, which will be the responsibility of the stroke center director;
(6) require the stroke center director to obtain a minimum of eight hours of continuing education on stroke each year; and
(7) demonstrate a continuing commitment to ongoing education to the general public about stroke, which includes conducting at least two programs annually for the general public on the prevention, recognition, diagnosis and treatment of stroke.
L.2004,c.136,s.3.
26:2H-12.30 Minimum criteria for comprehensive stroke centers.
4. A hospital designated as a comprehensive stroke center shall use proven state-of-the-art technology and medical techniques and, at a minimum, meet the criteria set forth in this section.
a. The hospital shall meet all of the criteria required for a primary stroke center pursuant to section 3 of this act.
b. With respect to patient care, the hospital shall:
(1) maintain a neurosurgical team that is capable of assessing and treating complex stroke and stroke-like syndromes;
(2) maintain on staff a neuro-radiologist with Certificate of Added Qualifications and a physician with neuro-interventional angiographic training and skills;
(3) provide comprehensive rehabilitation services either on site or by transfer agreement with another health care facility; and
(4) enter into and maintain written transfer agreements with primary stroke centers to accept transfer of patients with complex strokes when clinically warranted.
c. With respect to support services, the hospital shall:
(1) have magnetic resonance imaging and computed tomography angiography capabilities;
(2) have digital subtraction angiography and a suite equipped for neuro-interventional procedures;
(3) develop and maintain sophisticated outcomes assessment and performance improvement capability that incorporates data from affiliated primary stroke centers and integrates regional, State and national data;
(4) provide guidance and continuing medical education to primary stroke centers;
(5) provide graduate medical education in stroke; and
(6) conduct research on stroke-related topics.
d. If the Commissioner of Health and Senior Services determines that a new drug, device, technique or technology has become available for the treatment of stroke that provides a diagnostic or therapeutic advantage over existing elements included in the criteria established in this section or in section 3 of this act, the commissioner may, by regulation, revise or update the criteria accordingly.
L.2004,c.136,s.4.
26:2H-12.31 Awarding of matching grants to designated stroke centers.
5. a. In order to encourage and ensure the establishment of stroke centers throughout the State, the Commissioner of Health and Senior Services shall award matching grants to hospitals that seek designation as stroke centers and demonstrate a need for financial assistance to develop the necessary infrastructure, including personnel and equipment, in order to satisfy the criteria for designation provided pursuant to this act. The matching grants shall not exceed $250,000 or 50% of the hospital@s cost for developing the necessary infrastructure, whichever is less.
b. A hospital seeking designation as a stroke center shall apply to the commissioner for a matching grant, in a manner and on a form required by the commissioner, and provide such information as the commissioner deems necessary to determine if the hospital is eligible for the grant.
c. The commissioner may provide matching grants to as many hospitals as the commissioner deems appropriate, except that:
(1) Matching grant awards shall be made to at least two applicant hospitals in the northern region of this State (comprising Bergen, Hudson, Essex, Passaic, Morris, Sussex, and Warren counties), at least two applicant hospitals in the central region of this State (comprising Union, Somerset, Hunterdon, Mercer, Middlesex, and Monmouth counties) and at least two applicant hospitals in the southern region of this State (comprising Burlington, Camden, Gloucester, Salem, Cumberland, Cape May, Atlantic, and Ocean counties), provided in the case of each region that the applicant hospitals receiving the awards must be eligible therefor under the provisions of this act; and
(2) No more than 20% of the funds appropriated pursuant to this act shall be allocated to hospitals that seek designation as comprehensive stroke centers.
L.2004,c.136,s.5.
26:2H-12.32 Report to Governor, Legislature.
6. The Commissioner of Health and Senior Services shall, not later than September 1, 2005, prepare and submit to the Governor, the President of the Senate, and the Speaker of the General Assembly a report indicating, as of June 30, 2005, the total number of hospitals that shall have applied for grants under section 5 of this act and the number of those applicants that shall have been found to be eligible for such grants, the total number of grants awarded, the name and address of each grantee hospital and the amount of the award to each, and the amount of each award that shall have been paid to the grantee.
L.2004,c.136,s.6.
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