New Jersey Department of Health

MEDICAL DAY INSPECTION INFORMATION

Requirements for Standard Medical Day Care Surveys

(Adult and Pediatrics)

Facility Name

Survey Date

____ / ____ / _____
Name(s) of Registered Nurse(s) on Duty when surveyor arrives

Request the following upon arrival at facility:

1.	Census (day/days of survey)

2.	Staffing (day/days of survey)

3.	Hours and days of week of programming (one or two shifts)

4.	List of licensed staff (verify license number and expiration date)

5.	Staff member employment files (random selection) **

6.	Staff health files (can use same files in #5) **

7.	Resumes of Key Staff (* review if hired after last survey)

8.	Policy and Procedure Manual

9.	Signed Affidavit of Compliance

Adult REG # - N.J.A.C. 8:43F / Pediatric REG # - N.J.A.C. 8:43J

Resumes of Key Staff	Reg. # Adult/Peds	Reviewed
Administrator Qualifications	3.2
Designated Alternate Administrator

Peds – must meet same as Administrator	3.1(a) /

3.l (b)(1)
Director of Nursing Qualifications	7.2
Designated Alternate Director of Nursing	7.1
Peds – LPN/RN must have one year experience working with medically complex children	7.4
Social Worker Qualifications	12.1
Adult – Activities Director Qualifications *	13.2
Peds – Child Life Specialist/Teacher (document credentials)	11.1
Dietitian Qualifications	10.3
Food Service Supervisor (qualifications if new)	10.2 – 10.3
Employee Personnel and Health Files	Reg. # Adult/Peds	Reviewed
Adult – Application/background check/reference **

(new hires)	6.3
Peds – CBI clearance by DOH or DHS with waiver from DOH on all employees	2.2(g) & 6.3 (a)
Job descriptions – review if an issue during survey	6.3(b)
Staff Orientation (elder abuse, infection control, emergency plans, pain management) upon hire/annually ** (Review if there is an issue)	6.3(e)
Initial and subsequent physical exam **	16.3 / 15.5
Two step Mantoux upon hire/annually **	16.2(e) / 15.4
Adult – One person certified in Cardiac Life Support	14.17(b)1
Peds – CPR certified and AED (all direct care staff); AND	6.2(h)
One person certified in PALS or comparable	6.2(i)

Review if Warranted	Reg. # Adult/Peds	Reviewed
Abuse Policy	3.3(d) 8 / 3.4(e)(17)
Discharge, transfer, and readmission of participants	3.6(a)(7) / 3.5(c)(5)
Staffing Schedule

Adult – 1:9

Peds – 1:3 direct care staff

1:6 licensed Nurses

2 RNs at all times (can include DON)	6.3(d)

6.2(d)

6.2(c)

6.2(b)
Consultant Pharmacist Reports (quarterly for Adult)	9.1(b)
Peds – every 60 days	9.1(b)
Quality Improvement Program	18.1 / 17.1

Physical Environment	Reg. # Adult/Peds	Reviewed
Facility to post notice: all waivers, participants rights, means of contacting license holder, business hours	3.4(b) / 3.6 (c)
Facility to post name, address, and telephone number of DOH, Ombudsman, Medical Assistance and Health Services, Youth and Family Services, and APS	4.2(b)
Public/private telephone (Adult only)

Drinking water; space for wheelchair storage	14.4(b)
Peds – secure door between lobby/reception and children’s areas	13.4(b)
Housekeeping/Environment

Hot Water Temperatures (maximum 120 degrees F.)	16.7 / 15.9
Lockers and lounges for employee/volunteer staff	14.5 / 13.5
Janitor’s closet contains a service sink and storage for housekeeping supplies and equipment	14.6 / 13.6
Social work office space for private interview	14.7 / 13.7
Storage space for recreation equipment	14.8(b) / 13.8(d)
Adult – Rehab equipment (parallel bars, stairs, mat, padded table)	11.2(c)
Peds – Ped. table with mat, rolls and 1/2 rolls, nexting benches, wooden weighted push cart, toddler swing, floor mirror, steps, climbing equipment, etc.	11.3
Adult - Recliners or beds (1:10) and quiet area	14.10(a)
Peds - Cribs/Mats (1:1) (3 ft. between)	13.9
Lockable Refrigerator or locked box in refrigerator for medications	14.9(b) / 13.11(c)
Adult - Activities schedule (posted)

Peds – Plan of diversified activities for child based on IDCP	13.1 /

6.1(f)
Exam room with private area, with handwashing facilities, counter or shelf space for writing	14.9(d) / 13.11(e)
Peds – 3 Child Care Areas (Ambulatory, Toddlers, Non-Ambulatory)	13/8
Peds – 2 Diaper changing areas (separate from bathrooms), 5 ft. from handwashing sink minimum and privacy screened	13.3

Emergency Plans and Procedures	Reg. # Adult/Peds	Reviewed
Adult - Emergency equipment, O2 , suction, airway, ambu-bag	14.17(a)
Peds – all of above, plus AED	8.5(b)
Procedures for emergencies – review only if there is an issue	14.17 / 13.16
Written evacuation diagram includes evacuation procedure, location of fire exits, alarm boxes, fire extinguishers, “you are here” with evacuation route specific to facility	14.17(d) / 13.16(b)
Drills of emergency plans 4 per year	14.17(f) /

13.16(e)
Ask for system facility uses to track employee participation in drills annually	13.16(g)
Hot Water Temperature 120( Max.	16.7(a) 24
Fire extinguishers examined annually and labeled	14.17(h) / 13.1(d)
Peds – Emergency generator (onsite or contracted)	13.1(f)

Transportation	Reg. # Adult/Peds	Reviewed
Provide safe transportation services	17.1 / 16.1
Peds – One hour each way; MAV or equal with waiver; one direct care staff member on vehicle in addition to driver (minimum)	16.1 & 16.2
Food Services and Nutrition	Reg. # Adult/Peds	Reviewed
Scheduled consultation with a Dietitian

Peds – RD to assess every 60 days or more if needed	10.4(a)1 / 10.1(b)
Current Diet Manual (on site)	10.5(b) / 10.1(h)
Written, dated menus planned 14 days in advance	10.5(c)2 / 10.1(i)2
Record of diet order in kitchen/prep area	10.5(c)13 / 10.1(i)11
Minimum supplies of food (i.e., cereal, tuna, PB, canned fruit, juices)	10.5(c)8 / 10.1(j)
Peds – Is facility providing formula and food?	10.5(c) 8 ii
N.J.A.C. 8:24 Requirements

Ask diet staff what system is used to ensure proper food temperatures prior to serving.	10.5(a) /

10.1(g)
Refrigerator/thermometers	16.7 / 15.9
Handwashing sink located in food prep area	14.11(a)4 / 13.12(d)2
Warewashing facility – Dishwashing machine (temps) 3‑compartment sink (correct usage)	14.11(a)5 / 13.12(d)3

Contracts	Reg. # Adult/Peds	Reviewed
Adult - Medical Consultant (Physician)	8.2
Peds – Medical Director (Board Certified in Pediatrics)

(Review these only if new since last survey)	8.2
Consultant Pharmacist (no affiliation with pharmacy provider) (Review if issue with DRR)	9.1
Medical Records Practitioner (Review is issue with medical records)	15.2 / 14.2
Physical, Occupational and Speech Therapies (if new)

(Is the provider leasing space in the facility?)	11.2
Catering Service

(Review if issue with menus, complaints, etc.)	14.11(a) / 13.12(b)

Name of Surveyor

Date

Medical Day Inspection Information

Requirements for Standard Medical Day Care Surveys (Adult and Pediatrics)

(Continued)

AAS-59

JAN 13	Page 4 of 5 Pages.

JAN 13	Page 1 of 5 Pages.

AAS-59, Adult Medical Day Care, Inspection Information

AAS-59, adult medical day care, inspection, annual survey, hfel, health facility evaluation and licensing, assessment and survey

Elaine White

2012-03-09

ewhite

NJDOH