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Trenton, NJ 08625-0360

For Release:
August 16, 2010

Poonam Alaigh, MD, MSHCPM, FACP

For Further Information Contact:
Office of Commuincations
(609) 984-7160

Department of Health and Senior Services Proposes to Readopt N.J.A.C. 8:43G, Hospital Licensing Standards, with Amendments


The Office of Certificate of Need and Healthcare Facility Licensure of the Division of Health Facilities Evaluation and Licensing of the Senior Services and Health Systems Branch of the Department of Health and Senior Services (Department) is proposing to readopt N.J.A.C. 8:43G, the Hospital Licensing Standards, and proposes technical and substantive amendments.  The notice of proposal appears in the August 16, 2010, issue of the New Jersey Register.

Significant among proposed substantive amendments are the following:

·         The Department proposes amendments specifically identifying psychiatric hospitals as being among the types of facilities to which the chapter applies.

·         The Department proposes amendments reflecting a shift in focus of the Department’s Facility Survey Program away from biennial inspections, with reliance instead on a facility’s achievement of accreditation from an accrediting body recognized by the Centers for Medicare and Medicaid Services.  Facilities would submit proof of this accreditation, in the form of a proposed “regulatory compliance statement,” as part of its licensure renewal application.  The proposed amendments would refer to facilities holding this accreditation to as having “deemed status”; that is, the Department would deem that the facilities comply with applicable licensing standards.  This shift in focus away from routine inspections would enable the Department to direct its resources toward performing complaint investigations, surveys associated with complaint investigations, and surveys to monitor licensed healthcare facilities undergoing financial difficulties or strike activity.  The Department would continue to retain the option to perform random survey visits and investigations.

·         The Department proposes amendments affecting the timing of assessment, and purpose of, the biennial facility inspection fee.

·         The Department proposes amendments articulating specifically the obligations of hospitals to afford civil union partners and domestic partners the same rights and privileges to visitation and medical records access that they afford to spouses, and that hospitals are not to abridge these rights and privileges because of unlawful discrimination against suspect classes as established in the New Jersey Law Against Discrimination.

·         The Department proposes amendments reflecting the prohibition against smoking in indoor public places and workplaces, including hospitals, established by the New Jersey Smoke-Free Air Act.

·         The Department proposes amendments addressing the practice of anesthesia in hospitals.  Some of these amendments are in response to a petition for rulemaking addressing the performance of anesthesia in hospitals by certified nurse anesthetists, also known as advanced practice nurses who specialize in anesthesia or “APNs/anesthesia.”

·         The Department proposes amendments adding “hospitalists” to the list of professionals who are authorized to serve on an acute care stroke team in a stroke center, and to add critical care, family medicine, general internal medicine, general surgery, and anesthesiology to the list of specializations in which a stroke team member must hold board certification or board eligibility to be eligible to serve on the stroke team.

·         The Department proposes amendments to correct references to externally produced publications and guidelines, particularly documents the Centers for Disease Control and Prevention issues identifying best practices in infection control, hospital architecture standards, and building and fire codes, to remove inconsistencies and to reflect the most recent editions of these publications and the sources and web pages from which one can obtain them.

·         The Department proposes amendments that would provide patients and their healthcare providers with additional time in which to obtain preadmission and postadmission medical histories and physicals, and would expand the list of professionals authorized to perform these assessments and evaluations to acknowledge that the conduct thereof is within the authorized scope of practice of advanced practice nurses and physician assistants.

·         The Department proposes amendments to the employee tuberculosis screening rule that are consistent with the Department’s communicable disease standards reflecting best practices for management of tuberculosis at N.J.A.C. 8:57-5, including the addition of the interferon gamma release assay as an approved screening method, and establishment of requirements and procedures for repeat and follow-up screenings.

The public has until October 15, 2010, to comment on the proposal.  Persons wishing to comment on the proposal must submit their comments in writing by regular mail to Ruth Charbonneau, Director, Office of Legal and Regulatory Affairs, Office of the Commissioner, NJ Department of Health and Senior Services, P O Box 360, Trenton, NJ 08625-0360.  Written comments must be postmarked on or before October 15, 2010, which is the close of the 60-day public comment period.  The Department will not accept telefacsimiles or electronic mail messages as official comments on the notice of proposal.


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