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New Jersey Department of Health
Division of Health Facility Survey and Field Operations
DECLARATION OF COMPLIANCE WITH ADVISORY STANDARDS
(Please print information.)
Facility Name (as it appears on the license):
Street Address:
City: , NJ Zip Code:
County: Facility ID # (use MDS#):
This facility is (check one) For Profit Not for Profit Number of Licensed Long-Term Care Beds:
I, (print name) , Administrator of the aforementioned facility, hereby certify the facility’s compliance with the advisory standards checked below. (All identifiers refer to the number of the advisory standard contained in Chapter 8:39 of the New Jersey Administrative Code.) The Department will issue a “Statement of Compliance with Advisory Standards” report to a facility where at least 90% of the reviewed advisory standards are confirmed as met. The report will recognize compliance with advisory subchapters where at least 65% of all advisory standards are met in the subchapter. Facilities receiving a deficiency of level “E” and above are ineligible for an Advisory Survey.
PLEASE CHECK OFF ONLY THE ADVISORY STANDARDS, WHICH YOU BELIEVE ARE MET BY THE FACILITY. Use the blank space below the checked standards to describe proof of compliance (for example, “in activities portion of all medical records,” or “sign in lobby”). Where supporting documentation is required or useful, attach the documentation to this form, labeled clearly with the number(s) of the standard(s) which it supports.
THIS COMPLETED FORM AND ALL SUPPORTING DOCUMENTATION SHOULD BE GIVEN TO THE SURVEY TEAM ON THE FIRST DAY OF THE ANNUAL SURVEY.
(Signature of Administrator)
(Title)
(Date)
The surveyor will randomly select a total of 30 advisory standards for review by randomly selecting a standard as a starting point and selecting every fifth standard until thirty have been selected. If less than 30 standards have been checked by the facility, all of the checked standards will be evaluated by the surveyors. In the surveyor column next to each selected standard the surveyor will write “Yes” if their evaluation shows that the standard has been met and “No” if their evaluation shows that the standard has not been met.
When evaluating advisory subchapter 46 (Alzheimer/Dementia), all 19 standards are to be checked for compliance.
Team Leader: Team #: Survey Date(s): (Print Name)
Supervisor: (Print Name)
Ineligible – Scope and Severity level “E” and above New
Number of standards checked by team: ____________ Continuation
Number of checked standards not met: ____________ No longer participating
(Continued)
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SUBCHAPTER 3. COMPLIANCE WITH MANDATORY RULES AND ADVISORY STANDARDS
8:39-3.1 Mandatory Rules
(a) Mandatory rules contain minimum and essential requirements of care provided by a facility.
(b) Failure to comply with any mandatory rules contained in this chapter shall constitute a deficiency for which the Department may take any or all of the enforcement actions set forth in N.J.A.C. 8:43E.
8:39-3.2 Advisory Standards
(a) Advisory standards contain benchmarks of excellence or superior attainment in providing care of high quality.
(b) Facilities are strongly encouraged to use advisory standards in striving to provide the highest quality of care possible.
(c) Failure to comply with any or all advisory standards shall not constitute a deficiency or result directly or indirectly in any enforcement action by the Department.
(d) Compliance with advisory standards shall not be used as an indication of whether the facility is in compliance with mandatory rules or whether a facility should be made subject to a penalty or other action to protect residents.
8:39-3.3 Reporting Compliance with Advisory Standards
(a) Compliance with advisory standards shall be calculated in accordance with the following:
- The Department shall verify that at least 90 percent of no more than 30 advisory standards randomly selected from the total number of advisory standards which the facility claims to have met are in fact met; and
2, If the compliance rate determined at (a)1 above is 90 percent or greater, then, for any advisory subchapter in which the facility has claimed to meet 65 percent or more of the standards in the subchapter, recognition for meeting the entire subchapter shall be given.
(b) If a facility applies for a certificate of need, compliance with six or more of the following advisory subchapters at the time of the most recent survey of the facility shall be taken into consideration: access to care (N.J.A.C. 8:39-6), resident assessment and care plans (N.J.A.C. 8:39-12), pharmacy (N.J.A.C. 8:39-30), infection control and sanitation (N.J.A.C. 8:39-20), resident activities (N.J.A.C. 8:39-8), dietary services (N.J.A.C. 8:39-18), medical services (N.J.A.C. 8:39-24), nurse staffing (N.J.A.C. 8:39-26), physical environment (N.J.A.C. 8:39-32), and quality assessment and/or quality improvement (N.J.A.C. 8:39-34).
(c) If a facility can demonstrate that it has a system in place to meet the requirement, even though it is not applicable at the time of the survey, the surveyors may deem that, in their judgment, the standard is met.
(Continued)
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SUBCHAPTER 10. ADVISORY ADMINISTRATION 7 (5)
8:39-10.1 Advisory policies and procedures for administration
______ _____ (a) The administrator monitors trends in staff turnover.
______ _____ (b) Each of at least five service directors participates in facility planning through preparation of annual
budgets and annual reports, and participates in annual budget conferences among all service directors and the administrators.
8:39-10.2 Advisory staff qualifications
______ _____ The administrator holds current professional certification from the American College of Health Care
Administrators, or possesses a master’s degree in health care administration or a related field.
8:39-10.3 Advisory staff education and training
______ _____ (a) Personnel who provide direct resident care are offered an opportunity to attend at least one education
program each year and receive fee reimbursement or compensatory time off. Records of continuing education programs attended are maintained.
______ _____ (b) The facility conducts a tuition aid program directed toward the career development and upward mobility
of staff, including both professional and ancillary personnel.
______ _____ (c) The facility is a teaching nursing home, that is, the site of an internship, externship, or residency training
program for health professionals, as part of the curriculum of an accredited or State-approved school or training program. The facility has sought input from the residents and/or the resident council concerning teaching programs.
______ _____ (d) The facility maintains a library of textbooks and/or recent periodicals on long-term care, geriatric care,
nursing, and other disciplines that is accessible to staff.
SUBCHAPTER 12. ADVISORY RESIDENT ASSESSMENT AND CARE PLANS 3 (2)
8:39-12.1 Advisory policies and procedures for resident assessment and care plan
______ _____ (a) The resident care plan is developed at a meeting held by an interdisciplinary team that includes
professional and/or ancillary staff from each service providing care to the resident.
______ _____ (b) The facility makes care planning meetings available at mutually agreeable times, including evenings
and weekends, for the convenience of families and significant others.
8:39-12.2 Advisory resident services for off-site services
______ _____ The facility provides and/or arranges for someone to accompany each resident to scheduled visits to off-site
health care services.
SUBCHAPTER 14. ADVISORY COMMUNICATION 9 (6)
8:39-14.1 Advisory resident services
______ _____ (a) The facility has one or more wellness programs open to the public, such as programs to reduce or
prevent smoking, alcohol and drug abuse, elder abuse, obesity, or hypertension.
______ _____ (b) Periodic meetings are open to all staff, residents, and families to discuss any problems, encourage the
resident to reach his or her potential, examine the goals and expectations of different individuals, describe how questions and complaints can be presented, and review the concept of interdisciplinary care.
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______ _____ (c) Provision is made for residents to retain membership, join, and/or participate in community activities.
These should include organizations, community projects, holiday observances, or charitable events.
______ _____ (d) A facility newsletter is provided to residents and families at least quarterly.
______ _____ (e) Each staff member wears an easily readable name tag.
8:39-14.2 Advisory staff education and training for communication
______ _____ (a) Periodic meetings are held with each service to discuss ways to improve care to all residents.
______ _____ (b) Education and training of staff includes an accredited program in cardiopulmonary resuscitation (CPR)
which offers staff an opportunity to be recertified on an annual basis.
______ _____ (c) Each service establishes and implements education or training programs for members of other services
on diverse topics.
______ _____ (d) Education or training sessions are offered which address new concepts and directions in cultural and
interpersonal concepts.
SUBCHAPTER 16. ADVISORY DENTAL SERVICES 2 (1)
8:39-16.1 Advisory resident dental services
______ _____ (a) The facility provides in-house dental services, including treatment and prophylactic care.
______ _____ (b) The facility follows established protocols for providing all residents with regularly scheduled routine
prophylactic dental services and treatments when indicated, delivered by a dentist or a dental hygienist, except for residents whose medical records contain an explanation of why such services would not benefit the resident.
SUBCHAPTER 18. ADVISORY DIETARY SERVICES 11 (7)
8:39-18.1 Advisory structural organization for dietary services
______ _____ A registered dietitian performs the resident dietary assessment and participates in the interdisciplinary plan
of care.
8:39-18.2 Advisory staff qualifications for dietary services
______ _____ The director of dietary services or the dietitian is registered by the Commission on Dietetic Registration of
the American Dietetic Association (R.D.)
8:39-18.3 Advisory staffing amounts and availability for dietary services
______ _____ The dietitian spends an average of 20 minutes per resident each month providing dietary services in the
facility. (This is an average. It is equal to one full-time equivalent dietitian for every 520 residents.)
8:39-18.4 Advisory resident dietary services
______ _____ (a) There are dietary observances for national and/or religious holidays.
______ _____ (b) Fresh fruits and vegetables are served in season on a daily basis.
______ _____ (c) The facility utilizes a dining room/area, other than day rooms, for residents with special needs.
______ _____ (d) Residents have access to a refrigerator or snack bar.
______ _____ (e) Residents are offered a selective menu consisting of at least three main entrees at each meal.
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8:39-26.2 Advisory policies and procedures for nurse staffing
______ _____ (a) The facility establishes and implements a system for assigning nursing personnel on the basis of a
classification system involving resident acuity.
______ _____ (b) The facility uses a primary system in which nurse aides are assigned on a regular basis to specific
residents to provide continuity of care.
8:39-26.3 Advisory nurse staffing amounts and availability
______ _____ (a) A registered professional nurse is on duty at all times in facilities with fewer than 100 licensed beds; two
registered professional nurses are on duty at all times in facilities with 100 to 200 licensed beds; and three registered nurses are on duty at all times in facilities with more than 300 beds.
______ _____ (b) The facility provides direct nursing services pursuant to N.J.A.C. 8:39-25.2(b) of this chapter which are
increased by at least ten percent.
______ _____ (c) At least 50 minutes per resident per day of resident care is provided by licensed nurses, that is,
registered professional nurses and licensed practical nurses. (This is an average. It is equal to one full-time equivalent nurse for every ten residents.)
______ _____ (d) All nurse aides working in the facility have completed a training and orientation program to all services
of at least two weeks full-time duration within the facility prior to their permanent assignment in the facility.
______ _____ (e) Each resident care unit in the facility meets the nurse staffing requirements mandated in N.J.A.C. 8:39-
25.2(b).
8:39-26.4 Advisory qualifications for nurse staffing
______ _____ (a) The director of nursing has a baccalaureate or master’s degree in nursing or a health-related field.
______ _____ (b) An advanced practice nurse who is board-certified in family, adult, or geriatric practice is available on
staff or under contract with the facility to perform assessments and to provide consultation to other staff members.
______ _____ (c) The facility employs an advanced practice nurse certified in gerontology or psychiatric nursing on at
least a half time basis.
______ _____ (d) A nurse who holds certification in gerontological nursing, rehabilitation nursing, or a related field of
nursing from the American Nurses Credentialing Center of the American Nurses Association, is available on staff or under contract with the facility.
SUBCHAPTER 28. ADVISORY QUALITY OF CARE 7 (5)
8:39-28.1 Advisory policies and procedures for resident care
______ _____ (a) The facility conducts scheduled interdisciplinary staff discussions, and discussions with residents and
families, about the right of residents to die with dignity.
______ _____ (b) The facility develops and provides individualized non-restrictive equipment meeting individual needs
which fosters and supports a restraint-free environment for all residents.
______ _____ (c) The facility maintains an on-going and on-site program of preventative treatment and referral to mental
health services which includes prevention, treatment, and referral directed by a qualified mental health professional.
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8:39-28.2 Advisory resident care services
______ _____ (a) There are education programs provided on at least a quarterly basis, open and accessible to residents,
families, and significant others addressing the following issues:
- The enhancement and maintenance of physical and mental well-being;
- The prevention of deterioration;
- The teaching of self-care; and
- Death, dying and bereavement.
______ _____ (b) There are education and training programs provided on at least a quarterly basis, open and accessible
to families and significant others, which teach skills and help in the provision of support services that enable residents to leave the facility for visits and vacations.
______ _____ (c) Donated clothing is made available so that residents can select desired items.
______ _____ (d) The facility provides a non-commercial washer and dryer for residents who wish to launder their own
personal items.
SUBCHAPTER 30. ADVISORY PHARMACY 4 (3)
8:39-30.1 Advisory pharmacy staffing amounts and availability
______ _____ The consultant pharmacist or a licensed pharmacist representing the provider pharmacy provides or arranges
for quarterly meetings open to residents, families, and interested others to discuss medication issues.
8:39-30.2 Advisory pharmacy resident services
______ _____ The consultant pharmacist reviews drug records within 48 hours of admission via a facsimile service. All
dated and signed comments and recommendations made by the consultant pharmacist shall be added to the resident’s medical record and shall be distributed to the attending physician or advanced practice nurse and director of nurses for review and action.
8:39-30.3 Advisory provider formulary criteria
______ _____ The provider pharmacy through the Pharmacy and Therapeutics Committee, may establish a formulary
which is not in contradiction to the Drug Utilization Review Council Formulary, N.J.S.A. 24:6E-1 et seq., and N.J.A.C. 8:71. The formulary policies must be approved by the Pharmacy and Therapeutics Committee and every prescriber with prescriptive authority in the facility. The Pharmacy and Therapeutics Committee establishes policies for the prescribing of non-formulary agents. The formulary is developed to avoid negative outcomes.
8:39-30.4 Advisory consultant pharmacist certification
______ _____ The consultant pharmacist holds current certification by the Joint Board of Certification of Consultant
Pharmacists.
SUBCHAPTER 32. ADVISORY PHYSICAL ENVIRONMENT 7 (5)
8:39-32.1 Advisory general maintenance
______ _____ (a) Inspections or rounds are conducted at least monthly by a designated person or committee on all units
and areas for maintenance problems. Results of these rounds are reported to the administrator.
______ _____ (b) Maintenance services are under the supervision of an employee with at least one of the following:
- Five years of experience in maintaining a physical plant.
- A baccalaureate degree in engineering from an accredited college or university and two years of experience in maintaining a physical plant; or
- Professional licensure in New Jersey as an engineer with one year of experience in maintaining a physical plant.
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8:39-36.3 Advisory staff qualifications for medical records
______ _____ (a) The facility utilizes the services of a medical record practitioner or consultant who is:
- Certified or eligible for certification as a registered record administrator (RRA) or an accredited record technician (ART) by the American Medical Record Association (American Medical Record Association, 875 North Michigan Avenue, Suite 1850, John Hancock Center, Chicago, Illinois 60611); or
- A graduate of a program in medical record science accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association in collaboration with the Council on Education of the American Medical Record Association (American Medical Record Association, 875 North Michigan Avenue, Suite 1850, John Hancock Center, Chicago, Illinois 60611).
SUBCHAPTER 38. ADVISORY REHABILITATION 4 (3)
8:39-38.1 Advisory rehabilitation staff qualifications
______ _____ Speech therapy and audiology services are provided by individuals who hold a Certificate of Clinical
Competence issued by the American Speech-Language-Hearing Association.
8:39-38.2 Advisory rehabilitation space and environment
______ _____ The facility has an examination and treatment room for rehabilitation therapy.
8:39-38.3 Advisory rehabilitation supplies and equipment
______ _____ (a) In addition to parallel bars and stairs, physical therapy equipment available to residents includes a
whirlpool for hydrotherapy and ultrasound.
______ _____ (b) The occupational therapy program provides individually designed adaptive equipment as needed to
enhance residents’ independence.
SUBCHAPTER 40. ADVISORY SOCIAL WORK 11 (7)
8:39-40.1 Advisory staff qualifications for social work
______ _____ A social worker has a master’s degree in social work from an accredited university or education program.
He or she should provide consultant services at least eight hours per month, or be on the facility’s staff.
8:39-40.2 Advisory staff amounts and availability for social work
______ _____ (a) A social worker is available to the facility on evenings and weekends at scheduled times or by
previously arranged appointments for interaction with residents and families, and is available seven days a week in cases of emergency or serious need.
______ _____ (b) A social worker assists staff with problems and issues related to aging and illness.
______ _____ (c A social worker orients nurse aides to the social needs of new residents before the resident’s arrival in
the facility.
8:39-40.3 Advisory resident social work services
______ _____ (a) A social worker meets with the resident on the day of admission.
______ _____ (b) A social worker conducts support groups for families.
______ _____ (c A social worker conducts group counseling sessions for residents and families.
______ _____ (d) A social worker participates in pre-admission planning with residents and families prior to their
admission to the nursing home.
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______ _____ (e) The social worker encourages and monitors a regular visiting pattern by families and provides outreach
services to families where the visiting pattern has changed.
8:39-40.4 Advisory space and environment for social work
______ _____ Social workers are to be provided with a private office equipped with a telephone or, in facilities with 60 or
fewer licensed beds, with access to a private office equipped with a telephone.
8:39-40.5 Advisory social work staff education and training
______ _____ The facility encourages the social worker to participate in community agency associations and other
professional organizations.
SUBCHAPTER 44A. ADVISORY STANDARD FOR RESPITE CARE SERVICES 1 (1)
8:39-44A.1 Advisory staffing
______ _____ A long-term care facility assigns specific staff members to an individual respite care resident to provide
continuity of care during the resident’s stay in the facility.
SUBCHAPTER 46. ALZHEIMER’S/DEMENTIA PROGRAMS - ADVISORY STANDARDS 19 (17)
8:39-46.1 Advisory Alzheimer’s/dementia program policies and procedures
______ _____ (a) The long-term care facility has written policies and procedures for the Alzheimer’s/dementia program
that are retained by the administrative staff and available to all staff and to members of the public, including those participating in the program.
______ _____ (b) The facility has established criteria for admission to the program and criteria for discharge from the
program when the resident’s needs can no longer be met, based upon an interdisciplinary assessment of the resident’s cognitive and functional status.
8:39-46.2 Advisory staffing
______ _____ (a) Staffing levels are sufficient to provide care and programming, based upon resident census in the
program and an interdisciplinary assessment of the cognitive and functional status of residents in the program.
______ _____ (b) The facility has established criteria for the determination of each staff member’s abilities and
qualifications to provide care to residents in the program.
______ _____ (c) The facility provides an initial and ongoing educational, training and support program for each staff
member which includes at least the causes and progression of dementias, the care and management of residents with dementias, and communication with dementia residents.
______ _____ (d) Each Alzheimer’s/dementia program has a full-time employee, with specialized training and/or
experience in the care of residents with dementia, who has been designated as coordinator/director and whose duties include responsibility for the operation of the program.
______ _____ (e) A consultant gerontologist is available to residents and to the program, as needed, to address the
medical needs of the resident. “Consultant gerontologist” means a physician, psychiatrist, or geriatric advanced practice nurse who has specialized training and/or experience in the care of residents with dementia.
8:39-46.3 Advisory environmental modification
______ _____ (a) The program includes appropriate facility modifications to ensure a safe environment which allows each
Alzheimer’s/dementia resident to function with maximum independence and success.
