Current through Register Vol. 54, No. 7, April 4, 2022
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.
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
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.
Each policy and/or procedure shall provide:
A descriptive title which is unique as to permit easy reference and retrieval
of each document;
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.
A table of organization shall be incorporated in the administrative procedures
manual to clearly identify lines of authority, responsibility and
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
(c) A written procedure
shall be available detailing requirements for appointment of a guardian in
accordance with N.J.A.C. 10:43.
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.
The facility shall have a Human Rights Committee, in accordance with N.J.A.C.
(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.
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:
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;
3. B incidents shall be
reported the next working day.
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
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 §
Amended by R.2004 d.404,
See: 36 N.J.R. 2589(a), 36 N.J.R. 4961(a).
substituted "Department" for "Division of Developmental Disabilities" following
"shall be forwarded to the" in the introductory paragraph.
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