ࡱ> uwtq  ;8bjbjt+t+ %AAL]8TdMd*L  $T5  d ^ 8,@uzNew Jersey Department of Health PEDIATRIC MEDICAL DAY CARE INSPECTION INFORMATION Requirements for Initial Survey of Pediatric Medical Day Care Facility Name  FORMTEXT      Facility ID  FORMTEXT      Survey Date  FORMTEXT _____ / _____ / ________ Request the following to be on site: 1. Certificate of Occupancy 2. Resumes of Key Staff 3. List of Licensed Staff 4. Policy and Procedures Manual 5. Staff Personnel Files - Orientation 6. Staff Health Files 7. Childhood Emergencies in the Office, Hospital and the Community 8. The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care 9. Sample Medical Record Resumes of Key StaffReg. NumberDocument Name and Review QualificationsAdministrator Qualifications 3.2 FORMTEXT      Designated Alternate Administrator (must meet Administrator qualifications)3.1(a)(b) FORMTEXT      Director of Nursing Qualifications7.2 FORMTEXT      Designated Alternate Director of Nursing (All RNs and LPNs must have one year experience working with medically complex children) 7.1(a) / 7.4 FORMTEXT      Social worker Qualifications 12.1 FORMTEXT      Child Life Specialist/Teacher11.1 FORMTEXT      Dietitian Qualifications10.3 FORMTEXT      Medical Records Practitioner14.2 FORMTEXT      Food Service Supervisor (if applicable)10.3 FORMTEXT      Infection Control Designee15.1(b) FORMTEXT       Employee Personnel and Health FilesReg. NumberNotesCBI-all personnel including volunteers. If licensed by DHS/DYFS, then DHS clearance is okay, but facility should have overall waiver from licensing. Clearance by DOH or DHS with waiver from DOH on all employees. 2.5 FORMTEXT      Job Descriptions6.3(b) FORMTEXT      Staff Orientation (child abuse, infection control, emergency plans, and pain management) upon hire/ongoing (annually) emergency plans, and child abuse6.3(e) FORMTEXT      Initial and Subsequent Physical Exam15.5 FORMTEXT      Two-step Mantoux upon hire; One-step annually15.4 FORMTEXT       Policy and Procedures ManualReg. NumberFacility required to maintain manuals in compliance with N.J.A.C. 8:43J  Policy/policies will be reviewed on survey when systemic problems are identifiedManual for the organization and operation of the facility which must be reviewed every 6 months3.4(c) FORMTEXT      Manual of policies and procedures for the care of medically complex or technology dependant children3.5 FORMTEXT      Procedure manual, an organizational plan and a quality improvement program for medical record services14.1(b) FORMTEXT      Procedure manual for infection prevention and control services reviewed annually15.1 FORMTEXT       Physical EnvironmentReg. NumberNotesSecure door between lobby/reception and children s areas13.4(b) FORMTEXT      Facility to post on bulletin board all waivers, children s rights, means of contacting license holder, and list of deficiencies from last licensure inspection and any complaint surveys3.6(c) FORMTEXT      Facility to post name, address, and telephone number of DOH-HFE&L, Medical Assistance and Health Services, Youth and Family Services4.2(b)(c)(d) FORMTEXT      3 Child Care Areas with 2 means of egress each (Ambulatory, Toddler, Non-Ambulatory)13.8 FORMTEXT      Toilet facilities 1:10 as well as 2 diaper changing areas within 5 feet of hand washing sink  privacy screened13.3 FORMTEXT      Lockers and lounges for employee/volunteer staff 13.5 FORMTEXT      Janitor s closet contains a service sink and storage for housekeeping supplies and equipment13.6 FORMTEXT      Social work office space for private interview13.7 FORMTEXT      Rehab equipment Ped Table with mat, rolls & 1/2 rolls, nesting benches, wooden weighted push cart, toddler swing, floor mirror, steps, climbing equipment11.3 FORMTEXT      Storage space for recreation equipment13.8 FORMTEXT      Outdoor play area 13.1013.1 FORMTEXT      Crib/mats 1:1 Space for cribs or mats  3 ft. between13.9 FORMTEXT      Office space for nursing, If combined with pharmacy and exam 150 sq. ft. minimum with hand washing facilities13.11 FORMTEXT      Lockable refrigerator or locked box in refrigerator13.11 FORMTEXT       Emergency Plans and ProceduresReg. NumberNotesEmergency equipment, O2 , suction, airway, ambu-bag and AED8.5(b) FORMTEXT      CPR/AED-certified staff member (all direct care staff members and volunteers)6.2(h) FORMTEXT      Procedures for emergencies, including medical emergencies13.16(a) FORMTEXT      Written evacuation diagram includes evacuation procedure, location of fire exits, alarms boxes, fire extinguisher13.16(b) FORMTEXT      Fire extinguishers examined annually and labeled13.1(d) FORMTEXT      Hot water temperature 120( 15.9(a) 24 FORMTEXT      Emergency generator if on site/if non contract for provision in an emergency13.1(f) FORMTEXT       TransportationReg. NumberNotesProvide transportation services  MAV or waiver16.1 FORMTEXT      Transportation staffing16.2 FORMTEXT       Food Services and NutritionReg. NumberNotesCurrent Diet Manual (on site) days or more if needed10.1(h) FORMTEXT      Written, dated menus planned 14 days in advance with portion sizes10.1(i) FORMTEXT      Minimum supplies of food (i.e., cereal, tuna, PB, canned fruit, juices)10.1(j) FORMTEXT      Nutritionally appropriate snacks available10.1(c) FORMTEXT      Control station for receiving food storage facilities for food supply including cold storage Handwashing facility Warewashing facility Trash handling Desk space13.12(d) FORMTEXT       Quality Improvement ProgramReg. NumberNotesWritten plan for QI program, specify timetable and persons responsible, to include: review of 1/2 of records quarterly for quality of care, parental involvement in care planning and including formal discharge transition procedure, etc.17.1 FORMTEXT       ContractsReg. NumberNotesMedical Director8.2 FORMTEXT      Pharmacist Consultant9.1 FORMTEXT      Physical, Occupational and Speech Therapies 11.2 FORMTEXT      Copies of any waivers that may have been given during the application process3.6 FORMTEXT      Food Service Provider (if applicable)13.12(b) FORMTEXT      Medical Records Practitioner14.2 FORMTEXT      Registered Dietitian10.1 FORMTEXT       Name of Surveyor  FORMTEXT       PEDIATRIC MEDICAL Day Care Inspection Information Requirements for Initial Survey of Pediatric Medical Day Care (Continued) AAS-23 JAN 14 Page  PAGE 5 of  NUMPAGES 5 Pages. AAS-23 JAN 14 Page  PAGE 1 of  NUMPAGES 5 Pages. @ <>RTV`bd|~"*,@BDNPT     $ & * p x z j`CJUjCJUjCJUmHjxCJU jCJU5CJCJ5mHj5Ujj5Uj5UmHj5U5 j5U 56CJCJCJ6@ <d|,H`z< <  < $$TH04 h) $<$$xx@ <V`d|,H`z"*DNRT  $ ( * p x ( 2 L V Z \  " , 0 2 l v   " $ Z j   ^"*RTd>$$THX4F H)$<<$?$$TH 44F H)$$< <   ( * p x ( 2 t>$$THX4F H)<<$>$$THX4F H)$$$ ( 2 4 H J L V X \   " , . 2 l v x     $ Z j l jCJUj CJUjCJUj4CJUjCJUjHCJUjCJUCJjCJUmH jCJUA2 Z \  0 2 l v " $ Z  <<$ !$$<<$>$$THX4F H)$Z j sl<<$>$$TH 4F H)$$$>$$THX4F H)$$$  &(R(*,68<jxz  |> "$&026 jZCJUjCJUjnCJUjCJUjCJUjCJUmHj CJU6>*>*5CJCJ jCJUA (,6:<jx |<> &046 ",02*48: >Vbd   a:<jxh>$$THX4F H) <<$ !$$$<<$>$$THX4F H)  |< {yyssi $$$$$$>$$THD4F H)$$$>$$THX4F H) <> 460oh<<$>$$THX4F H)$$$ <<$ !>$$TH4F H)  ",.2&(*46:  d  j CJUj CJUj CJUj2 CJU5CJj CJUjF CJUjCJUmH jCJUjCJUCJ@028:>Vb$$$$$$<<$>$$THX4F H)bdXoTh<<$>$$THX4F H)$$$ <<$ !>$$TH 4F H)o>$$THX4F H)$$$ <<$ !>$$THX4F H)^hLV~(q0qq$>$$THX4F H)$$$ <<$ !<$$TH4F H) ^hLVpz~   F!P!j!t!x!z!!!!!!!,"6"P"Z"^"`"~"""""####$$$$|$$$$$$$$$ %%%%%%%%%f&t&&&&&'$'>'H'L'N'2(D(^(h(l(n(((()) )B)  a^hj~LVXlnpz|    F!P!R!f!h!j!t!v!z!!!!!!!!!!,"6"8"L"N"P"Z"\"`"""""jCJUjXCJUj CJUjl CJUj CJUj CJUjCJUmH jCJUj CJUCJ@  F!P!x!z!!!!!,"6"^"`"~"D <$ !>$$THX4F H)$$$ <<$ !~"""####$$|$$$$e<>$$THX4F H) <<$ !>$$THX4F H)$$$ <$ ! """""####$$$$$$|$$$$$$$$$%F%H%%%%%%%%%%f&t&v&&&&&&&'$'&':'<'>'H'J'N'2(D(F(Z(\(^(h(j(n((jCJUjCJUjCJUjCJUH*5CJj0CJUjCJUCJjCJUmH jCJUjDCJU?$$$$$ %%%%%%{`tkt$<<$<<$>$$THH4F H)$$$>$$THX4F H) %%f&t&&&'$'L'N'2(D(l(n(`s@s8>$$THX4F H)$<<$<<$>$$THX4F H) n((() )B)X)))*,*T*V*X*Z*x***$$$>$$THX4F H)$$$<<$(((((()) )<)>)B)X)Z)n)p)r)|)~))*,*.*B*D*F*P*R*Z***+ ++ +"+,+.+2+b+l+n++++++++b,r,t,,,,,,,"-2-4-H-J-jBCJUjCJUjVCJUjCJU5CJjjCJUjCJU jjCJUmHj~CJU jCJUCJ>B)H)X)r)|)))*,*F*P*T*V*X*Z*x*****+"+,+0+2+b+l+++++++++++b,r,,,,,"-2-L-V-Z-\---. .$.&.|......p///// 0 0$0.020406080p0000n2x222222222223 3$3.32343   _***+0+2+b+l++({>$$TH 4F H)$$$>$$THH4F H)++++++++b,r,,{Hojg$$$ <<$ !>$$THH4F H)$$$>$$THD4F H) ,,"-2-Z-\---$.t>$$THX4F H)$$$<<$>$$THX4F H)J-L-V-X-\----... .".&.|........./ 0 0 0"0$0.000800n2x2z22222222223 3 3 3"3$3.30343`3h3j3~333333333 4ʾjCJUjCJU5jCJU5CJjCJUj.CJUjCJUCJjCJUmH jCJUB$.&.|....p///// tog] <$ !$ !<$>$$THX4F H)$$$<<$>$$THX4F H) / 020406080p0000n2x2mf<<$>$$THH4F H)$$$$$$>$$TH@4F H)$$$ x2222222223 323up$$>$$THH4F H)$$$$>$$THX4F H)$ 2343`3h333334 4444{>$$TH4F H)$$$>$$TH4F H) 43`3h3333333444 4444444:5L5f5p5t5v555555566.626<6@6B6D6F6H6J6l6666666x7777888888"8#8.8/898:8;8   A 44444 4444444444:5L5N5b5d5f5p5r5v5555555555666.60626<6>6l6n666666666x7777⳱CJ 56CJ5;j5UmHj5U5 j5UjTCJUjCJUjhCJUjCJUCJjCJUmH jCJUj|CJU644:5L5t5v5555566@6B6D6{{{y>$$TH4F H)$$$>$$TH4F H)D6F6H6J6l66666x77778888898:8;8 !)$x$H$$THD4)h$<$777777777777788888888"8#8-8.8/8087888;8CJ 0JCJmH0JCJj0JCJU# 0&P/ =!"#$%jDjDDText5_____ / _____ / ________tDText6tDText7tDText8tDText9vDText10vDText11vDText12vDText13vDText14vDText15vDText16vDText17vDText18vDText19vDText20vDText21vDText22vDText23vDText24vDText25vDText26vDText27vDText28vDText29vDText30vDText31vDText32vDText33vDText34vDText35vDText36vDText37vDText38vDText39vDText40vDText41vDText42vDText43vDText44vDText45vDText46vDText47vDText48vDText49vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText57vDText58vDText59vDText60tDText1 [,@,Normal OJQJmH 4@4 Heading 1 $$@&5<A@<Default Paragraph Font&>@&Title$5,@,Header  !, @,Footer  !&)@!& Page NumberHC@2HBody Text Indentx ;}} "(J- 47;8$',259>DG2 Z <0b~"$%n(*+,$./x2234D6;8 "#%&)*+-./034678;<=?@ABEF B)43;8!(1:C!'ams;GM}  COU     s  H T Z  ^ j p 4@F'-lx~DPV:FL".4p|"(9EK FRX<HN bnt 6BH;FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF!!9Text2Text5Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Text19Text20Text21Text22Text23Text24Text25Text26Text27Text28Text29Text30Text31Text32Text33Text34Text35Text36Text37Text38Text39Text40Text41Text42Text43Text44Text45Text46Text47Text48Text49Text50Text51Text52Text53Text54Text55Text56Text57Text58Text59Text60b<~ D  t I _ 5mE;#q:GLc <  !"#$%&'()*+,-./012345678(tNV   [  q G.WM5)LYOu< L9<L9<ewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhiteOC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of AAS-23 (NJDOH).asdewhite2\\dhss-ha-99\home\ewhite\FORMS\AAS-23 (NJDOH).dotewhite2\\dhss-ha-99\home\ewhite\FORMS\AAS-23 (NJDOH).dotewhite2\\dhss-ha-99\home\ewhite\FORMS\AAS-23 (NJDOH).dotewhite)\\dhss-ha-99\home\ewhite\FORMS\AAS-23.dot@"'""0 ;PP @PP P PPPPPPPP P"P$P&P(P*P,P.P0P2P4P6Pp@G:Ax Times New Roman5Symbol3& :Cx Arial"qh:g!!_ .ٖ4$r0d9AAS-23, Pediatric Medical Day Care Inspection InformationPAAS-23, assessment and survey, pediatric medical day care inspection informationewhiteewhiteOh+'0Th x    :AAS-23, Pediatric Medical Day Care Inspection InformationdAS-ewhite QAAS-23, assessment and survey, pediatric medical day care inspection informationc AAS-23.doteewhited7hiMicrosoft Word 8.0a@vE @z@Գ~@z՜.+,D՜.+,h$ hp  NJDOH . 1 :AAS-23, Pediatric Medical Day Care Inspection Information Title 6> _PID_GUIDAN{E65AB540-B173-11D9-B1CE-00105A219C26}  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHJKLMNOPQRSTUVXYZ[\]^_`abcefghijkmnopqrsvRoot Entry Fa~ zxData I>1TableWKWordDocument%SummaryInformation(dDocumentSummaryInformation8lCompObjjObjectPool z z  FMicrosoft Word Document MSWordDocWord.Document.89q