New Jersey Department of Health

PEDIATRIC MEDICAL DAY CARE INSPECTION INFORMATION

Requirements for Initial Survey of Pediatric Medical Day Care

Facility Name

Facility ID

Survey Date

_____ / _____ / ________

Request the following to be on site:

1.	Certificate of Occupancy

2.	Resumes of Key Staff

3.	List of Licensed Staff

4.	Policy and Procedures Manual

5.	Staff Personnel Files - Orientation

6.	Staff Health Files

7.	“Childhood Emergencies in the Office, Hospital and the Community”

8.	“The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”

9.	Sample Medical Record

Resumes of Key Staff	Reg. Number	Document Name and Review Qualifications
Administrator Qualifications	3.2
Designated Alternate Administrator (must meet Administrator qualifications)	3.1(a)(b)
Director of Nursing Qualifications	7.2
Designated Alternate Director of Nursing (All RNs and LPNs must have one year experience working with medically complex children)	7.1(a) / 7.4
Social worker Qualifications	12.1
Child Life Specialist/Teacher	11.1
Dietitian Qualifications	10.3
Medical Records Practitioner	14.2
Food Service Supervisor (if applicable)	10.3
Infection Control Designee	15.1(b)

Employee Personnel and Health Files	Reg. Number	Notes
CBI-all personnel including volunteers. If licensed by DHS/DYFS, then DHS clearance is okay, but facility should have overall waiver from licensing. Clearance by DOH or DHS with waiver from DOH on all employees.	2.5
Job Descriptions	6.3(b)
Staff Orientation (child abuse, infection control, emergency plans, and pain management) upon hire/ongoing (annually) emergency plans, and child abuse	6.3(e)
Initial and Subsequent Physical Exam	15.5
Two-step Mantoux upon hire; One-step annually	15.4

Policy and Procedures Manual	Reg. Number	Facility required to maintain manuals in compliance with N.J.A.C. 8:43J – Policy/policies will be reviewed on survey when systemic problems are identified
Manual for the organization and operation of the facility which must be reviewed every 6 months	3.4(c)
Manual of policies and procedures for the care of medically complex or technology dependant children	3.5
Procedure manual, an organizational plan and a quality improvement program for medical record services	14.1(b)
Procedure manual for infection prevention and control services reviewed annually	15.1

Physical Environment	Reg. Number	Notes
Secure door between lobby/reception and children’s areas	13.4(b)
Facility to post on bulletin board all waivers, children’s rights, means of contacting license holder, and list of deficiencies from last licensure inspection and any complaint surveys	3.6(c)
Facility to post name, address, and telephone number of DOH-HFE&L, Medical Assistance and Health Services, Youth and Family Services	4.2(b)(c)(d)
3 Child Care Areas with 2 means of egress each (Ambulatory, Toddler, Non-Ambulatory)	13.8
Toilet facilities 1:10 as well as 2 diaper changing areas within 5 feet of hand washing sink – privacy screened	13.3
Lockers and lounges for employee/volunteer staff	13.5
Janitor’s closet contains a service sink and storage for housekeeping supplies and equipment	13.6
Social work office space for private interview	13.7
Rehab equipment Ped Table with mat, rolls & 1/2 rolls, nesting benches, wooden weighted push cart, toddler swing, floor mirror, steps, climbing equipment	11.3
Storage space for recreation equipment	13.8
Outdoor play area 13.10	13.1
Crib/mats 1:1

Space for cribs or mats – 3 ft. between	13.9
Office space for nursing, If combined with pharmacy and exam 150 sq. ft. minimum with hand washing facilities	13.11
Lockable refrigerator or locked box in refrigerator	13.11

Emergency Plans and Procedures	Reg. Number	Notes
Emergency equipment, O2 , suction, airway, ambu-bag and AED	8.5(b)
CPR/AED-certified staff member (all direct care staff members and volunteers)	6.2(h)
Procedures for emergencies, including medical emergencies	13.16(a)
Written evacuation diagram includes evacuation procedure, location of fire exits, alarms boxes, fire extinguisher	13.16(b)
Fire extinguishers examined annually and labeled	13.1(d)
Hot water temperature 120(	15.9(a) 24
Emergency generator if on site/if non contract for provision in an emergency	13.1(f)

Transportation	Reg. Number	Notes
Provide transportation services – MAV or waiver	16.1
Transportation staffing	16.2

Food Services and Nutrition	Reg. Number	Notes
Current Diet Manual (on site) days or more if needed	10.1(h)
Written, dated menus planned 14 days in advance with portion sizes	10.1(i)
Minimum supplies of food (i.e., cereal, tuna, PB, canned fruit, juices)	10.1(j)
Nutritionally appropriate snacks available	10.1(c)
Control station for receiving food storage facilities for food supply including cold storage

Handwashing facility

Warewashing facility

Trash handling

Desk space	13.12(d)

Quality Improvement Program	Reg. Number	Notes
Written plan for QI program, specify timetable and persons responsible, to include: review of 1/2 of records quarterly for quality of care, parental involvement in care planning and including formal discharge transition procedure, etc.	17.1

Contracts	Reg. Number	Notes
Medical Director	8.2
Pharmacist Consultant	9.1
Physical, Occupational and Speech Therapies	11.2
Copies of any waivers that may have been given during the application process	3.6
Food Service Provider (if applicable)	13.12(b)
Medical Records Practitioner	14.2
Registered Dietitian	10.1

Name of Surveyor

PEDIATRIC MEDICAL Day Care Inspection Information

Requirements for Initial Survey of Pediatric Medical Day Care

(Continued)

AAS-23

JAN 14	Page 5 of 5 Pages.

JAN 14	Page 1 of 5 Pages.

AAS-23, Pediatric Medical Day Care Inspection Information

AAS-23, assessment and survey, pediatric medical day care inspection information

ewhite

2012-03-07

NJDOH