ADMINISTRATIVE OPERATIONAL POLICY STATEMENT

 

POLICY STATEMENT:

The Division of Veterans Healthcare Services requires that each of the New Jersey Veterans Memorial Homes make reasonable efforts to ensure those hired/employed are in good physical and mental health, emotionally stable, of good moral character, and concerned for the safety and well-being of residents; and have not been convicted of a crime relating adversely to the person’s ability to provide care, such as homicide, assault, kidnapping, sexual offenses, robbery, and/or crimes against family, children, or incompetents, except where the applicant or employee with a criminal history has demonstrated his/her rehabilitation in order to qualify for employment. Individuals shall be qualified, credentialed, and privileged in accordance with the New Jersey Department of Health and Senior Services and the Federal Veterans’ Affairs standards, and have current, valid licensure and/or certification in good standing.

NOTE: “Reasonable Efforts” shall include an inquiry on the employment applications, reference and criminal background checks, and credentialing and privileging in accordance with provisions set forth in CFR 51.210(j).

PURPOSE:

This policy/procedure shall serve to assure that each of the New Jersey Veterans Memorial Homes employ qualified individuals for any given position, in keeping with the New Jersey Department of Personnel Rules and Regulations, Equal Employment Opportunity values, New Jersey Department of Health and Senior Services and Federal Veterans’ Affairs licensing standards guiding the hiring and employment practices of those who serve individuals that reside in a health care setting.

DEFINITIONS:

CREDENTIALING - is the process of obtaining, verifying, and assessing the qualifications of a health care practitioner, which includes among others physicians, podiatrists, psychologists, dentists, physician assistants, nurse practitioners, licensed nurses, certified nurses aides, and other related health care professionals.

PRIVILEGING - is the process whereby a specific scope and content of resident care services are authorized for a health care practitioner by the facility management, based on evaluation of the individual’s credentials and job performance.

SCOPE AND PRACTICE STATEMENTS - generally refers to the scope of practice for groups of individuals, for example: staff nurses. Scope and Practice Statements may also be known as job descriptions and/or initial agreements (section one of the Performance Evaluation System/PES)

PROCEDURE:

A. New Jersey Veterans Memorial Homes

 

1. The New Jersey Veterans Memorial Homes will develop and implement procedures governing the hiring practices of the home to ensure all applicants for employment are
qualified, are of good morale character, have a valid license/certification in good standing, and are able to perform the duties assigned to the post.

2. The New Jersey Veterans Memorial Homes will ensure those individuals employed by the home remain capable, credentialed/privileged where required (a period not to exceed the period of time permitted by the State’s license/certification requirement), to perform the duties assigned to the post.

3. An Internal Audit Control System shall be utilized to assure policies, rules, regulations, and related State and Federal Licensing Standards which govern the operational practices of Health Care Facilities are met, service-specific committees are in place, and that responses to external audits are issued in a timely manner.

4. Results of all surveys and/or inspections conducted by the New Jersey Department of Health and Senior Services and the United States Department of Veterans Affairs shall be posted in all work areas in a conspicuous location, as mandated. Surveys shall remain posted, with corrective action plans, as required by the respective surveying agency.

5. The New Jersey Veterans Memorial Homes shall notify the New Jersey Department of Health and Senior Services immediately by telephone and/or facsimile of the resignation or termination of employment of the licensed Nursing Home Administrator of record, or the Director of Nursing Services, and the name and qualifications of the proposed replacement.
 

a. Written confirmation must be forwarded to the New Jersey Department of Health and Senior Services within 72 hours.

 

Revised: July 2005

 

ADMINISTRATION - 09-02-001

_

« Administration Table of Contents