New Jersey Department of Health

Division of Health Facility Survey and Field Operations

AFFIDAVIT OF COMPLIANCE

WITH NEW JERSEY LICENSURE STANDARDS FOR

PEDIATRIC MEDICAL DAY CARE FACILITIES

I,	, Administrator of
, hereby state

that to the best of my personal knowledge and understanding, the facility is in substantial compliance with the mandatory standards enumerated in this statement except as follows:

Describe exceptions to compliance:

I acknowledge that I must provide prompt notification to the Director, Division of Health Facility Survey and Field Operations, at the address below, should I become aware of any substantial changes in compliance:

Director, Division of Health Facility Survey and Field Operations

New Jersey Department of Health

PO Box 367

Trenton, NJ 08625-0367

I understand that a willfully false statement could result in enforcement penalties.

Signature of Administrator	Date

New Jersey Department of Health

Division of Health Facility Survey and Field Operations

PEDIATRIC MEDICAL DAY CARE FACILITIES

MANDATORY STANDARDS COVERED BY THIS AFFIDAVIT

(ALL REFERENCES ARE TO N.J.A.C. 8:43J)

3.3

3.4

3.5

3.6

3.7

3.10

3.11

3.12

3.13

4.1

4.2

5.1

6.1

6.2

6.3

7.2

7.3

7.4

7.5

7.6

8.1

8.3

8.4

8.7

9.1

9.2

9.3

9.4

10.1

10.2

10.3

10.4

11.2

12.1

12.2

13.16

14.1

14.3

14.4

15.1

15.2

15.3

15.4

15.5

15.6

15.8

15.9

16.1

16.2

16.3

17.1

17.2

17.3

Signature of Administrator	Date

New Jersey Department of Health

Division of Health Facility Survey and Field Operations

ADDENDUM TO AFFIDAVIT OF COMPLIANCE

FOR PEDIATRIC MEDICAL DAY CARE FACILITIES

This addendum lists the topics of all New Jersey Pediatric Medical Day Care Facilities licensure standards referenced in the Administrator’s Affidavit of Compliance. This addendum may be helpful to the administrator in determining compliance.

3.2	Qualifications of Administrator
3.4	Administrative policies and procedures
3.5	Childcare policies and procedures
3.6	Mandatory notification
3.7	Financial arrangements
3.10	Interpretation services
3.11	Notification of parent
3.12	General record policies
3.13	Required documents
4.1	Policies and procedures regarding the rights of children
4.2	Rights of each child
5.1	Pre-admission assessment
6.1	General services provided
6.2	General staffing requirements
6.3	Personnel
7.2	Qualifications of nursing director
7.3	Responsibilities of the nursing director
7.4	Qualifications of nursing staff
7.5	Provision of nursing services
7.6	Responsibilities of licensed nursing personnel
8.1	Provision of medical services
8.3	Medical director’s responsibilities
8.4	Role of primary health care providers
8.7	Medical emergencies
9.1	Designation and responsibilities of consultant pharmacist
9.2	Medication administration policies and procedures
New Jersey Department of Health

Division of Health Facility Survey and Field Operations

ADDENDUM TO AFFIDAVIT OF COMPLIANCE

FOR PEDIATRIC MEDICAL DAY CARE FACILITIES

(Continued)

9.3	Pharmacy reporting policies and procedures
9.4	Pharmacy control policies and procedures
10.1	General requirements for dietary services
10.2	Qualification of the dietitian
10.3	Qualifications of food service supervisor
10.4	Administrator’s responsibilities for dietary services
11.2	Rehabilitation services
12.1	Qualifications of social workers
12.2	Provision of social work services
13.16	Emergency plans and procedures
14.1	Maintenance of medical records
14.3	Contents of medical records
14.4	Medical records policies and procedures
15.1	Administrator’s responsibilities for infection control
15.2	Child immunization
15.3	Infection control policies and procedures
15.4	Employee Mantoux
15.5	Employee health history and examinations
15.6	Regulated medical waste
15.8	Housekeeping
15.9	Pediatric medical day care facility environment
16.1	Transportation services
16.2	Transportation staffing levels
16.3	Security and accountability during transportation
17.1	Quality improvement program
17.2	Use of restraints
17.3	Staff development

AAS-84

AUG 15	Page 4 of 4 Pages.

AAS-84, Affidavit of Compliance with NJ Licensure Standards for Pediatric Medical Day Care Facilities

affidavit of compliance, AAS-84, AAS, pediatric medical day care facilities, licensure standards, health facilities evaluation and Licensing, HFEL

ewhite

2012-03-13

NJDOH