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
3.2(a) 1-3 3.1(a) 7.2 7.1(a) 12.1 13.2(a) 1-5 10.3 15.2 10.2(a) 1-3 16.1(b)

MO Number
225 221 433 425 577 587 533 699 531 765

Reviewed

Administrator Qualifications Designated Alternate Administrator Director of Nursing Qualifications Designated Alternate Director of Nursing Social Worker Qualifications Activities Director / Qualifications Dietitian Qualifications Medical Records Consultant / Qualifications Food Service Supervisor Infection Control Designee

AAS-22 SEP 12

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ADULT MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Adult Medical Day Care

(Continued)
Employee Personnel and Health Files Reg. Number
6.3(a)1 6.3(a)1i 6.3(b)

MO Number
409 411 415

Reviewed

Application/Background Check/Reference (New Hires) Administrator/Owner (CBI) Job Description Staff Orientation (*elder abuse, rights, infection control, *emergency plans, pain management), upon hire/annually* Two-step Mantoux upon hire/one-step annually

6.3(e)1i

421

16.2(f)(g)

777 779

Physical Environment

Reg. Number
4.1(a) 3.4(b)

MO Number
305 267

Reviewed

Facility to post all waivers participants rights, means of contacting license holder Facility to post name, address, and telephone number of NJDOH, Ombudsman, Medical Assistance and Health Services, Youth and Family Services, APS Public/Private Telephone Toilet facilities 1:10 Entrance at grade level to accommodate devices Lockers and lounges for employee/volunteer staff Janitors closet contains a service sink and storage for housekeeping supplies and equipment Social work office space for private interview Storage space for recreation equipment Office space for recreation director or designated area Recliners or couch 1:10; quiet area (40 sq. ft. per bed/crib)

4.1 4.2(b,c,d)

309 347

4.2(a)13 14.3(b)1 14.4(a) 14.5

337 611 617 631

14.6

633

14.7 14.8(b) 14.8(c) 14.10(a)1i

635 639 641 651

AAS-22 SEP 12

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ADULT MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Adult Medical Day Care

(Continued)
Physical Environment Reg. Number
14.1(b)

MO Number
619

Reviewed

Fountain/bottled water Office space for nursing with sink. If combined with pharmacy area, 100 sq. ft. minimum Dispensing area with handwashing facilities Lockable refrigerator or locked box in refrigerator Exam room with private area with handwashing facilities, counter or shelf space for writing (80 sq. ft. minimum floor area) Activities Calendar

14.9(a)

643

14.9(b)1 14.9(b) 3

645 645

14.9(d) 3

649

13.1(a)

585

Emergency Plans and Procedures

Reg. Number
14.17(b) 14.17(b)1 14.17(a)

MO Number
679 681 677

Reviewed

Emergency Equipment, O2, Suction, Airway, Ambu-Bag CPR-certified staff member (One on duty at all times) Procedures for emergencies Written evacuation diagram includes evacuation procedure, location of fire exits, alarms boxes, fire extinguishers POSTED Drills of emergency plans 4 per year Fire extinguishers examined annually and labeled Hot water temperature 120 max.

14.17(d)

689

14.17(f,g) 14.17(h) 16.7(a) 24

689 691 815

Transportation

Reg. Number
17.1(a) 17.1(e)

MO Number
821 825

Reviewed

Provide transportation services Transportation rules (i.e., CDL license for drivers) (Time)
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ADULT MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Adult Medical Day Care

(Continued)
Reg. Number
10.5(a) 10.5(b) 10.5(c)2 10.5(c)8ii

Food Services and Nutrition

MO Number
535 537 541 543 549

Reviewed

Posted Sanitary Inspection (if applicable) Current Diet Manual (on site) Written, dated menus planned 14 days in advance with portion sizes Minimum supplies of food (i.e., cereal, tuna, PB, canned fruit, juices) 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
15.3(a)1 15.3(a)2 15.3(a)3

MO Number
701 703 705

Reviewed

Participant identification data Acknowledgement that participant has received "rights" Home environment assessment Medical history/physical exam (60 days prior to admission); orders for specific type and intensity of care and verification is free of communicable disease Comprehensive assessment Record of medications Attendance records Current photo of participant Care plan shall include: orders for treatment, participant needs/preference, specific goals, scheduled days of attendance, time intervals at which participants response to treatment will be reviewed Quarterly reassessments

8.4(b)1-4

491

5.3(e) 15.3(a) 10,11 15.3(a)20 15.3(a)21

373 719 721 739 741

5.4(c)

375

5.4(c)

379

AAS-22 SEP 12

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ADULT MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Adult Medical Day Care

(Continued)
Medical Records and Care Plan Reg. Number
5.4(d) 16.2(c)(d) 3.1(b)7

MO Number
381 771 773 223

Reviewed

Care plan shall include discharge planning Annual Flu/pneumonia vaccination Prior authorization (Medicaid)

Quality Improvement Program

Reg. Number
18.1(a)

MO Number
829

Reviewed

Written plan for QI program; specify timetable and persons responsible 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 Medical Consultant Pharmacist Consultant Food Service Provider (if applicable) Medical Records Consultant Physical, Occupational, and Speech Therapies Pest control program Copies of any waivers that may have been given during the Application Approval Process Registered Dietitian

Reg. Number
8.2 9.1(a) 10.4(b) 15.2 6.1(c) 16.5(b)

MO Number
481 495 537 699 395 805

Reviewed

2.2(a)

173

10.4

535, 537

Name of Surveyor

AAS-22 SEP 12

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