Health care facilities in New Jersey are licensed and regulated by the State. They are also certified and inspected by a number of public and private agencies at the state and federal levels. These agencies have separate, sometimes overlapping, responsibilities.
The New Jersey Department of Health (Department), the Division of Health Facilities Evaluation and Licensing both regulates acute care facilities and long-term care facilities. The regulations and procedures promulgated by the Department are intended to promote the health, safety and welfare of patients/residents in New Jersey health care facilities.
The Department also collects financial and utilization data from the State's 82 general acute care hospitals to monitor their financial status, availability of beds, service patterns, and other issues pertinent to the development of public policy and distribution of subsidies to hospitals serving low income, uninsured persons.
To evaluate compliance with regulatory standards, the Department conducts comprehensive facility inspections and also responds to specific complaints. During these inspections, state survey teams evaluate the compliance of facility premises, equipment, personnel, policies and procedures with state licensure regulations.
In addition to these surveys, the Department also conducts inspections annually under contract to the U.S. Department of Health and Human Services to evaluate facility compliance with federal regulations and with Medicare conditions of participation or certification.
Many health care facilities also undergo a voluntary inspection process periodically by and approved accreditation organization.
Facilities are also required by state licensure regulations to have their own internal quality assurance program to monitor the quality of care. In addition, the facilities are required to review and update policies and procedures to ensure the health and safety of their patients and to monitor and maintain compliance with state and federal statutes and regulations.
In addition to the facilities themselves, health care professionals who work in health care facilities are also licensed or certified by state agencies.
Inquires or complaints regarding New Jersey licensed physicians may be directed to Executive Director, at the State Board of Medical Examiners, PO Box 183, Trenton, NJ 08625-0183, or (609) 826-7100.
Inquiries or complaints concerning New Jersey licensed nurses should be directed to Acting Executive Director, New Jersey Board of Nursing, PO Box 45010, Newark, NJ 07101, or (973) 504-6430.
New Jersey State Licensure Inspection
New Jersey's acute care facility licensure inspection surveys may take from one to multiple days, depending on the type of survey and size and type of institution. During the survey which a multidisciplinary inspection team - comprised of nurses, pharmacists, architects and other professionals, as needed - evaluates all aspects of patient care and facility procedures and practices. Specific areas of care assessed during the survey include access, continuity and comprehensiveness of patient care; patient rights; coordination of services; infection control; safety of environment; staffing levels; professionalism of caregivers; quality assurance; pharmacy, emergency department services and physical plant.
The Department's evaluation of patient care facilities may include an inspection of medical records, observation of patient care, inspection of all areas of the physical plant, and interviews with patients or other individuals.
Complaint investigations are also generally shorter in duration than licensure surveys and focus primarily on those areas of patient care alleged to be faulty. Complaints may be investigated with an on-site inspection or through telephone interviews and a review of relevant patient and health care facility records. If, during the course of a complaint investigation, additional problems are uncovered, a full on-site licensure survey may be conducted.
At the conclusion of each survey, a preliminary summary of the Department's findings is shared verbally with the facility's administrative staff in an exit interview. A detailed written survey report is forwarded later to the facility. If the Department determines that the facility failed to comply with all applicable licensure standards, it will be cited for the specific deficiencies.
Deficiencies and Plans of Correction
A deficiency is a determination by the Department that a health care facility has violated one or more specific state or federal standards. Deficiencies may be cited as a result of an on-site inspection or evaluation of written reports or documentation.
Health care facilities have the opportunity to dispute survey deficiency findings. They may request an opportunity to discuss the accuracy of survey findings, or the regulatory interpretation supporting the finding, during the course of a survey or during the exit interview. After the survey is completed and the deficiency report is issued, a facility may request an informal meeting with Department supervisory staff who were not directly involved in the survey.
When deficiencies are cited, the Department requires the facility to submit a written plan of correction within 10 business days detailing how and when each deficiency will be corrected. The department may also require facility representatives to attend an office conference to review findings of serious or repeated deficiencies and to discuss the causes of the violations and the facility's plan of correction.
Plans of correction are reviewed and, when acceptable, approved by the Department. If a plan is not accepted, the health care facility must revise and submit a new plan within five business days. In situations where current conditions at the facility pose a serious risk to the health and safety of patients, the Department may demand or initiate immediate corrective actions.
Once the Department has accepted facility's plan of correction, it designates the complete survey report and the accepted a plan of correction as public documents, subject to the New Jersey Open Public Records Act (N.J.S. 47:1A-1 et seq.). The Open Public Records Act provides standards governing the processing of requests from the public to review or copy government records. Individuals requesting copies of survey reports and/or acute care facility plans of correction, edited to ensure patient confidentiality, or scheduling an on-site review of these documents at the offices of the Department of Health' Division of Health Facilities Evaluation and Licensing must complete a Government Records Request Form.
Requestors should follow one of these procedures:
Requestors with access to the internet can obtain the government records request form on-line at www.state.nj.us/health/opra/index.html. The completed request form may be transmitted to the Division’s record custodian by e-mail at
by US mail, or by hand-delivery. Requests must be in writing and cannot
be made by telephone.
Requestors who do not have access to the Internet can obtain a copy
of the government records request form by calling 609-292-8772 or by directing
a letter request to the following address:
New Jersey Department of Health
Division of Health Facilities Evaluation and Licensing
P.O. Box 367
Trenton, New Jersey 08625-0367
Attn: Record Custodian
Media inquiries (excluding requests for government records filed pursuant
to the Open Public Records Act) must be made to the Office of Communications
In many cases, health care facilities are given the opportunity to correct deficiencies identified through inspection surveys without incurring fines or other penalties. The Department may, however, impose a monetary fine, curtail admissions, issue a conditional license, suspend or revoke a facility's license, close an unlicensed facility, or use other remedies for violations of standards as provided by state or federal law and regulations. Fines are also imposed on hospitals that fail to submit required financial and utilization data in a timely manner.
The most common penalty imposed by the Department is a civil monetary penalty or fine:
Under state law, the maximum fine the Department may impose for a licensure violation is $5,000 per violation, per day. An enforcement action based on one inspection may reflect violations, or a single type of violation that occurred on more than one day.
With respect to submission of financial data, state regulations provide that the Department assess a penalty of $100 per working day for late submission of annual acute care hospital cost reports and $50 per working day for late submission of quarterly financial data. A separate fine of $100 per working day is assessed for late submission of a hospital's annual financial statement.
With respect to hospital utilization data reports, when reports are not received by the Department within the specified time frame, including the correction of fatal errors and records with missing or incorrect information, the Department may assess penalties of $1.00 per record per day.
When a health care facility is cited for a deficiency that results in a fine, curtailments of admissions, suspension and/or revocation of a license, or placement on a conditional license, the Department issues a penalty letter identifying the specific violations, charges or reasons for the Department's enforcement action, as well as the penalty being levied.
Appeal of Enforcement Actions
Facilities may request a formal hearing before the Office of Administrative Law to appeal deficiency findings and enforcement actions. At any time before or during the hearing, the Department and the health care facility may agree to a settlement.