Health Facilities

The Division of Health Facility Survey and Field Operations conducts license and Medicare certification inspections of the state's healthcare facilities. It also monitors the financial status of the general, acute care hospitals and responds to complaints from the public about acute care facilities. This report describes the Division's regulatory process and summarizes the inspection and oversight results.

Oversight of Acute Care Health Care Facilities

Health care facilities in New Jersey are licensed and regulated by the State. They may also be certified and inspected by a number of public and private agencies at the state and federal levels. These agencies have separate, sometimes overlapping, responsibilities.

The New Jersey Department of Health regulates health facilities. The regulations and procedures promulgated by the Department are intended to promote the health, safety and welfare of patients/residents in New Jersey health care facilities.

The Department also collects financial and utilization data from the State's 71 hospitals to monitor their financial status, availability of beds, service patterns, and other issues pertinent to the development of public policy and distribution of subsidies to hospitals serving low income, uninsured persons.

To evaluate compliance with regulatory standards, the Department conducts comprehensive facility inspections and also responds to specific complaints. During these inspections, state survey teams evaluate the compliance of facility premises, equipment, personnel, policies and procedures with state licensure regulations.

In addition to these surveys, the Department also conducts periodic inspections under contract to the U.S. Department of Health and Human Services to evaluate facility compliance with federal regulations and with Medicare conditions of participation or certification.

Many health care facilities also undergo a voluntary inspection periodically by an accreditation organization.

In addition to the facilities themselves, health care professionals who work in health care facilities are also licensed or certified by state agencies.

How to file a complaint

New Jersey State License Inspection Surveys

New Jersey's acute care facility licensure inspection surveys may take from one to multiple days, depending on the type of survey and size and type of institution. During the survey which a multidisciplinary inspection team - comprised of nurses, pharmacists, life safety code inspector and other professionals, as needed - evaluates all aspects of patient care and facility procedures and practices. Specific areas of care assessed during the survey include access, continuity and comprehensiveness of patient care; patient rights; coordination of services; infection control; safety of environment; staffing levels; professionalism of caregivers; quality assurance; pharmacy, emergency department services and physical plant.

The Department's evaluation of patient care facilities may include an inspection of medical records, observation of patient care, inspection of all areas of the physical plant, and interviews with patients or other individuals.

Complaint investigations are also generally shorter in duration than licensure surveys and focus primarily on those areas of patient care alleged to be faulty. Complaints may be investigated with an on-site inspection or through telephone interviews and a review of relevant patient and health care facility records. If, during the course of a complaint investigation, additional problems are uncovered, a full on-site licensure survey may be conducted.

At the conclusion of each survey, a preliminary summary of the Department's findings is shared verbally with the facility's administrative staff in an exit interview. A detailed written survey report is forwarded later to the facility. If the Department determines that the facility failed to comply with all applicable standards, it will be cited for the specific deficiencies.

Deficiencies and Plans of Correction

A deficiency is a determination by the Department that a health care facility has violated one or more specific state or federal standards. Deficiencies may be cited as a result of an on-site inspection or evaluation of written reports or documentation.

Health care facilities have the opportunity to dispute survey deficiency findings. They may request an opportunity to discuss the accuracy of survey findings, or the regulatory interpretation supporting the finding, during the course of a survey or during the exit interview. After the survey is completed and the deficiency report is issued, a facility may request an informal meeting with Department supervisory staff who were not directly involved in the survey.

Plans of correction are reviewed and, when acceptable, approved by the Department. If a plan is not accepted, the health care facility must revise and submit a new plan. In situations where current conditions at the facility pose a serious risk to the health and safety of patients, the Department may demand or initiate immediate corrective actions.

Once the Department has accepted facility's plan of correction, it designates the complete survey report and the accepted a plan of correction as public documents, subject to the New Jersey Open Public Records Act (N.J.S. 47:1A-1 et seq.). The Open Public Records Act provides standards governing the processing of requests from the public to review or copy government records. Individuals requesting copies of survey reports and/or acute care facility plans of correction, edited to ensure patient confidentiality, or scheduling an on-site review of these documents at the offices of the Department of Health' Division of Health Facilities Evaluation and Licensing must complete a Government Records Request Form.