New Jersey Department of Health

Division of Health Facility Survey and Field Operations

AFFIDAVIT OF COMPLIANCE

ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES

AND ASSISTED LIVING PROGRAMS

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:36)

I,	, Administrator of
, hereby state
that to the best of my personal knowledge and understanding, the facility is in substantial compliance with the mandatory standards enumerated in this statement except as follows:
Describe exceptions to compliance:

I acknowledge that I must provide prompt notification to the Director, Division of Health Facility Survey and Field Operations, at the address below, should I become aware of any substantial change in compliance:

Director, Division of Health Facility Survey and Field Operations

New Jersey Department of Health

PO Box 367

Trenton, NJ 08625-0367

Telephone Number: (609) 633-8993

I understand that a willfully false statement could result in enforcement penalties.

Signature of Administrator	Date

AFFIDAVIT OF COMPLIANCE

ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES

AND ASSISTED LIVING PROGRAMS

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:36)

3.1 (a)

4.1

5.1 (e)

5.1 (g)

5.1 (h) through (k)

5.2 (b)

5.5 (a)

5.5 (b)

5.6 (b) (1-7)

5.6 (c) and 9.3 (c)

5.7 (a) 1-8

5.8

5.9

5.10 (a) 1-6

5.11 (a) 1-7

5.13

5.14

5.15

5.16

5.17

5.18

6.1(a) (1-11)

6.3 (a)

6.3 (b) (c)

7.4 (b)

7.4 (c)

7.5

9.1

9.2

10.5 (b)

11.3 (a)

11.6 (a) 3

11.7 (e)

11.7 (f)

11.7 (g)

14.1 (b)

14.2 (a) (b) (c)

14.3 (a)

14.3 (b)

14.3 (c)

15.3

15.4

15.6

15.7

17.2

17.3 (b) 8

17.4 (a)

17.6

17.8

18.1

18.2 (a) through (d)

18.3

18.4 (a) (b)

18.5

18.6 (a) (b)

19.2 (a)

19.2 (b)

19.3 (a)

19.4 (a) 1

19.4 (b) 1 and 2

19.4 (b) 3

20.2 (a)

20.2 (f)

21.1

21.2 (a)

22.1 – 22.7

23.1 – 23.18

8:43E

6.1 through 6.6

10.1 through 10.5

Signature of Administrator	Date

AFFIDAVIT OF COMPLIANCE

ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES

AND ASSISTED LIVING PROGRAMS

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:36)

3.1 (a)	Administrator and alternate is designated in writing.

4.1	Resident rights.

5.1 (e)	Facility admission agreement.

5.1 (g)	Facility adheres to all applicable Federal, State and Local laws.

5.1 (h) - (k)	Compliance with 10% Medicaid occupancy if licensed on or after 9/1/01.

5.2 (b)	Facility is not owned or operated by any person convicted of a crime.

5.5 (a)	Written job descriptions.

5.5 (b)	Staff licensure, certification and authorization as required.

5.6 (b) 1-7	Develop and implement orientation and education plan as required.

5.6 (c) & 9.3 (c)	Staffing at level of care required by residents.

5.7 (a) 1-8	Policy and procedures developed, implemented and reviewed.

5.8	Resident transportation.

5.9	Written agreements for services not provided directly by facility.

5.10 (a) 1-6	Reportable events.

5.11 (a) 1-7	Required postings.

5.13	Admission and retention of residents.

5.14	Involuntary discharge.

5.15	Notification requirements.

5.16	Interpretation services.

5.17	Written transfer agreements.

5.18	Managed risk agreements.

6.1 (a) 1-11	Written resident care policies and procedures.

6.3 (a)	Policies and procedure for handling monthly personal needs allowance.

6.3 (b) (c)	Written records of personal needs accounts maintained.

7.4 (b)	RN develops nursing practice policies and procedures.

7.4 (c)	Health care policies and procedures are implemented.

7.5	Written policies and procedures to ensure quality care.

9.1	Qualifications of personal care assistants.

9.2	Qualifications of certified medication aides.

10.5 (b)	Current diet manual available.

11.3 (a)	Staff trained to supervise self administration of medications.

11.6 (a) 3	Pharmacy policy and procedures regarding self administration of medications.

11.7 (e)	Medication destruction.

11.7 (f)	Medication destruction witnessed.

11.7 (g)	Unit of use crediting mechanism.

AFFIDAVIT OF COMPLIANCE

ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES

AND ASSISTED LIVING PROGRAMS

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:36)

14.1 (b)	Written plan for emergency transportation.

14.2 (a) - (c)	Emergency plans, policies and procedures developed.

14.3 (a)	Fire drills.

14.3 (b)	One joint drill with local fire department.

14.3 (c)	Facility tests one pull alarm per month and documents result.

15.3	Confidentiality of resident records.

15.4	Record retention.

15.6	Residents’ individual records.

15.7	Record of death.

17.2	Written housekeeping work plan and staff trained as required.

17.3 (b) 8	Annual electrical inspection.

17.4 (a)	Solid waste procedure.

17.6	Water supply.

17.8	Written laundry service policies and procedures.

18.1	Infection Control Program.

18.2 (a) - (d)	Infection control policies and procedures. Pneumovac and Flu vaccine requirements.

18.3	General facility infection control policies and procedures.

18.4 (a) (b)	Mantoux testing for employees.

18.5	Staff trained in infection control procedures.

18.6 (a) (b)	Regulated medical waste.

19.2 (a)	Individualized Alzheimer’s care.

19.2 (b)	Criteria for admission to Alzheimer’s unit.

19.3 (a)	Mandatory staff training in Alzheimer’s/Dementia care.

19.4 (a) 1	Staffing schedules for Alzheimer’s unit available to public on request.

19.4 (b) 1 & 2	Alzheimer activity schedule and frequency, available to public on request.

19.4 (b) 3	Safety and security policies and procedures in Alzheimer’s unit.

20.2 (a)	Respite care policies and procedures.

20.2 (f)	Pharmacist’s policies and procedures for residents receiving respite services.

21.1	Quality Improvement Program.

21.2	Use of restraints.

22.1 – 22.7	CPCH

23.1 – 23.18	ALP

8:43E

6.1 – 6.6	Pain management.

10.1 – 10.5	Patient safety policies, committee, plan.

AFFIDAVIT OF COMPLIANCE

ASSISTED LIVING RESIDENCES, COMPREHENSIVE PERSONAL CARE HOMES

AND ASSISTED LIVING PROGRAMS

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:36)

PHYSICAL ENVIRONMENT INSPECTIONS

Date of Last Standard Survey:
Quarterly Fire Official Inspections since last Standard Survey:
Dates:
Municipality
Semi-annual Kitchen Suppression System Inspections and Maintenance since last Standard Survey:
Dates:
Vendor:
Fire Alarm Detection System Tests and Maintenance since last Standard Survey:
Dates:
Vendor:
Boiler or Heating System Inspections since last Standard Survey:
Dates:
Inspector:
Electrical Inspections by a Licensed Electrician since last Standard Survey:
Dates:
Electrician:
Elevator Inspections (if applicable) since last Standard Survey:
Dates:
Inspector:
Quarterly Sprinkler System Tests and Maintenance since last Standard Survey:
Dates:
Vendor:
Fire Drills conducted since last Standard Survey. Complete grid below.
Shift	Date	Shift	Date	Shift	Date
Identify drills performed for disasters other than a fire:
Identify joint drills with the local fire officials:
Drills conducted: In-house Out-sourced If out-sourced, Vendor:
Has every employee participated in at least one fire drill each year? Yes No
Signature of Person Completing Form	Date

AAS‑24

AUG 97 Page 6 of 5.

AAS-24

FEB 15	Page 5 of 5 Pages.

AAS-24, Affidavit of Compliance, Assisted Living

AAS-24, affidavit of compliance, assisted living, cpch, long term care, LTC, Health Facility survey and field operations

EWhite

2012-03-07

NJDOH