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NJ Hospital Licensure Regulations Updated

March 24, 2011 | No Comments
Posted by Beth Christian

The New Jersey Department of Health and Senior Services recently adopted amendments to the existing hospital licensure regulations.  One of the more controversial amendments deals with the expansion of the scope of practice for advanced practice nurses specializing in anesthesia.  Under the original regulatory proposal, advanced practice nurses specializing in anesthesia were included within the list of professionals authorized to administer general anesthesia, major regional anesthesia, conscious sedation or minor regional blocks so long as the administration of anesthesia was performed in accordance with a joint protocol between the advanced practice nurse and a collaborating physician. 

In the final regulations, the Department did not change the scope of anesthesia that may be administered by an advanced practice nurse specializing in anesthesia, but clarified the physical presence requirements for anesthesiologists in the preamble to the final regulations.  The joint protocol between the anesthesiologist and the advanced practice nurse specializing in anesthesia must include sections addressing the availability of a physician on site, on call or by electronic means.  The amendments to the regulations also require that the joint protocol contain sections governing the availability of an anesthesiologist.  In comments that accompanied the adoption of the amendments, the Department of Health and Senior Services stated that the intent of the regulations is to ensure

“that the rule is understood to mean that the required joint protocol governing anesthesia services would require the presence of an anesthesiologist during induction of and emergence from anesthesia and during critical changes in status.  The level of presence (such as in the room where the procedure is being performed, and the operating suite or merely in the building) would be determined in the joint protocol depending on the type of procedure and related risk factors, including any exigent circumstances.  Contrary to the issue of consultation, presence is understood to mean physical presence rather than by electronic or other means.”

The Department noted that it was its intention to defer to the authority of the New Jersey Board of Nursing to regulate the practice of the professionals under its jurisdiction, and likewise intended the proposed amendments to defer to the comparable jurisdiction vested in the Board of Medical Examiners.

There are several other significant changes to the hospital licensure regulations.  Under the amendments, hospitals will no longer be automatically subject to biennial surveys.  Instead, the Department has indicated that it will concentrate its efforts upon complaint investigations.  Although hospitals will not have to undergo routine biennial inspections any longer, the hospital’s chief executive officer will now be required to submit a regulatory compliance certification and evidence from an accrediting body recognized by the Centers for Medicare and Medicaid Services as part of a hospital’s licensure renewal application. 

The amendments to the regulations also:

  • include amendments to the time frames for obtaining or updating preadmission history and physical examinations;
  • add a new section to the patient rights regulations that incorporates visitation rights for partners in civil unions and domestic partners;
  • include a domestic partner or civil union partner within the definition of the patient’s “legally authorized representative” for purposes of requesting copies of medical records;
  • incorporate a new definition for the term “hospitalist”;
  • set forth specific requirements for the physician director of a primary stroke center and the membership of the acute care stroke team;
  • amend the criteria for infection control prevention and control activities, and the detection and control of the transmission of tuberculosis; and
  • amend the medical records staff qualifications. 


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