N.J. Admin. Code § 10:47-3.8 - Administrative procedures manual

Current through Register Vol. 54, No. 7, April 4, 2022

(a) The facility shall assemble and maintain an administrative procedures manual which incorporates all of the written policies and procedures designed to implement the facility's objectives, and key procedures which address the implementation of applicable law and rules.
1. The administrative procedures manual shall describe the policies and procedures of the major operating units, and shall be available to all interested persons. Each procedure shall be designed in accordance with the principles of normalization, age appropriateness, least restriction and shall be consistent with the organizational structure and management philosophy of the facility.
2. The procedures shall be reviewed and updated as necessary but at least every five years.
3. All procedures shall identify the dates of issuance and review or revision.
4. Each policy and/or procedure shall provide:
i. A descriptive title which is unique as to permit easy reference and retrieval of each document;
ii. An explanation regarding the purpose of the document;
iii. A description of sequential steps required to successfully complete a task or action;
iv. Assignment of staff responsibilities at each step in the implementation; and
v. Reporting and recording requirements for each person involved.
5. A table of organization shall be incorporated in the administrative procedures manual to clearly identify lines of authority, responsibility and communication.
6. All staff shall be able to describe procedures that they routinely implement.
7. Policies and procedures shall be readily available and accessible for staff use.
(b) A written procedure shall be available that specifies one individual responsible for the overall operation of the facility at any specific time. The procedure shall provide a schedule for continuous administrative coverage, and responsibilities shall be clearly defined.
(c) A written procedure shall be available detailing requirements for appointment of a guardian in accordance with N.J.A.C. 10:43.
(d) A written procedure detailing round-the-clock accountability of individuals shall be implemented.
(e) A written procedure shall be available to delineate action to be taken in cases where an individual is discovered missing.
(f) A written policy shall be available that defines the use of mechanical restraints in accordance with N.J.A.C. 10:42. Such policies shall be reviewed by the Director for compliance with N.J.A.C. 10:42 prior to implementation.
(g) The facility shall have a Human Rights Committee, in accordance with N.J.A.C. 10:41-4.
(h) A written procedure shall be available which specifies the maintenance of an unusual incidents log and staff responsibilities regarding unusual incidents.
(i) There shall be a written procedure to ensure the investigation of each alleged mistreatment of an individual or an unusual incident or accident.
(j) Any unusual incident or accident (categories are found in the subchapter Appendix, incorporated herein by reference) shall be reported to the appropriate Regional Office in the Division of Developmental Disabilities based upon the following time frames:
1. A+ incidents shall be reported immediately;
2. A incidents shall be reported the same working day during normal working hours. If the incident occurs after regular working hours, the incident shall be reported the next working day; and
3. B incidents shall be reported the next working day.
(k) A copy of the written investigative report, unless otherwise indicated, shall be forwarded to the Department within 30 calendar days. The report shall contain, but not be limited to, the following information:
1. The name of the alleged victim(s), date, and time of the incident;
2. Name(s) of the person(s) involved, including participants and witnesses;
3. A description of the incident, including any medical treatment administered;
4. Sanctions that were invoked when the allegation was substantiated; and
5. Any corrective actions taken to prevent a recurrence or to provide additional protection.


N.J. Admin. Code § 10:47-3.8
Amended by R.2004 d.404, effective 11/1/2004.
See: 36 N.J.R. 2589(a), 36 N.J.R. 4961(a).
In (k), substituted "Department" for "Division of Developmental Disabilities" following "shall be forwarded to the" in the introductory paragraph.
Amended by R.2007 d.72, effective 3/5/2007.
See: 38 N.J.R. 4352(a), 39 N.J.R. 777(a).
In the introductory paragraph of (j), deleted "New Jersey Department of Health and Senior Services, Bureau of Licensing, and the" preceding "appropriate"; in (j)3, substituted "B" for "All other reportable"; and in (k), substituted "30 calendar" for "10 working".

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