New Jersey Department of Health

Division of Health Facility Survey and Field Operations

AFFIDAVIT OF COMPLIANCE

WITH NEW JERSEY LICENSURE STANDARDS FOR

ADULT DAY HEALTH CARE FACILITIES

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 changes in compliance:

Director, Division of Health Facility Survey and Field Operations

New Jersey Department of Health

PO Box 367

Trenton, NJ 08625-0367

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

Signature of Administrator	Date

New Jersey Department of Health

Division of Health Facility Survey and Field Operations

ADULT DAY HEALTH CARE FACILITIES

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:43F)

3.2

3.3(d) 1-8

3.4(a)

3.5

3.6

3.10

3.11

3.12

3.13

4.1

4.2

5.1(c)

6.1

6.2

6.3

7.2

7.3

7.4

7.5

8.1

8.3

8.4

9.1

9.2

9.3

9.4

10.2

10.4

10.5

11.1

12.1

12.2

13.2

13.3

14.17

15.1

15.3

15.4

16.1

16.2

16.2(c)

16.2(d)

16.2(f)

16.2(j) 1-8

16.3

16.4

16.5

16.6

17.1

17.2

18.1

18.2

Signature of Administrator	Date

New Jersey Department of Health

Division of Health Facility Survey and Field Operations

ADDENDUM TO AFFIDAVIT OF COMPLIANCE

FOR ADULT DAY HEALTH CARE FACILITIES

This addendum lists the topics of all New Jersey Adult Day Health Care Facilities licensure standards referenced in the administrator’s affidavit of compliance. This addendum may be helpful to the administrator in determining compliance.

3.2	Qualifications of Administrator
3.3(d) 1-8	Policy and Procedure Manual
Program Philosophy
Organizational Chart
Description of Referral Mechanisms
Description of Quality Improvement Programs
Specification of Hours of Operation
Procedures for Maintenance of Personnel Records
Policies for Staff Physical Examinations
Procedures for Reporting Abuse
3.4(a)	Notification to Department of Reportable Events
3.5	Description of Fees for Services and Financial Records
3.6	Participant Care Policies
Staffing Based on Acuity Levels
Referrals to Other Health Care Providers
Emergency Care and Notification of Participant’s Relative
Health Education
Advance Directives
Smoking Policy
Discharge, Transfer and Readmission
Care and Control of Facility Pets
Exclusion of Participant due to Communicable Disease
3.10	Interpretation Services
3.11	Notification of Family and Documentation in Record
3.12	Follow-up on Participant Absence
3.13	General Records Policies
4.1	Policies and Procedures on Participant Rights and Staffing Training on Rights
4.2	Delineation of Participant’s Rights
5.1(c)	Participant’s Inappropriate Behavior
6.1	General Services Provided
6.2	Description of Staffing Capabilities
6.3	Personnel Policies, Job Descriptions
7.2	Qualifications of Director of Nursing
7.3	Responsibilities of Director of Nursing Services

New Jersey Department of Health

Division of Health Facility Survey and Field Operations

ADDENDUM TO AFFIDAVIT OF COMPLIANCE

FOR ADULT DAY HEALTH CARE FACILITIES

(Continued)

7.4	Description of Nursing Services
7.5	Responsibilities of Licensed Nursing Personnel
8.1	Description of Medical Services
8.3	Medical Consultant’s Responsibilities
8.4	Responsibilities of Physicians, Advanced Practice Nurses and Physician Assistants
9.1	Description of Pharmacy Services
9.2	Medication Administration Policies/Procedures
9.3	Description of Pharmacy Reporting Policies/Procedures
9.4	Description of Pharmacy Control Policies/Procedures
10.2	Qualifications of Food Services Supervisors
10.4	Administrator’s Responsibilities for Dietary Services
10.5	General Requirements for Dietary Services
11.1	Description of Rehabilitative Services
12.1	Qualification of Social Worker
12.2	Description of Social Work Services
13.2	Qualification of Activities Director
13.3	Description of Activities Services
14.17	Written Emergency Plans, Policies, Procedures
Staff Training in Emergency Procedures
15.1	Policies for Maintenance of Medical Records
15.3	Contents of Medical Records
15.4	Medical Records Policies and Procedures
16.1	Administrator’s Responsibilities to Infection Control
16.2	Description of Infection Control Policies/Procedures
16.2(c)	Policies/Procedures Regarding Flu Vaccination
16.2(d)	Policies/Procedures Regarding Pneumococcal Vaccination
16.2(f)	Policies/Procedures Regarding Employee Mantoux Testing
16.2(j) 1-8	Comprehensive Infection Control Policies
16.3	Description of Employee Health and Examination Procedures
16.4	Description of Regulated Medical Waste Policies
16.5	Written Housekeeping, Sanitation and Safety Policies
16.6	Written Housekeeping, Work Plans and Staff Training
17.1	Description of Transportation Services
17.2	Written Plan for Security and Accountability during Transport
18.1	Description of Quality Improvement Program
18.2	Use of Restraints

AAS-

JAN 02 Page 6 of 5 Pages.

AAS-40

AUG 15	Page 1 of 4 Pages.

AAS-40, Affidavit of Compliance, Adult Day Health Care Facilities

adult day health care facilities, AAS-40, affidavit of compliance, AAS

ewhite

2012-03-07

NJDOH