New Jersey Department of Health

ADULT MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Adult Medical Day Care

Facility Name

Survey Date

_____ / _____ / ________

Request the following to be on site:

1.	Certification of Occupancy

2.	Resume of Key Staff

3.	List of Licensed Staff

4.	Policy and Procedure Manual

5.	Employee Member Files

6.	Employee Health Files

7.	Contracts

8.	Register 3.13(a) MO 304

9.	Staffing Schedule 6.3(d) MO 419

Resumes of Key Staff	Reg. Number	MO Number	Reviewed
Administrator Qualifications	3.2(a) 1-3	225
Designated Alternate Administrator	3.1(a)	221
Director of Nursing Qualifications	7.2	433
Designated Alternate Director of Nursing	7.1(a)	425
Social Worker Qualifications	12.1	577
Activities Director / Qualifications	13.2(a) 1-5	587
Dietitian Qualifications	10.3	533
Medical Records Consultant / Qualifications	15.2	699
Food Service Supervisor	10.2(a) 1-3	531
Infection Control Designee	16.1(b)	765

Employee Personnel and Health Files	Reg. Number	MO Number	Reviewed
Application/Background Check/Reference (New Hires)	6.3(a)1	409
Administrator/Owner (CBI)	6.3(a)1i	411
Job Description	6.3(b)	415
Staff Orientation (*elder abuse, rights, infection control, *emergency plans, pain management), upon hire/annually*	6.3(e)1i	421
Two-step Mantoux upon hire/one-step annually	16.2(f)(g)	777

779

Physical Environment	Reg. Number	MO Number	Reviewed
Facility to post all waivers participants rights, means of contacting license holder	4.1(a)

3.4(b)	305

267
Facility to post name, address, and telephone number of NJDOH, Ombudsman, Medical Assistance and Health Services, Youth and Family Services, APS	4.1

4.2(b,c,d)	309

347
Public/Private Telephone	4.2(a)13	337
Toilet facilities 1:10	14.3(b)1	611
Entrance at grade level to accommodate devices	14.4(a)	617
Lockers and lounges for employee/volunteer staff	14.5	631
Janitor’s closet contains a service sink and storage for housekeeping supplies and equipment	14.6	633
Social work office space for private interview	14.7	635
Storage space for recreation equipment	14.8(b)	639
Office space for recreation director or designated area	14.8(c)	641
Recliners or couch 1:10; quiet area (40 sq. ft. per bed/crib)	14.10(a)1i	651
Fountain/bottled water	14.1(b)	619
Office space for nursing with sink. If combined with pharmacy area, 100 sq. ft. minimum	14.9(a)	643
Dispensing area with handwashing facilities	14.9(b)1	645
Lockable refrigerator or locked box in refrigerator	14.9(b) 3	645
Exam room with private area with handwashing facilities, counter or shelf space for writing

(80 sq. ft. minimum floor area)	14.9(d) 3	649
Activities Calendar	13.1(a)	585

Emergency Plans and Procedures	Reg. Number	MO Number	Reviewed
Emergency Equipment, O2, Suction, Airway, Ambu-Bag	14.17(b)	679
CPR-certified staff member (One on duty at all times)	14.17(b)1	681
Procedures for emergencies	14.17(a)	677
Written evacuation diagram includes evacuation procedure, location of fire exits, alarms boxes, fire extinguishers

POSTED	14.17(d)	689
Drills of emergency plans 4 per year	14.17(f,g)	689
Fire extinguishers examined annually and labeled	14.17(h)	691
Hot water temperature 120( max.	16.7(a) 24	815

Transportation	Reg. Number	MO Number	Reviewed
Provide transportation services	17.1(a)	821
Transportation rules (i.e., CDL license for drivers) (Time)	17.1(e)	825

Food Services and Nutrition	Reg. Number	MO Number	Reviewed
Posted Sanitary Inspection (if applicable)	10.5(a)	535

537
Current Diet Manual (on site)	10.5(b)	541
Written, dated menus planned 14 days in advance with portion sizes	10.5(c)2	543
Minimum supplies of food (i.e., cereal, tuna, PB, canned fruit, juices)	10.5(c)8ii	549
Control station for receiving food; storage facilities for food supply including cold storage; handwashing facility; trash handling; desk space	14.11(a)1	653

Medical Records and Care Plan	Reg. Number	MO Number	Reviewed
Participant identification data	15.3(a)1	701
Acknowledgement that participant has received "rights"	15.3(a)2	703
Home environment assessment	15.3(a)3	705
Medical history/physical exam (60 days prior to admission); orders for specific type and intensity of care and verification is free of communicable disease	8.4(b)1-4	491
Comprehensive assessment	5.3(e)	373
Record of medications	15.3(a)

10,11	719

721
Attendance records	15.3(a)20	739
Current photo of participant	15.3(a)21	741
Care plan shall include: orders for treatment, participant needs/preference, specific goals, scheduled days of attendance, time intervals at which participant’s response to treatment will be reviewed	5.4(c)	375
Quarterly reassessments	5.4(c)	379
Care plan shall include discharge planning	5.4(d)	381
Annual Flu/pneumonia vaccination	16.2(c)(d)	771

773
Prior authorization (Medicaid)	3.1(b)7	223

Quality Improvement Program	Reg. Number	MO Number	Reviewed
Written plan for QI program; specify timetable and persons responsible	18.1(a)	829
QI activities to include annual review of staff qualifications, staff orientation, evaluation of participant care services, staffing, med. error, medical record review, and objective criteria for evaluation	18.1(b)	831

Agreements	Reg. Number	MO Number	Reviewed
Medical Consultant	8.2	481
Pharmacist Consultant	9.1(a)	495
Food Service Provider (if applicable)	10.4(b)	537
Medical Records Consultant	15.2	699
Physical, Occupational, and Speech Therapies	6.1(c)	395
Pest control program	16.5(b)	805
Copies of any waivers that may have been given during the Application Approval Process	2.2(a)	173
Registered Dietitian	10.4	535, 537

Name of Surveyor

Adult Medical Day Care Inspection Information

Requirements for Initial Survey of Adult Medical Day Care

(Continued)

AAS-22

SEP 12	Page 5 of 5 Pages.

SEP 12	Page 1 of 5 Pages.

AAS-22, Adult Medical Day Care Inspection Information

AAS-22, adult medical care inspection, assessment and survey,

ewhite

2012-03-07

NJDOH