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Guidance Memorandums

Certificate of Need and Facility Licensing

Guidance Memorandums

Date Issued	Name	Summary
January 8, 2025	Online Verification of Hospital Nurses Memo	Waiving provisions at N.J.A.C. 8:43G-18.3(c) that require hospitals to verify licensure or permission to work letters by visually examining the current pocket license or original permission to work letter for newly hired nurses. Under the new terms of this waiver, hospitals can verify licensure of newly hired nurses through electronic verification available through NJ State Board of Medical Examiners.
October 17, 2024	Certificate of Occupancy Waiver	With the established new standards for the transfers of nursing homes, the requirement to submit a certificate of occupancy or similar document as part of the transfer is waived until further rulemaking is completed.
September 16, 2024	Sale or Transfer of Real Property Where a Nursing Home is Located	Advising the changes to the Department’s procedures for transferring ownership of the real property where a nursing home is located. The new process is required due to legislation codified at N.J.S.A. 226:2H-7.27.
June 6, 2024	Hospital Harm Reduction Supplies	Guidance to inform general acute care hospitals of new and existing laws concerning the distribution of harm reduction supplies in emergency departments and acute care hospitals.
May 15, 2024	Routine HIV Testing in Healthcare Settings	Guidance on whether separate written consent is necessary to initiate HIV testing for a patient; specifically, whether an "opt out" approach to HIV testing is permissible.
April 18, 2024	Nursing Home Residents	To provide clarification on the meaning of “resident” as utilized for licensure of long-term care facilities and specifically whether individuals receiving subacute care are considered “residents” under this rule.
April 15, 2024	Reportable Events	To provide guidance and clarification regarding the reporting of events that are unrelated to or not covered under the Patient Summary Act.
April 4, 2024	Radiologist Contrast Medium	Blanket waiver to waive certain standards at N.J.A.C. 8:43A-25.2 which pertain to the requirement that a radiologist be present on facility premises when a contrast medium is administered
March 26, 2024	Temporary Adult Acute Closed Psychiatric Beds	To explain the application process to allow general acute care hospitals to apply for temporary licensure of adult acute closed psychiatric beds
March 13, 2024	The Centers for Medicare & Medicaid Services (CMS) Changes to Hospital Price Transparency Regulations	On November 2, 2023, CMS finalized changes to its hospital price transparency regulations. The policies in the hospital price transparency regulations are intended to increase price transparency and enforce compliance and apply to each hospital operating in the United States. The effective date of the rule is January 1, 2024, but hospitals will have until July 1, 2024, to implement many of the updates and until January 1, 2025, to implement others.
December 6, 2023	Participation in CMS Acute Hospital Care at Home Program	Establishing a program to permit a licensed acute care general hospital to provide acute care services to an individual outside of the hospital’s licensed facility and within a private residence designated by the individual.
November 29, 2023	Health Care Heroes Act	Advises of the statute concerning the Health Care Heroes Act which states it is a criminal offense to intentionally threaten healthcare professionals or volunteers in an effort to intimidate them or interfere with their work; in addition, establishes additional penalties against individuals who assault healthcare workers or volunteers. Facilities must post proper signage in common area of facility.
October 5, 2023	Long Term Care Facility Reporting and Notification Requirements	Reminder to long term care facilities of the reporting and notification requirements for payment default, facility closure, transfer or discharge of patient, and enforcement remedies.
September 26, 2023	Hospital Operations During a Temporary Surge in Demand	This memo is intended to clarify the Department’s policy and an Acute Care General Hospital’s responsibility when confronted with an unanticipated, temporary surge or increase in demand for a licensed bed type maintained by the hospital.
August 17, 2023	End of Life Training for LTC and Hospitals	All LTCs and hospitals are required to have staff complete annual training on advance care planning, end-of-life care, and the use of advance directives and Physician Orders for Life-Sustaining Treatment (POLST) forms; provide patients and residents, and their families with educational materials; and develop and implement policies to identify and address end-of-life care issues for patients and residents upon admission to the facility.
August 16, 2023	End of Life Training all General Hospital Emergency Departments	This statute requires Emergency Departments and Satellite Emergency Departments to develop and implement a plan to integrate the provision of palliative care services for patients treated in the emergency department for whom palliative care is appropriate.
July 2023	Dialysis Setting in LTC	Frequently Asked Questions – Licensure of Home Hemodialysis in Nursing Homes
April 26, 2023	Replacement of the Advanced Standing Pilot Program with the Deemed Status Program, effective November 1, 2023	Effective November 1, 2023, New Jersey's Advanced Standing Pilot Program will be replaced by a Deemed Status Program. The Deemed Status Program will be in lieu of periodic inspections of Assisted Living Residences (ALRs) licensed pursuant to N.J.A.C. 8:36.
April 14, 2023	Human Trafficking Handling and Response Training	New human trafficking training programs to be provided to workers at licensed healthcare facilities. This update is necessary as the links and programs listed in the current version of N.J.A.C. 8:43E-14.3 are no longer up to date.
March 22, 2023	Support Person for Patients	Guidance for Acute Care Hospitals to accommodate support persons during hospitalizations.
January 6, 2023	Replacement for Rules Regarding SUD Client Tuberculin Skin Testing	Replacement rule establishing a new tuberculin screening process for clients of substance use disorder facilities.
April 19, 2022	Rights of LGBTQI+ and HIV+ Residents of Long Term Care Facilities	Advises of the statute concerning the rights of LGBTQI+ and HIV+ residents of long term care facilities and the facility’s responsibilities under the LGBTQI+ and HIV+ Law which was signed on March 3, 2021 and took effect on August 30, 2021.
April 14, 2022	LTC Temperature Level Standards	Advising the new statue, P.L. 2021, c, 260, codified at N.J.S.A. 26:2H-14.13 et seq, which establishes new temperature level standards for nursing homes, dementia care homes and residential health care facilities.
July 23, 2021	Cardiac Services Memo	The statute removes the Certificate of Need requirements for full-service adult diagnostic cardiac catheterization, primary angioplasty and elective angioplasty, and permits general hospitals to add these three services through a licensing process.
July 21, 2021	Hospital at Home Waiver	This waiver provides the requirements for general hospitals to participate in the CMS Hospital at Home program.
July 6, 2021	Statutory Amendments to the licensing of cardiac services pursuant to P.L. 2021, c. 18	Changes to licensing process for full-service adult diagnostic cardiac catheterization, primary angioplasty and elective angioplasty
May 12, 2021	P.L. 2020, c. 87 Additional Responsibilities	Duties of long-term care facilities during an infectious disease outbreak Reporting Requirements to the National Healthcare Safety Network Database included in the Act Electronic Health Record System Outbreak Response Plans
January 28, 2021	Staffing Ratio Memorandum to Facilities	Notice of requirement to comply with the new minimum certified nurse aide staffing requirements in N.J.S.A. 30:13-18.
October 7, 2020	Influenza vaccination in health care facilities	Requires certain healthcare facilities to establish and implement an annual influenza vaccination program.
March 29 2020	One Support Person in Labor and Delivery Settings - COVID-19 restrictions	Instructions for Acute Care Hospitals on how to accommodate support persons for Labor and Delivery patients during the COVID-19 emergency
March 6 2020	Required Outbreak Response Plan	Reminder of Outbreak Response Plan Requirement
March 18, 2019	Deemed Status Waiver	Licensed Substance Use Disorder Facilities can apply for deemed status. Facilities granted full deemed status will forgo the required biennial inspection while facilities granted partial deemed status will undergo a biennial inspection that will primarily focus on, but not be limited to, staffing and clinical records.
March 18, 2019	Shared Space Guidance	This guidance clarifies that a single legal entity licensed to provide both mental health services and substance use disorder services is permitted to share clinical space for those services.
March 18, 2019	Frequently Asked Questions	An infographic chart outlining the licensed capabilities of different categories of health care facilities in New Jersey, with particular focus on substance use disorder services and mental health services.
November 5 2018	Certificate of Waiver for Medication Assisted Treatment in Ambulatory Care Facilities Pursuant to N.J.A.C. 8:43A	This waiver grants relief from the provisions of N.J.A.C. 8:43A-1.3. NJDOH will interpret the definition of "drug abuse treatment services" to include buprenorphine or any other medication approved by SAMHSA for the treatment of opioid use disorders.