10:47-1.1 Purpose and scope

10:47-1.2 Definitions

10:47-2.1 Admissions to private facilities

10:47-2.2 Surveys of facilities

10:47-2.3 License

10:47-3.1 Management and organizational standards

10:47-3.2 Inspection

10:47-3.3 Waiver

10:47-3.4 Mission statement

10:47-3.5 Conflict of interest; provision of goods and services

10:47-3.6 Governing body; non-proprietary facilities

10:47-3.7 Governing body; proprietary facilities

10:47-3.8 Administrative procedures manual

10:47-3.9 Abuse of minors

10:47-3.10 Abuse of dependent adults

10:47-3.11 Quality assurance system

10:47-3.12 Behavior management

10:47-3.13 Transportation

10:47-3.14 Admission policies

10:47-3.15 Pre-admission

10:47-3.16 Individual records

10:47-3.17 Discharge record

10:47-3.18 Maintenance of records

APPENDIX A. DDD CLASSIFICATION OF INCIDENT CATEGORIES

10:47-4.1 Policies

11:47-4.2 Personnel records

10:47-4.3 Staff training

10:47-4.4 Staff ratios

10:47-4.5 Volunteer services

10:47-5.1 General provisions

10:47-5.2 Personal funds

10:47-5.3 Clothing and personal possessions

10:47-5.4 Privacy

10:47-5.5 Personal hygiene

10:47-6.1 General medical and health care

10:47-6.2 Physician services

10:47-6.3 Nursing services

10:47-6.4 Dental services

10:47-6.5 Pharmaceutical services

10:47-6.6 Psychoactive medication

10:47-6.7 Medical records

10:47-6.8 Lead control

10:47-7.1 Individual Habilitation Plan

10:47-7.2 Education

10:47-7.3 Adult training and vocational services

10:47-7.4 Psychological services

10:47-7.5 Behavior management procedure manual

10:47-7.6 Use of Level III techniques

10:47-7.7 Medical certification in cases of physical risk

10:47-7.8 Emergency mechanical restraint

10:47-7.9 Emergency mechanical restraint

10:47-7.10 Social services

10:47-7.11 Rehabilitation services

10:47-7.12 Adaptive equipment

10:47-8.1 Dining environment

10:47-8.2 Nutritional services

10:47-8.3 Meal service

10:47-8.4 Food service and menu planning

10:47-8.5 Food sanitation

10:47-9.1 General requirements

10:47-9.2 Bedrooms

10:47-9.3 Bathrooms

10:47-9.4 Laundry services

10:47-10.1 Fire safety

10:47-10.2 Sanitation

10:47-10.3 Transportation


SUBCHAPTER 1. GENERAL PROVISIONS

  (a) The purpose of this chapter is to provide for the protection of persons with developmental disabilities who require such supervision and to provide for overall improvement in the quality of life for individuals residing in private residential facilities for the developmentally disabled in New Jersey. The Health Care Facilities Planning Act, N.J.S.A. 26:2H-1 et seq., vests the responsibilities for licensing and regulation of health care facilities with the State Department of Health and Senior Services. 

  (b) N.J.S.A. 30:1-15, however, vests the New Jersey Department of Human Services with the responsibility for inspection of private residential facilities for persons with developmental disabilities as necessary, but at least once a year. These statutes also authorize the Commissioner of the Department of Human Services to set appropriate operating standards for these facilities.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. 

  "Abuse" means any act or omission that deprives an individual of his or her rights or which has the potential to cause or causes actual physical injury or emotional harm or distress. Examples of abuse include, but are not limited to: acts that cause pain, cuts, bruises, loss of body function, sexual abuse, temporary or permanent disfigurement, death; striking with a closed or open hand; pushing to the ground or shoving aggressively; twisting a limb; pulling hair; withholding food; forcing an individual to eat obnoxious substances; use of verbal or other communication to curse, vilify, degrade an individual or threaten with physical injury. Planned use of behavioral intervention techniques which are part of an approved behavior modification plan or Individual Habilitation Plan shall not be considered to be abuse or neglect. 

  "Advance practice nurse," also known as a nurse practitioner (see N.J.S.A. 45:11-46c), is defined in N.J.S.A. 45:11-23, and may, in addition to those tasks lawfully performed by a registered professional nurse, manage specific common deviations from wellness and stabilized long term care illnesses by initiating laboratory and other diagnostic tests and prescribing certain medications and devices. (See N.J.S.A. 45:11-49.) 

  "Age appropriate" means that aspect of normalization that reinforces recognition of an individual as a person of a certain chronological age. This includes, but is not limited to, an individual's dress, behavior, use of language, choice of leisure and recreation activities, personal possessions and self-perception. 

  "Assessment" means the process of identifying a person's developmental strengths and needs, and the conditions that impede and promote development. There are two levels of assessment: screening and evaluation. 

  "Aversive technique" means the presentation of stimuli or conditions to decrease the frequency, intensity or duration of maladaptive behavior by inducing distress, discomfort or pain, which may place the individual at some degree of risk of physical and/or psychological injury. 

 "Behavior disorder" means an abnormal action which may interfere with the individual's activities of daily living. 

  "Behavior Management Committee" means a representative body of individuals who have clinical expertise and individuals who have administrative authority within the Division component or provider agency who review behavior plans and who make a judgment as to whether or not the plans are clinically/technically appropriate. Other behavior management issues may be referred to this committee. The committee acts as an advisory body to the Chief Executive Officer. 

  "Behavior objective" means one of a series of short range steps which are developmentally sequenced and directed toward the achievement of an established goal. Each behavioral objective specifies a single, learned response to be exhibited by the individual and the criterion against which progress is measured. The objective is developed and based upon knowledge of assessed developmental strengths and needs. 

  "Chief executive officer" means the person having administrative authority over, and responsibility for, a private residential facility licensed under this chapter. 

  "Developmental disability" means a severe, chronic disability of a person which: 

  1. Is attributable to a mental or physical impairment or combination of mental or physical impairments; 

  2. Is manifest before age 22; 

  3. Is likely to continue indefinitely; 

  4. Results in substantial functional limitations before the age of 22 in three or more of the following areas of major life activity, that is, self-care, receptive and expressive language, learning, mobility, self-direction and capacity for independent living or economic self-sufficiency; and 

  5. Reflects the need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or extended duration and are individually planned and coordinated. 

  "Developmental disability" includes, but is not limited to, severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina bifida and other neurological impairments where the above criteria are met. 

  "Director" means the Director of the Division of Developmental Disabilities. 

  "Division" means the Division of Developmental Disabilities. 

  "Exploitation" means any unjust or improper use of an individual or his or her resources for one's profit, advantage, or gratification. 

  "Goal" means a long range outcome. Goals are generally expected to be achieved by an individual within one to five years; they are stated in measurable terms so that their attainment can be determined. Goals must be individually centered and written to reflect the intent and direction of the Individual Habilitation Plan. Goals are broad in nature, realistic, based upon assessed needs and capabilities and attained through the use of behavioral and/or service objectives. 

  "Habilitation" means the process of providing those comprehensive services that are deemed necessary to meet the needs of persons who are developmentally disabled in programs designed to achieve objectives of health, welfare and the realization of an individual's maximum physical, social, psychological and vocational potential for useful and productive activities. Habilitation services may include, but are not limited to, the following: 

  1. Developing socially appropriate behaviors including sexual behaviors and interpersonal skills, and eliminating maladaptive behaviors; 

  2. Developing cognitive skills including, but not limited to, recognizing personal danger, telling time, managing money, making change, recognizing street and other signs, solving problems, etc.; 

  3. Developing recreation and leisure time skills; 

  4. Orienting to the community and training for mobility and travel; 

  5. Developing or remediating communication skills; 

  6. Developing appropriate activities of daily living such as grooming, dressing and self-care habits, such as toileting, eating and shaving; and 

  7. Training in assertiveness, and advocacy in dealing with citizenship, legal, family and/or social needs. 

  "Human Rights Committee" means a group comprised of professionals, individuals served, advocates and/or interested persons from the community at large who function as an advisory body to the CEO on issues directly or indirectly affecting the rights of individuals served. 

  "Individual Habilitation Plan (IHP)" means a written plan of intervention and action that is developed by the interdisciplinary team. It specifies both the prioritized goals and objectives being pursued by each individual and the steps being taken to achieve them. It may identify a continuum of skill development that outlines progressive steps and the anticipated outcomes of services. The IHP is a single plan that encompasses all relevant components, such as an education plan, a behavior modification plan, a program plan, a rehabilitation plan, a treatment plan and a health care plan. The complexity of the IHP will vary according to the needs, capabilities and desires of the person. In most instances, the IHP shall address all major needs identified. The major needs shall be prioritized. For an individual who makes only specific service requests, the IHP shall be a service plan which addresses only those specific requests. 

  "Imminent danger" means a situation which could reasonably be expected to cause a serious risk to the health, safety or welfare of an individual receiving services. 

  "Individual with developmental disabilities" (individual, person served) means that person with developmental disabilities residing in a licensed private facility for the developmentally disabled. 

  "Informed consent" means a formal expression, oral or written, of agreement with a proposed course of action by an individual who has the capacity, the information and the ability to render voluntary agreement on his or her own behalf or on behalf of another. 

"Interdisciplinary Team (IDT)" means an individually constituted group responsible for the development of a single, integrated IHP. The team shall consist of the person receiving services, the legal guardian, the parents or family member (if the adult desires that the parent or family member be present), those persons who work most directly with the individual served, and professionals and representatives of the service areas who are relevant to the identification of the individual's needs and the design and evaluation of programs to meet them. 

  "Inspecting agency" means the Department of Human Services, Division of Developmental Disabilities. 

  "Investigation" means the systematic inquiry into the factors which have contributed to an incident, allegation or complaint. An investigation may range from a brief examination of records and statements to a comprehensive collection and analysis of all pertinent evidence. 

  "Least restrictive" means a principle whereby the interventions in the lives of persons with developmental disabilities are carried out with a minimum of limitation, intrusion, disruption, or departure from commonly accepted patterns of living. 

  "License" means the authorization issued by the New Jersey Department of Health and Senior Services, pursuant to N.J.S.A. 26:2H-1 et seq. and N.J.A.C. 8:39-2.9, for a period of one year, to the legally responsible person or entity in the facility providing residential services to persons with developmental disabilities. 

  "Measurable" means there are established criteria which are observable and can be quantified via a data collection system. 

  "Neglect" means the failure of the facility staff to provide for or maintain the care and safety of individuals under his or her supervision, including, but not limited to, failure to provide and maintain proper and sufficient food, clothing, health care, shelter and/or supervision. 

  "Normalization" means a principle of making available to the persons receiving services the commonly accepted patterns and conditions of everyday life.

   "Physical restraint" means physical contact with an individual, initiated by one or more staff members, which restricts freedom of movement either partially or totally. Physical restraint as herein defined may be implemented as: 

  1. A procedure intended to protect an individual from inflicting injury upon himself or herself, staff or other individuals; or 

  2. As a behavior reduction procedure intended to reduce the frequency of a maladaptive behavior including, but not limited to, self injurious or otherwise aggressive behavior. 

  "Pica" means the maladaptive behavior of ingesting inedible substances or objects, including, but not limited to, soil, toys, or paint chips. 

  "Psychoactive medication" means those chemical substances which exert a direct effect upon the central nervous system and which are utilized as part of a treatment plan to address psychiatric disorders, symptoms of psychiatric disorders or to influence and modify behavior.  Specifically, the generic classes of psychoactive medication include, but are not limited to: 

  1. Neuroleptics, such as chlorpromazine; 

  2. Anti-depressants, such as imipramine;

   3. Agents for control of mania and depression, such as lithium; 

  4. Sedatives, hypnotics to promote sleep, such as flurazepam hydrochloride; 

  5. Psychomotor stimulants, such as methylphenidate hydrochloride; and 

  6. Anti-convulsants, such as Carbamazepine. 

  "Regulated medical waste" means any solid waste generated in the diagnosis, treatment, immunization of human beings or animals, research pertaining thereto, or in the production or testing of biologicals listed in the following: cultures or stocks; pathological wastes; human blood and blood products; sharps; animal waste; isolation wastes; and unused sharps, in accordance with N.J.A.C. 7:26-3A. 

  "Service objective" means a significant desired outcome that cannot be achieved as a result of learning or training. It includes quantifiable but non-behavioral outcomes such as seizure reduction or maintenance of blood pressure within a stated range, and quality of life outcomes such as developing and maintaining social networks. It also includes outcomes dependent on the behavior of staff, such as provision of adaptive or mobility equipment, obtaining specialized assessments, or referral for alternative placement.

  "Severe medical problem" means any acute or long term condition which warrants frequent nursing care or monitoring, including, but not limited to, nasogastric tube feedings, gastrostomy, colostomy, tracheostomy, intravenous therapy, decubitus ulcer, quadriplegia and poorly controlled diabetes. 

  "Unusual incident" means an event involving an individual served by the Division or employee involving indications or allegations of criminal actions, injury, negligence, exploitation, abuse, clinical mismanagement or medical malpractice, a major unforeseen event, for example, serious fire, explosion, power failure that presents a significant danger to the safety or well being of individuals served and/or employees; or a newsworthy incident. 

  "Volunteer" means an unpaid person who supports and supplements daily programs and services. A person may volunteer individually, or as a member of an organized group.

 SUBCHAPTER 2. LICENSURE

No private facility for persons with developmental disabilities shall accept individuals until the facility has obtained a license issued by the Licensing, Certification and Standards office of the Department of Health. The facility shall not exceed its licensed capacity.

 10:47-2.2 Surveys of facilities

Survey visits may be made to a facility at any time by authorized staff of the Department of Health and Senior Services or the Department of Human Services. Such visits may include, but not be limited to, the review of all facility documents, individuals' records and conferences with individuals and staff.

  (a) A temporary license may be issued to a facility for a period of six months and may be renewed as determined by the Department of Health and Senior Services, based upon the achievement of a substantial degree of compliance with this chapter. 

  (b) A full license may be issued by the Department of Health and Senior Services, based upon compliance with this chapter. 

  (c) Any license shall be conspicuously posted in the facility.

 SUBCHAPTER 3. ADMINISTRATION

 The facility shall have available a copy of this chapter (N.J.A.C. 10:47) and other State and Federal regulations relevant to the function of the facility. This includes copies of all regulations cited within this chapter.

 (a) The facility shall allow the licensing agency or its representatives to inspect all aspects of a program's operations and to interview any staff member of, or any individual in the care of, the facility. 

  1. A facility shall make all information related to assessment of compliance with these requirements available to the licensing agency or its representative.

10:47-3.3 Waivers

 (a) The facility shall be in compliance with all applicable provisions of Federal, State and local or municipal laws, regulations and codes unless a waiver for specific requirement(s) has been granted through a prior written agreement with the licensing agency. This agreement shall specify the particular requirement(s) to be waived, the duration of the waiver, and the terms under which the waiver is granted. 

  1. Waiver of requirements may be granted providing that such a waiver would present no danger to the health, safety, welfare, or rights of the individual and when strict enforcement of a requirement would place an undue burden upon the facility.

10:47-3.4 Mission statement

  1. The statement of philosophy and goals shall be reevaluated at least annually.

10:47-3.5 Conflict of interest; provision of goods and services

The facility shall not permit public funds to be paid or committed to be paid to any corporation, firm, association, partnership, or business in which any of the members of the governing body of the facility, or the members of the immediate families of members of the governing body or executive personnel have any direct or indirect financial interest, or in which any of these persons serve as an officer or employee, unless the services or goods involved are provided at a competitive cost or under terms favorable to the facility.

 (a) In a non-proprietary facility, there shall be a board of directors, board of trustees, or other similar governing body responsible for the facility's management, control, and operation, the welfare of the individuals served and the formulation of administrative policy. 

  1. A non-proprietary facility shall have a governing body which includes representatives of the community in which the facility is located, representatives of the parents, and providers of services. 

   i. The names and addresses of all board members shall be supplied to the licensing and inspecting agencies. 

   ii. The professional background of each member shall be provided. 

   iii. Changes in membership shall be reported to the licensing and inspecting agencies annually. 

  2. The governing body shall elect any of the following to its membership: president or chairperson, vice president or co-chairperson, secretary, treasurer, or other members, based upon the governing needs of the facility. It shall have the power to appoint such officers and committees as it may require to assist in carrying out its functions. 

   i. The governing body shall conduct regular meetings and such special meetings as required. 

   ii. Minutes shall be recorded and readily available to representatives of the licensing and inspecting agencies. 

  3. The governing body of a facility shall designate a person to act as chief executive officer of the facility and shall delegate sufficient authority to such person necessary to manage the affairs of the facility effectively. 

   i. The chief executive officer, in conjunction with the governing body, shall be responsible for the general direction and   establishment of policies concerning the operation of the facility and welfare of the individuals served. 

  4. The governing body of a facility shall ensure that the facility: 

   i. Is in continual compliance and conformity with all relevant laws and/or regulations, whether Federal, State, local or   municipal, affecting the operation of the facility; 

   ii. Is in continual compliance and conformity with the terms of all leases, contracts, or other legal agreements to which  the facility is a party; 

   iii. Is maintained, staffed, and equipped in such a manner as to effectively implement the programs of the facility; 

   iv. Is adequately funded and fiscally sound. To this end, the governing body shall be responsible for: 

    (1) The review and approval of the facility's annual budget; and 

    (2) The review of an annual report completed by an independent auditor. The audit shall be made available upon request to any public agency which provides funds to the facility and the licensing agency; and 

   v. Consults with the licensing and inspecting agencies prior to making any substantial alteration in the program provided by the facility or the physical plant.

 (a) A proprietary facility operated by an owner, partnership, or corporation shall certify to the Division of Developmental Disabilities the names, addresses, occupations or professions of all the owners and the extent of financial interest of each. 

  (b) A proprietary facility shall have documents which fully identify its ownership. A corporation, partnership, or association shall identify its officers and shall have, where applicable, the charter; partnership agreement; constitution, articles of association; and/or bylaws of the corporation, partnership, or association.

 (a) The facility shall assemble and maintain an administrative procedures manual which incorporates all of the written policies and procedures designed to implement the facility's objectives, and key procedures which address the implementation of applicable law and rules. 

  1. The administrative procedures manual shall describe the policies and procedures of the major operating units, and shall be available to all interested persons. Each procedure shall be designed in accordance with the principles of normalization, age appropriateness, least restriction and shall be consistent with the organizational structure and management philosophy of the facility.

  2. The procedures shall be reviewed and updated as necessary but at least every five years. 

  3. All procedures shall identify the dates of issuance and review or revision. 

  4. Each policy and/or procedure shall provide: 

   i. A descriptive title which is unique as to permit easy reference and retrieval of each document; 

   ii. An explanation regarding the purpose of the document; 

   iii. A description of sequential steps required to successfully complete a task or action; 

   iv. Assignment of staff responsibilities at each step in the implementation; and 

   v. Reporting and recording requirements for each person involved. 

  5. A table of organization shall be incorporated in the administrative procedures manual to clearly identify lines of authority, responsibility and communication. 

  6. All staff shall be able to describe procedures that they routinely implement. 

  7. Policies and procedures shall be readily available and accessible for staff use. 

  (b) A written procedure shall be available that specifies one individual responsible for the overall operation of the facility at any specific time. The procedure shall provide a schedule for continuous administrative coverage, and responsibilities shall be clearly defined. 

  (c) A written procedure shall be available detailing requirements for appointment of a guardian in accordance with N.J.A.C. 10:43. 

  (d) A written procedure detailing round-the-clock accountability of individuals shall be implemented. 

  (e) A written procedure shall be available to delineate action to be taken in cases where an individual is discovered missing.

   (f) A written policy shall be available that defines the use of mechanical restraints in accordance with N.J.A.C. 10:42. Such policies shall be reviewed by the Director for compliance with N.J.A.C. 10:42 prior to implementation. 

  (g) The facility shall have a Human Rights Committee, in accordance with N.J.A.C. 10:41-4. 

  (h) A written procedure shall be available which specifies the maintenance of an unusual incidents log and staff responsibilities regarding unusual incidents. 

  (i) There shall be a written procedure to ensure the investigation of each alleged mistreatment of an individual or an unusual incident or accident. 

  (j) Any unusual incident or accident (categories are found in the subchapter Appendix, incorporated herein by reference) shall be reported to the New Jersey Department of Health and Senior Services, Bureau of Licensing, and the appropriate Regional Office in the Division of Developmental Disabilities based upon the following time frames: 

  1. A+ incidents shall be reported immediately; 

  2. A incidents shall be reported the same working day during normal working hours. If the incident occurs after regular working hours, the incident shall be reported the next working day; and 

  3. All other reportable incidents shall be reported the next working day. 

  (k) A copy of the written investigative report, unless otherwise indicated, shall be forwarded to the Division of Developmental Disabilities within 10 working days. The report shall contain, but not be limited to, the following information: 

  1. The name of the alleged victim(s), date, and time of the incident; 

  2. Name(s) of the person(s) involved, including participants and witnesses; 

  3. A description of the incident, including any medical treatment administered; 

  4. Sanctions that were invoked when the allegation was substantiated; and 

  5. Any corrective actions taken to prevent a recurrence or to provide additional protection.

(10:47-3.9 Abuse of minors

In the case of persons under the age of 18, allegations of abuse or neglect shall also be reported immediately to the local district office of the New Jersey Division of Youth and Family Services (see N.J.S.A. 9:6-8.10).

In the case of individuals 60 years of age and over, allegations of abuse or neglect shall also be reported to the New Jersey Office of the Ombudsman (see N.J.S.A. 52:27q-7.1).

 (a) A facility shall develop, and implement on a continuing basis, and internal administrative quality assurance system which shall ensure: 

  1. Compliance with pertinent Federal, State and local laws and regulations; 

  2. Effective implementation of the facility's internal policies and procedures; and 

  3. An annual summary encompassing the results of the requirements in (a)1 and 2 above including a corrective action plan.

 (a) The facility shall establish rules of conduct which promote individual growth by incorporating procedures for reinforcement of positive behaviors and consequences for negative behaviors. 

  1. No medication shall be used for the convenience of staff, as a substitute for programs, as punishment, or in quantities that interfere with an Individual's Habilitation Plan (IHP). 

  2. Corporal punishment, physical and verbal abuse, neglect and exploitation shall be prohibited. 

  3. Seclusion and isolation (that is, the placement of an individual alone in a locked room) shall be prohibited.

(a) The facility shall ensure that each individual is provided with transportation: 

  1. In order to implement the individual's IHP; and 

  2. For use in cases of emergency.

(a) The facility shall have written admission policies and criteria for admission which shall include: 

  1. Chronological age; 

  2. The level of developmental programming; 

  3. Other services offered; 

  4. A physical description of the facility; and 

  5. Fees for care. 

  (b) The written description of admission policies, criteria and fees shall be provided to all placement agencies and shall be available to the parent(s) or guardian of any individual referred for placement. 

  (c) An individual shall not be admitted unless his or her needs can be met by the facility's established programs. 

  (d) The facility shall establish and make available written procedures concerning admission, readmission, and discharge of an individual with developmental disabilities. 

  (e) The number of individuals admitted to a facility shall not exceed its licensed capacity nor its provision for adequate programming. 

  (f) The facility shall maintain a record of all admissions and discharges, including names and dates, for the previous 10 years. 

  (g) The following written reports shall be available upon admission: 

  1. Complete psychological examination conducted not more than three years prior to the admission of an individual; 

  2. Complete medical examination conducted within 48 hours before admission; and 

  3. Determination of an initial living unit and program assignment(s).

 10:47-3.16 Individual Records

  (a) Individual records shall include the following data: 

  1. The date of admission; 

  2. The individual's social history and Medicaid numbers; 

  3. The individual's religious preference; 

  4. The name, address and telephone number of all personal physicians and dentists; 

  5. A physical examination by the physician within one week of admission which includes: 

   i. An examination for physical injury and disease; 

   ii. An assessment of the individual's general health; and 

   iii. Referrals to an appropriate medical specialist for further assessment and/or treatment; 

  6. Dental information, vision testing, and audiological evaluation, if not present in pre-admission data; 

  7. A prescribed medical program if required; 

  8. Physician's orders prescribing medication treatment and/or therapy; 

  9. Reports of clinical laboratory, X-ray, operation, and other diagnostic services; 

  10. Height and weight records; 

  11. A medically-prescribed diet, if required; 

  12. A medication administration record, including name and strength of drug, date and time of administration, dosage administered, route of administration and signature of the person administering the drug. (Initials may be used after the individual's full name, signature appears at least once on each page of the document); 

  13. Physician's periodic progress notes as required on the physical, emotional and behavioral status of the individual and course and results of treatment; 

  14. Progress notes of ancillary services including podiatry, physical therapy, optometry, speech and hearing, etc.; 

  15. The current Individual Habilitation Plan; 

  16. Previous reports of individual's social and behavioral progress to correspond to the current Individual Habilitation Plan; and 

  17. A record of the individual's personal property and funds.

(a) Individual records shall include the following discharge data: 

  1. The date of discharge, reason for discharge, and the name, telephone number, and address of the person or agency to whom the individual was discharged; and 

  2. A written discharge summary describing the individual's medical, behavioral and program needs, current programming goals and developmental progress, and recommendations for future programming to ensure an orderly transition to the new environment. 

  (b) The facility shall have a written policy concerning emergency discharge of an individual. For individuals receiving services from the Division of Developmental Disabilities, the policy on emergency discharge shall comply with the requirements of N.J.S.A. 30:4-107.1. 

  (c) The facility shall ensure that the individual's clothing accompanies him or her at the time of discharge.

 (a) The facility shall maintain a central record for each individual, which shall include social information, health care, programming, and educational data from the time of admission until the time the individual leaves the facility. 

  1. Records shall be retained for a minimum of 10 years after the death or most recent discharge of the person. In the case of a discharged minor, such records shall be kept for 10 years following the last date of discharge or until the minor reaches the age of 23 years, whichever is the longer period of time. In the case of a deceased minor, the record shall be kept for 10 years following the date of death. 

  2. All active records shall be maintained on the premises and shall be complete, current and readily available for review by authorized persons. 

  3. Individual records shall be conspicuously and appropriately identified and maintained in a central records file. 

  4. All entries in the record shall be current, legible, dated, and authenticated by the signature and title of the person making the entry. 

  5. The facility shall provide a legend to explain any symbol or abbreviation used in an individual's record. 

  (b) The facility shall protect and maintain the confidentiality of all records in accordance with N.J.A.C. 10:41-2.

 (a) Personnel practices shall comply with all applicable Federal, State, and local laws, ordinances, rules and regulations pertaining to employment, including civil rights, retirement plans or social security, minimum wages, hours and workmen's compensation. 

  1. The facility shall assure that all staff undergo a criminal background check as required by N.J.S.A. 30:6D-63 et seq. 

  (b) Upon employment, all staff shall submit a written statement from a licensed physician or advance practice nurse indicating that he or she is in good health and medically determined to be free of communicable and infectious diseases. 

  (c) The facility shall be responsible to obtain professional services required for the implementation of the Individual Habilitation Plan, when these services are not provided by employees of the facility. 

  (d) The facility shall have written evidence that all professionals providing services to the facility, by direct employment or on a fee for service basis, whether working directly with the individuals being served or providing consultation to employees of the facility, are appropriately qualified, certified, and/or licensed to provide the service(s) rendered. 

  (e) The facility shall have written personnel policies and procedures that shall be provided to all staff members and available to all persons seeking employment. 

  (f) The facility shall have complete written job descriptions for each job title within the facility. Documentation that each employee has been given a copy of his or her job description shall be maintained. 

  (g) The facility shall have a written policy for the supervision and evaluation of all employees. 

  (h) Staff shall have the ability to communicate with the individuals for whom they are responsible.

  1. The application for employment and/or resume; 

  2. Reference letters from former employer(s) and personal references or notation of telephone contacts with such references;

   3. Medical examinations; 

  4. Documentation that upon employment the employee received a two-step Mantoux tuberculin skin test with five tuberculin units of purified protein derivative. The only exceptions shall be employees with documented negative two-step Mantoux skin test results (zero to nine millimeters of induration) within the last year, employees with a documented Mantoux skin test result (10 or more millimeters of induration), employees who have received appropriate medical treatment for tuberculosis, or when medically contraindicated. Results of the Mantoux tuberculin skin tests administered to new employees shall be acted upon as follows:

   i. If the first step of the Mantoux tuberculin skin test result is less than 10 millimeters of induration, the second step of the two-step Mantoux test shall be administered one to three weeks later. 

   ii. If the Mantoux test is significant (10 millimeters or more of induration), a chest x-ray shall be performed and, if necessary, followed by chemoprophylaxis or therapy. 

  5. A copy of any professional credentials/certifications; 

  6. A copy of the employee's written job description; 

  7. Annual performance evaluations and/or personnel actions or other appropriate materials, reports, and notes relating to employment with the facility; 

  8. The employee's hiring and termination dates; and 

  9. The results of the employee's criminal background check. 

  (b) The facility shall maintain the personnel file of an employee during their tenure and for a period of five years after termination.

(a) The facility shall provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently. 

  (b) Before assuming their normal duties, new employees shall receive an orientation to acquaint them with: 

  1. The organization's philosophy, goals, programs, and practices; 

  2. An overview of developmental disabilities and any special needs of the individuals being served, for example, medical or behavioral problems requiring specific, tailored training; 

  3. The appropriate job description and the personnel policies of the organization; 

  4. The prevention of abuse, neglect and exploitation; 

  5. Unusual incident reporting and investigating procedures; and 

  6. The facility's emergency and safety procedures. 

  (c) Direct service staff shall be accompanied by experienced workers on initial tours of duty for at least a period of two weeks or such time as these staff person(s) are able to safeguard the health and safety of individuals being served by the facility. 

  (d) Within 120 calendar days of employment, each employee shall receive in-service training which shall address, at a minimum: 

  1. Training in the principles of normalization; 

  2. Review of all policies and procedures not covered during orientation which are relevant to the employee's job; 

  3. Acceptable behavior management techniques, including crisis management and restraint usage, if applicable; 

  4. Standard First Aid Training based on the American Red Cross curriculum; 

  5. Cardio-Pulmonary Resuscitation; 

  6. Training in universal precautions; 

  7. Detecting signs of illness or dysfunctions that warrant medical or nursing intervention; and 

  8. Basic skills to meet health needs and problems of the individual with developmental disabilities. 

  (e) The facility shall provide specialized training programs to staff which focus on skills and competencies directed toward the developmental, behavioral, and health needs of the individuals being served. These areas may include, but are not limited to: 

   1. Persons who work with individuals who require specialized feeding techniques shall receive training in the use of those techniques; 

  2. Persons who work with individuals who use mobility devices shall receive training in mobility procedures and the safe use of mobility devices; 

  3. Persons who work with individuals with seizure disorders, physical disabilities or other identified medical needs shall receive training in the provision of training, assistance, and care to those individuals; and 

  4. Persons who work with individuals with identified mental health needs shall receive training in the provision of training, assistance, and care to those individuals. 

  (f) All staff shall be able to demonstrate the skills and techniques necessary to: 

  1. Intervene when an individual exhibits inappropriate behavior; and 

  2. Implement the program plans for each individual for whom they are responsible. 

  (g) Facility training records shall be maintained and include the following: 

  1. The curriculum and training plan; 

  2. A record of attendance which includes the dated signature of the trainer and the trainee; and 

  3. An employee's record indicating all training sessions attended. 

   i. The employee's record shall include a section on mandated training.

 (a) The facility shall have a minimum of direct care personnel as follows: 

  1. The on-duty ratio for the day shift shall be at least one to 8.5. 

   i. Facilities sending individuals out of the living units for a major portion of the day need not provide coverage during the   period of time which the individuals are absent. 

  2. The on-duty ratio for the evening shift shall be at least one to 8.5. 

  3. The on-duty ratio for the night shift shall be at least one to 17. 

   i. The facility shall ensure that each individual has ready access to a responsible, awake staff member throughout the night. 

  (b) Nursing personnel shall be available to deliver the prescribed medical and nursing care. 

  1. The facility shall have at least one registered nurse on staff. 

  2. A facility which serves individuals with severe medical problems shall have a minimum of one licensed practical or registered nurse to every 60 individuals served on each shift from 7:00 A.M. to 11:00 P.M. 

   i. In addition, each facility shall have a minimum of one registered nurse present on each shift from 7:00 A.M. to 11:00 P.M. to   supervise nursing services. 

  (c) The facility shall have available qualified professional staff through direct employment and/or services provided through written agreement with outside vendors to carry out and monitor the various professional programs and/or services in accordance with the stated goals and objectives of each individual program plan.

(a) A facility which has volunteers working directly with individuals shall have a written policy pertaining to the use of volunteers, which shall include the methods of recruitment, training and supervision of volunteers. 

  1. Volunteers may supplement but shall not be used in lieu of paid employees. 

   i. The facility shall not depend upon volunteers to perform direct care services.

   2. Where volunteers are utilized, the facility shall provide: 

   i. Mantoux screenings as required for employees; 

   ii. A note from a physician indicating that the person is in good health and free of communicable diseases; 

   iii. Direct supervision of volunteers at all times by an experienced staff member; 

   iv. An orientation and training program that includes the philosophy, goals, programs and practices of the facility; and 

   v. Training in the performance of specific tasks performed by the volunteer. 

  (b) The facility shall develop and distribute procedures for volunteers. 

  (c) A facility which accepts students for field placements shall have a written policy describing student placements and responsibilities. Copies should be provided to each student and to his or her school.

 SUBCHAPTER 5. PROTECTING INDIVIDUALS' RIGHTS

 (a) The facility shall have a written statement of policies and procedures that protects the civil and legal rights of all individuals in accordance with N.J.S.A. 30:6D-4.

   1. The facility shall ensure that each person admitted is fully informed of their rights and responsibilities and is advised of all rules and regulations governing their conduct while at the facility. 

   i. Information shall be provided prior to, or at the time of, admission or, in the case of a person already in the facility,   upon adoption or amendment to existing rights policies, and receipt of such information shall be acknowledged by the individual  and/or guardian in writing. 

  2. The facility shall inform each individual, parent or legal guardian, of the medical condition, developmental and behavioral status, attendant risks of treatment, and the right to refuse treatment. 

  3. The facility shall promote participation of parents and/or legal guardians in the process of developing and implementing the IHP. 

  (b) The facility shall assure the civil and legal rights of all individuals with developmental disabilities in accordance with N.J.S.A. 30:6D. These rights shall include, but are not limited to: 

  1. The opportunity to register and vote at elections; 

  2. The opportunity to exercise religious freedom; 

   i. Religious services and instruction shall be arranged consistent with the individuals interests. 

   ii. Licensees and/or staff shall not impose their religious beliefs on individuals under their care. 

  3. The opportunity to receive and send unopened correspondence and, upon request, to obtain assistance in the writing and reading of such correspondence; 

  4. The opportunity for private visitations and private telephone conversations with interested parties, without prior notice to the facility, during such reasonable hours as may be established by the facility; 

  5. Reasonable opportunities for interaction with members of the opposite sex; 

  6. The confidential handling of personal and medical problems; 

  7. A reasonable schedule concerning the hours the individuals shall rise and retire according to their developmental level; and 

  8. An active social and therapeutic recreation program consistent with the individuals interests and capabilities. 

  (c) In addition to the rights specified in (b) above, the facility shall allow and encourage individuals to exercise their rights as citizens of the United States, including the right to file complaints, and the right to due process. 

  (d) The facility shall not compel individuals to perform services for the facility. The facility shall compensate individuals who are working for the facility at prevailing wages, commensurate with their abilities.

(a) The facility shall establish and maintain a system that: 

  1. Assures a detailed accounting of each individual's personal funds entrusted to the facility on behalf of individuals; 

  2. Precludes any commingling of individual's funds with facility funds or that of any other person; and 

  3. Assures that the individual's financial records are available on request to the individual, parents and/or legal guardian. 

  (b) The facility shall develop a policy that permits and encourages the possession and use of money by individuals who are determined capable by the interdisciplinary team. 

  1. The facility shall provide training in the use of money to individuals in accordance with their needs and abilities, and establish the amount of money an individual may possess in accordance with their needs and abilities which then shall be recorded in the Individual Habilitation Plan.

(a) Each individual shall have the opportunity to select and purchase clothing according to individual taste and preference. 

  (b) The facility shall provide assistance to individuals who require assistance in order to maintain their own clothing. 

  (c) The facility shall maintain an annual inventory of each person's clothing. 

  (d) The facility shall ensure that individuals have the right to retain and use personal possessions. 

  1. The facility shall ensure that individuals have access to their personal possessions. 

  (e) Provisions shall be made for the protection of the individual's personal possessions. 

  1. The facility shall maintain an annual inventory of each person's personal possessions. 

  (f) The facility shall provide storage space to include drawers and closets for personal possessions and in-season clothing in each individual's room.

  (a) The facility shall provide each individual with the opportunity for personal privacy, to include, but not limited to: 

  1. The free use of all common living areas within the home without infringing on the privacy of others; 

  2. The opportunity to communicate, associate and meet privately with individuals of their choice; and 

  3. The opportunity for privacy during treatment and care of personal needs. 

  (a) The facility shall provide for the basic hygienic needs of the individuals served. Individuals shall be helped to attain maximum independence in caring for their needs. The following shall be assured: 

  1. Baths or showers shall be provided daily; 

  2. Individuals who soil shall bathe and change immediately; 

  3. Individuals shall brush their teeth at least twice a day and provisions shall be made for the cleaning of dentures; 

  4. Individuals shall shampoo their hair at least twice a week, or more frequently if necessary; 

  5. Toe nails and finger nails shall be cut as needed; 

  6. Men shall have the opportunity to shave as needed; 

  7. Individual toilet articles such as hairbrush, comb, toothbrush, toothpaste, razor, soap, shampoo, washcloth and towel, shall be supplied to each individual and kept in a separate receptacle; 

  8. Feminine hygiene protection shall be provided as needed; and 

(a) At least one physician, licensed to practice in New Jersey, shall assume overall responsibility for the direction and provision of medical and health care. 

  (b) Arrangements shall be made with a community hospital for the acceptance of any person requiring inpatient or outpatient hospital services. Services shall include emergency, diagnostic, and/or treatment services. 

  1. Written approval for treatment in emergency situations shall be obtained from the legal guardian or competent adult at the time of admission. 

  2. Written approval for routine hospital treatment shall be obtained from the legal guardian, or from the competent adult individual before treatment is rendered to that individual. 

  (c) Primary immunizations shall be given, as required, upon admission and reimmunizations as recommended on a regular basis for diphtheria, tetanus, pertussis, polio, measles, and other diseases as identified consonant with acceptable medical practices and New Jersey Department of Health and Senior Services regulations in accordance with N.J.A.C. 8:57. 

  (d) Provision shall be made for the isolation of persons with a communicable disease and the prevention of its spread in accordance with N.J.A.C. 8:57. 

  1. Communicable disease shall be reported to State and local health authorities and the inspecting agency in accordance with N.J.A.C. 8:57. 

  2. Private accommodations shall be provided for observation and/or for temporary isolation until transfer is made. 

  3. The Mantoux Skin Test for tuberculosis shall be given every three years. If the individual has had a previous positive Mantoux tuberculin skin test, or the result of the Mantoux tuberculin skin test is significant (10 or more mm of induration), the licensee shall require: 

   i. That the individual obtain a written statement from a physician or advance practice nurse certifying that he or she poses no  threat of tuberculosis contagion; or 

   ii. A protocol to follow, recommended by the physician or advance practice nurse, before allowing the individual to come   into contact with other individuals being served and staff. 

  (e) Written procedures shall be prominently posted for staff members to follow in the event of a medical emergency. 

  (f) Health services staff shall be trained in the facility's procedures for medical emergencies. 

  (g) First aid supplies shall be available and accessible to all staff. 

  (h) Other than first aid, no medication or treatment shall be administered by employees of the facility except on written order of a licensed physician.

 (a) A physician licensed in the State of New Jersey shall perform examinations and administer and/or prescribe treatment as needed for preventive, routine and emergency medical care. 

  (b)  An annual complete physical examination with findings noted shall be performed for each individual. The physical examination shall require: 

  1. Vision and hearing shall be grossly evaluated. For persons with observed problems, visual acuity and audiology studies shall be performed as clinically indicated. 

  2. The stool shall be tested for occult blood annually after age 50 for persons of average risk for colon-rectal cancer; and 

  3. An annual breast examination shall be recorded for all adult women. Mammography and cervical cytology shall be performed in accordance with standards recommended by the American Cancer Society, unless the physician documents that the tests are medically contraindicated. (American Cancer Society, 1599 Clifton Road NE, Atlanta, Georgia 30329)

   (c) The physician or advance practice nurse shall follow-up on each individual's medical needs on an ongoing basis and record necessary information in the individual's record. 

  1. Physician's or advance practice nurse's orders for medical treatment shall be updated as necessary. 

  2. Medication orders shall be reviewed and revised as necessary but at least annually. 

  (d) Specialists' services in all pertinent fields of medicine shall be provided. 

  (e) When referring an individual to a specialist or hospital for services, the physician or designee shall ensure that copies of all necessary medical records are forwarded to the specialist.

  (b) A licensed professional nurse shall assess each individual's health status and record their findings in the individual's record as needed but at least annually.

1. Routine and preventive dental care, including, but not limited to:

i. An annual dental examination;

1. Prophylaxis;
2. Dental x-rays; and
3. Repair of teeth;

2. Prosthetic dentistry, for individuals in need;

3. Oral surgery, when necessary; and

4. Periodontal services, when necessary.

(b) Where applicable, all sterilization techniques shall be properly performed on dental equipment by trained employees.

(a) The facility shall provide pharmaceutical services under the direction of a New Jersey licensed pharmacist, in accordance with N.J.A.C. 13:39. 

  (b) The facility shall provide pharmaceutical services, both dispensing and consultant, either directly or through written contractual agreements. 

  (c) The facility shall have written policies and procedures, describing the methods for obtaining, dispensing, storing, administering, and usage of medications. The policies and procedures shall be reviewed and updated annually. 

  (d) The facility shall have a policy and a procedure for the use of "as needed" (PRN) orders. 

  (e) The facility shall comply with Federal and State rules and regulations governing the order, storage, dispensing, administration, recording and disposal of medications. 

  (f) Any medication or change in medication dosage by the physician or advance practice nurse shall be immediately noted on the current written medication record by staff. 

  1. Verbal orders from the physician or advance practice nurse shall be confirmed in writing within 24 hours or by the first business day following receipt of the verbal order. 

  2. The prescription or medication sheet shall be revised at the earliest opportunity. 

  (g) Medications shall be distributed by either a unit dose or an individual prescription system. 

  1. All medication shall have the label affixed by the pharmacy, in accordance with N.J.A.C. 13:39. 

   i. All medication shall be kept in their original containers from the pharmacy and shall be properly identified with the   pharmacist's label. 

  2. When medication is prescribed "as needed" (PRN), the prescription label shall include the following: 

   i. The individual's name, date, name of medication, dosage, specification of interval between dosages, maximum amount to be given during a 24 hour period, a stop date, an under what conditions the PRN medication shall be administered. 

  3. Discontinued and outdated medications and containers with worn, illegible, or missing labels shall be returned to the dispensing pharmacy within 30 days for proper disposal or disposed of by the facility in accordance with N.J.A.C. 13:39-9.6(a)13. 

 (h) The facility shall have a system of accountability for drug administration that identifies each medication to the point of administration. 

  1. Medications shall be administered by authorized employees to the right individual, in the right amount, through the right route and at the right time. 

  2. Medications prescribed for one individual shall not be administered to another. 

  3. Each dose of medication administered shall be recorded in the medication administration record immediately after administration. 

  4. The administration of PRN medication shall be documented in the medication administration record and communicated to the oncoming shift. 

  5. Medication errors shall be reported in writing in accordance with the facility's written procedures. Medication errors with serious or potentially serious consequences should be considered an unusual incident and reported in accordance with N.J.A.C. 10:47-3.8(j). In addition, the physician shall be notified immediately. 

  (i) All adverse drug reactions shall be reported to the attending physician immediately and a description of the incident shall be included in the individual's record. 

  (j) The facility shall provide a locked storage area for all medications. 

  1. All medications shall be kept in a locked cabinet, closet or medication cart. 

  2. Storage areas shall be locked at all times except when medications are being prepared for administration or placed into storage. 

  3. Poisons and external preparations (including eye and ear medications) shall be stored separately from internal medications. 

  4. A refrigerator shall be provided for medications requiring refrigeration. 

   i. The refrigerator shall be maintained at a temperature between 36 degrees Fahrenheit and 45 degrees Fahrenheit. 

   ii. Medications stored in multi-use refrigerators shall be kept in a locked box and properly labelled. 

  (k) Aseptic techniques shall be maintained in the handling of instruments, surgical supplies, syringes and needles. 

  (l) Needles and syringes shall be stored, used, and disposed of in accordance with N.J.A.C. 7:26-3A.

  (m) A record shall be maintained of the purchase, storage, and disposal of needles and syringes.

(a) The facility shall have a written policy governing the use of psychoactive medication. 

  (b) The use of psychoactive medication shall be premised on the grounds that it constitutes an appropriate intervention either alone or in conjunction with other strategies to treat a psychiatric disorder or to manage a behavior disorder, as follows: 

  1. For treatment of psychiatric disorders, the medication shall be prescribed for the purpose of reducing or eliminating the symptoms of a psychiatric disorder which is diagnosed by a psychiatrist using the DSM-IV. (DSM-IV can be obtained from the American Psychiatric Association, 1900 K Street, Washington, D.C. 20005.) Except in an emergency, the IDT shall meet and determine if behavior interventions should be used in conjunction with psychoactive medication. The decision of the team shall be documented. 

  2. For behavior management, the psychoactive medication shall be prescribed for the purpose of managing a severe problem behavior when no specific psychiatric diagnosis has been made. Before the psychoactive medication is administered, the IDT shall meet. The use of psychoactive medication shall not be considered the sole modality to address the behavior but shall be supplemented by appropriate interventions based on functional analysis, for example, environmental strategies and/or behavior modifications, staff training, and individual management strategies. The IDT may decide to use other appropriate behavior interventions in lieu of psychoactive medication.

   (c) When a psychiatric condition is not diagnosed and a psychoactive medication is being recommended for behavior management, the Behavior Management Committee and the chairperson of the Human Rights Committee shall review and recommend their approval of the medication prior to implementation. 

  1. Review by the full Human Rights Committee, with medical input, shall occur within 30 days of implementation. 

  (d) Psychoactive medication shall not be used for punishment, for the convenience of staff, or as a substitute for programmatic intervention.

  (e) Informed written consent shall be required for each generic class of psychoactive medication. A new consent would not be needed if there is a change of medication within the same generic class. 

  (f) All individuals receiving psychoactive medication and the legal guardian, where applicable, shall be informed of the generic class of psychoactive medication proposed, the purpose, the dosage, and possible side effects of the medication. Steps to inform each individual shall be documented in their record. 

  (g) Individuals receiving psychoactive medication shall be personally examined by the prescribing physician prior to the initial administration. 

  (h) Except in emergencies, psychoactive medication shall always be prescribed in writing prior to its administration. Telephone orders shall be permitted in an emergency and countersigned by the physician within 24 hours. 

  (i) Short-acting injectable psychoactive medication used in emergencies shall be administered only by a licensed physician or licensed professional nurse. 

  1. The individual shall be monitored continuously by a staff person trained to observe potential adverse effects. 

  2. The physician ordering the intramuscular psychoactive medication shall examine the individual within a 48 hour time period. 

  (j) "As needed" or "PRN" usage of psychoactive medications shall be prohibited. 

  (k) Persons receiving services shall be maintained on the lowest possible effective dosage of psychoactive medication.

  (l) All psychoactive medication shall be monitored by the prescribing physician for clinical effectiveness as necessary but at least quarterly. 

  (m) Because of potential serious toxicity, lithium, carbamazepine, valproic acid, clozapine, and clomipramine shall be used only after a complete history, physical examination, and laboratory assessment of the individual has been made by a physician. Lithium shall be administered under the surveillance of a physician, or advance practical nurse, preferably a psychiatrist, to include monitoring of blood levels. 

  (n) The use of psychoactive medication shall be incorporated in the individual's habilitation plan. 

  1. The IDT shall review the use of psychoactive medication quarterly. If, after a reasonable length of time, there is no apparent improvement, other treatment options should be considered. The IDT shall determine whether the individual is being negatively affected by the medication or other concerns associated with the medication are noted. 

  2. The results of the review shall be documented in the individual's record. Concerns of the IDT shall be referred to the Physician, Behavior Management Committee and/or Human Rights Committee. 

  3. When a psychotropic medication is prescribed and administered in an emergency, the IDT shall meet to review the use of the psychotropic medication within the next five working days. The results of this review shall be documented in the client record.

 (a) An accurate, complete and up to date medical record shall be maintained for each individual. This record shall include: 

  1. A list of all current diagnoses, which shall be located in an identified area of the record; 

  2. A list of all significant past illnesses, surgeries and trauma, which shall be located in an identified area of the record; 

  3. A health status review by licensed professional nurses as needed but at least annually; 

  4. An annual physical examination; 

  5. An immunization record; 

  6. List of known allergies; 

  7. Vision examination every three years; 

  8. Report of annual dental examination or accurate dental records; 

  9. Physician's orders; 

  10. Physician's periodic progress notes on the physical, emotional, and behavioral status of the individual; 

  11. Nurse's and clinical notes; 

  12. Reports of clinical laboratory x-rays, surgical, or other diagnostic services; 

  13. Height and weight records; and 

  14. A medication administration record.

 (a) A lead control program shall be developed in each facility which shall ensure that all individuals served shall be protected from the harmful effects of lead poisoning. 

  (b) Because pica is a form of maladaptive behavior, a behavior modification plan shall be considered by the interdisciplinary team as part of the Individual Habilitation Plan (IHP) of each individual who exhibits pica behavior. If a behavior medication plan is not recommended, the team shall document the justification in the IHP. The team shall follow the provisions of N.J.A.C. 10:47-7.4 in developing a behavior modification plan. 

  (c) Diagnosis of pica and/or history of pica must appear in a visible area in the IHP (preferably on the cover sheet).

SUBCHAPTER 7. HABILITATION SERVICES