01-01-001

GENERAL PROVISIONS

NEW JERSEY DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
DIVISION OF VETERANS HEALTHCARE SERVICES

MISSION STATEMENT

The mission of the Division of Veterans Healthcare Services (DVHS) is to provide veterans and eligible others with dignified, compassionate, and professional long-term health care.
 
The New Jersey Veterans Memorial Homes (VMH) at Menlo Park, Paramus, and Vineland will strive to:

  • Serve the aging with the various levels of care needed, regardless of race, color, creed, age, sex, disability, or source of payment.
  • Structure rates in accordance with N.J.A.C. 5A:5-2.1 Admission Eligibility.
  • Expand the facilities and programs where there is a demonstrable need, and where it is consistent with sound financial management.
  • Provide facilities which, in their relationship with both their residents and their employees, maintain and promote the dignity and personal growth of the individual, provide a caring environment, and promote the rights of the individual.
  • Provide competent leadership for the facilities in the recruiting of managers and staff, regardless of race, color, creed, age, sex or disability, who are qualified and provide the best possible care for the residents.
  • Interpret to the employees the service programs available for residents. Develop awareness of these service programs among the facilities and various health care agencies in the communities.
  • Encourage the support of the New Jersey Veterans Memorial Homes’ programs through gifts and services by volunteers.
  • Ensure that all funds and finances are prudently used, controlled, and accounted for by the facilities management, in accordance with State and Federal regulations.
  • Provide such auxiliary services as would enhance and facilitate various programs within the New Jersey Veterans Memorial Homes.
PHILOSOPHY

It is the philosophy of the New Jersey Veterans Memorial Homes (VMH) to provide a setting for residential living which meets the physical, emotional, and spiritual needs of the resident, without regard to financial status, social position, race, color or creed.

The New Jersey Veterans Memorial Homes provide a secure and comfortable environment where the resident maintains a sense of high self-esteem, has the opportunity for self-expression, and maintains a feeling of independence and self-direction.

It is the goal of the New Jersey Department of Military and Veterans Affairs (DMAVA) to provide the highest quality of services, from a qualified knowledgeable staff, in a manner that enables the resident to understand the purpose of, and need for, such health care services.

GOVERNING AUTHORITY

The New Jersey Veterans Memorial Homes (VMH) are owned by the State of New Jersey and operate under the jurisdiction of The Adjutant General (TAG) of the Department of Military and Veterans Affairs (DMAVA), through its Division of Veterans Healthcare Services (DVHS).

Under the general policies established by The Adjutant General, an Advisory Council, whose members are appointed by the Governor for each of the Homes, shall serve to assist and advise the Chief Executive Officers (CEOs) in the operation of the veterans’ facilities, and shall:

  1. Recommend standards and procedures for application and termination of eligibility for admission to veterans’ facilities;
  1. Recommend standards and methods for designating the veterans’ facility in which an eligible person shall receive care and treatment, consistent with available services and individual needs and circumstances;
  1. Recommend standards of care, treatment, and discipline governing the relationships between the veterans’ facilities and persons admitted thereto; and
  1. Recommend standards and procedures for the determination and payment of amounts which residents may be required to contribute toward the cost of care and treatment, in accordance with their financial ability.
  1. Authorize expenditures over $500.00 from the Welfare Fund, to ensure monies are spent in accordance with policies and procedures.

                                                                                                           

DEVELOPMENT, MODIFICATION, DELETION

PURPOSE.

To established a system to incorporate developments, modifications, and deletions to the Divisional Policy and Procedure Manual by the New Jersey Veterans Memorial Homes.

DEFINITION.

Development is creating and/or writing a policy and/or procedure.

Modification is altering an existing policy and/or procedure.

Deletion is to eliminate a policy and/or procedure from the Divisional Manual.

PROCEDURE.

  1. New Jersey Veterans Memorial Home Staff Responsibilities:

    1. A New Jersey Veterans Memorial Home employee may recommend a change in a policy and/or procedure.

    2. The Chief Executive Officer(s) will be notified of the desired change and, if it is determined there is a need for policy and/or procedure changes, the recommendation will be presented to the Policy and Procedure Committee, and reviewed by the Chief Executive Officer(s) for approval.

  2. Division Director Responsibilities:

  1. The proposed policy and/or procedure will be reviewed by the Director of the Division of Veterans Healthcare Services/designee for approval within 30 days of receipt.

    1. If approved, the document will be implemented within 60 days.

    2. If denied, a written response will be forwarded to the chairperson of the Policy and Procedure Committee.

 

FORMS CODIFICATION

DIVISIONAL POLICY AND PROCEDURE MANUAL.

Numbering of the policies and procedures will be accomplished as follows:

The first two numbers shall indicate the Departmental Section.  (See Table of Contents Codification.)

EXAMPLE:    07-02-001 – Resident Activities

The second two numbers will indicate the appropriate subsections of the Policy and Procedure Manual.

            EXAMPLE:    07-02-002 – Resident Activities – Volunteer Program

The third and final numbers shall indicate the direct placement of the informative material and procedures included in the subsections.

            EXAMPLE:    07-02-003 – Resident Activities - Donations

 

FACILITY PROCEDURAL MANUALS.

Facility manuals will contain procedures only.  Numbers will be accomplished as follows:

-The first two numbers shall indicate the Departmental Section. 

-The second three numbers will indicate the placement of procedures under the Departmental Section.

 

The coding system is a ten-digit alpha-numeric code.

EXAMPLE:

The Policy and Procedure Committee of the using facility will approve the facility’s forms. A “Forms Register” will be maintained whereby all forms necessary for implementation are submitted for prior administrative review and approval, with appropriate instructions for usage and substantiation of the need for such a form.  Revised forms will show the month and year of revision.

Departmental forms will carry the following department alphabetic designations:

ACT

-

Resident Activities

ADM

-

Administration

BUS

-

Business Office

DIE

-

Dietary Services

EME

-

Emergency Preparedness

LAB

-

Laboratory, Radiology and Diagnostic Services

MAI

-

Maintenance

MED

-

Medical Services

MER

-

Medical Records

NUR

-

Nursing Services

PER

-

Personnel

REH

-

Rehabilitation Services

SOC

-

Social Services

EDT

-

Employee Development (Training)

QUI

-

Quality Improvement

ERO

-

Employee Relations Office/Officer

AAO

-

Affirmative Action Office/Officer

FDS

-

Food Service

ENV

-

Environmental Services

Copies of all forms and instructions for use will be filed in the forms register and maintained through the designated department of each facility.

GENERAL REQUIREMENTS

SCOPE AND PURPOSE.

The Divisional Policy and Procedure Manual contains guidelines intended to ensure that quality care is delivered in the three long-term care facilities throughout New Jersey, within the New Jersey Department of Military and Veterans Affairs.  Components of quality care addressed by these policies and procedures include: access to care, continuity of services, comprehensiveness of care, coordination of services, humaneness of treatment, safety of the environment, professionalism of staff, and participation in useful studies.

DEFINITIONS.

The following words and terms, when used in the Divisional Policy and Procedure Manual, have the following meaning, unless the context clearly indicates otherwise:

“Bed” or “licensed bed” means – with reference to a veterans home resident - the item of furniture assigned to no more than one veterans home resident for sleeping, resting, relaxing, or otherwise used for the veterans home resident’s personal comfort or convenience.  In reference to a Veterans Memorial Home facility, one of the total number of beds for which each licensed long-term care facility is approved by the Commissioner of the New Jersey State Department of Health and Senior Services, which is used for veterans home resident care.

“Facility” means a New Jersey Veterans Memorial Home, licensed by the New Jersey Department of Health and Senior Services, to provide health care under medical supervision and continuous nursing care for 24 or more consecutive hours.

“Veterans Home Resident” (VHR) means a person who is under medical care and treatment in the facility, and who resides in the facility.  Also referred to as a resident or patient.

“Each service” refers to all personnel assigned managerial responsibility for the provision, within the facility, of medical, nursing, resident activities, pharmaceutical, social work, dietary or, if specified, rehabilitative (including physical therapy, occupation therapy and speech therapy), dental, or housekeeping (or environmental) services to the veterans home resident.

“Providers” means any outside agents who render services within a facility for the veteran’s home resident, either by contract or direct fee services.

CODIFICATION
TABLE OF CONTENTS

TITLE
SECTION
 
FOREWORD
--
GENERAL PROVISIONS 
01
SHORT-TERM STAY ADMISSIONS    
02
 
RESIDENT RIGHTS

04

ADMISSIONS

05

RESIDENT ACTIVITES

07

ADMINISTRATION

09

RESIDENT ASSESSMENTS

11

COMMUNICATIONS/COMMITTEES

13

DENTAL SERVICES

15

NUTRITIONAL SERVICES

17

FOOD SERVICES

18

INFECTION CONTROL

19

ENVIRONMENTAL SERVICES

21

MEDICAL SERVICES

23

NURSING SERVICES

25

RESIDENT CARE

27

PHARMACY

29

QUALITY IMPROVEMENT

33

INTERNAL CONTROLS

34

MEDICAL RECORDS

35

REHABILITATION

37

SOCIAL SERVICES

39

PHYSICAL PLANT & SAFETY

41

PERSONNEL

43

BUSINESS

44

EMPLOYEE DEVELOPMENT & TRAINING

45

OFFICE INFORMATION SYSTEMS

46

EMPLOYEE RELATIONS OFFICE

47

AFFIRMATIVE ACTION OFFICE

48

 

Revised: May 2011