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Incident Reporting New Jersey 20-22181 1 Hour Back to Course Index

 

 


    

INCIDENT REPORTING

 

 

  

Introduction

In a health care facility, such as a hospital, recovery center, nursing home, or assisted living, an incident report is a form filled out to record details of an unusual event that occurs at the facility, such as an injury to a patient or client.

images-2What is the Purpose of an Incident Report?

Incident reports should not be used to blame or punish staff but rather to learn areas of concern and better client/patient safety approaches. 

Incident Reports are used to communicate information to others and document significant events within individual records, as required by state standards.  People often use the information obtained from incident reports when formulating plans or profiles, to develop support strategies, and when making decisions.

Consequently, the content of the Incident Report needs to reflect clear information in a factual, unbiased manner to avoid passing along opinions and judgments.  What a staff person has to say concerning an incident is essential to others trying to understand what has happened and why it occurred.

Staff should re-read the reports they have written before submitting them to ensure that they are legible, have been completed correctly and that the report honestly states what the writer intended to convey.  All sections of the report must be completed (avoid leaving blanks).  Incident Reports are legal documents that the individual may view, their guardian, designee, or legal representative, and may be utilized by courts.  Be sure to use the full name of staff or providers when referencing them in a report; the initials of staff/providers are insufficient.

imgres-7When Should An Incident Report Be Written?

Staff should prepare an incident report to document unusual or significant events or emergencies involving individuals who receive services or support.  Examples of such events include but are not limited to the following:

imgres-1

 

 

 

  • Injury to an individual
  • Aggressive behavior directed at others
  • Self-abusive behavior
  • Endangering or threatening others
  • Severe illness or hospitalization
  • Imminent death or death
  • Property destruction
  • Serious disruptive situation while in the community
  • Illegal or unusual problematic behavior
  • Being victimized by another individual who receives services
  • Any incident involving the police, fire department, ambulance, etc.
  • Any time someone has physically intervened with an individual when such intervention is not in accordance with an approved behavioral treatment plan
  • Any time an individual is involved in an automobile accident while receiving services
  • Being a victim of a crime reported to a law enforcement agency;
  • Being incarcerated (in jail or prison for at least one overnight stay);
  • Others should note significant accomplishments or other positive changes.

If you are unsure whether to complete an incident report, complete one.

If an incident involves the behavior/injury of more than one individual, separate reports are necessary.  Ensure you do not include confidential information about others on an individual’s report.

images-1Writing an Incident Report

First and most important, don’t delay.  Obtain the proper documentation as soon as possible and fill out the details as clearly as you can remember.  Make sure to outline the following:

-The name and address of the organization.

-The concern in one or two pages, including:

Who – Who was involved in the incident?

What – What exactly happened?

When – When the event occurred; note the specific date and time.imgres-5

Where – Where did the situation occur?

How – How was the situation or event handled?

Safety – Also, if the situation warrants it, implement a safety plan and note what you did to keep everyone safe.

 

Each person writing an Incident Report should consider the following:

Cause of Incident:

Make every attempt to provide only factual information.  Even if the actual cause of an incident remains unknown after you have attempted to determine it, you should give as much information as you have concerning what happened before the event/during the event, as this may provide a clue to the reader.  If you did not witness the incident or event, you might still write an Incident Report; however, be sure to state that the information is based on what was reported to you and by whom it was reported.

Language:

Describe the incident in concrete, behavioral terms.  Do not use generalities…be specific.  Review your report to verify that you have not used judgmental terminology or left unanswered questions.  It is best to prepare an Incident Report immediately following the incident while the facts are still clear.  However, staff may still be emotionally involved at that time, so it may be helpful to have another person review the report before it is submitted.

Please remember that your description of the incident is what other people will rely on to obtain information concerning the individual and the incident.  Your report mustn’t convey negative images of you or the individual when a more neutral one should be given.  Examples: stating someone stole food from the refrigerator when the individual took food out of the fridge.  Your report can influence others, so it must be adequately prepared and provides a factual accounting of the incident.

Reliability of your observation:

Would other people seeing or hearing the incident agree with your written account?  If another person was involved in the incident or witnessed it, consult with that person to ensure that the report concurs with that person’s observations.  When writing your report, use specific terms and clearly describe the behavior that occurred.  For example, don’t use generalities such as aggressive/upset/agitated.  State the behavior you observed that made you believe the person was aggressive, upset, or agitated.

Objectivity: When writing your report, be sure you have not allowed an earlier situation or prior information to influence your perception of the current incident.  You are writing your report as a recorder, not as a judge.  Consequently, ensure your report is free from judgmental statements, sarcasm, or condescending comments.

 

imgres-9New Jersey Administrative Code Regarding Incident Reporting 

NJ Admin.  Code § 8:43E-10.6 states that a health care facility should report to the Department or, in the case of a State psychiatric hospital, to the Department of Human Services every preventable severe adverse event that occurs in the facility.  Please note the complete code is at the bottom of this lesson.

Suppose a facility does not have all the information required for a complete report, as noted below.  In that case, the facility should submit a partial report on a severe preventable adverse event no later than five business days after the facility discovers the event’s occurrence.  They should then update this initial partial report as soon as the other information required becomes available.
  If a facility finds an event subject to mandatory reporting and occurred in a different facility, the facility that discovers the event should notify the Department within the time specified above but should be exempt from the requirement to perform a root cause analysis.
  If the facility that discovers the event knows the identity of the facility where the event occurred, the reporting facility shall include this information in its notice to the Department.
  A facility should submit this form which consists of the following information: 
1.  The facility name, license number, address, and the name and title of the person submitting the report;
2.  A brief description of the event, including the impact on the patient or resident;
3.  The date and time the event occurred;
4.  Where the patient or resident was when the event occurred;
5.  The date and time the facility became aware of the event;
6.  How the event was discovered;
7.  The patient or resident’s billing and medical record number, admission date or ambulatory encounter, demographic information, and, for inpatients, whether the patient was admitted directly, by transfer, or through the emergency department;
8.  The type of serious preventable adverse event, using the categories provided at (e) through (j) below;
9.  The facility took immediate corrective actions to eliminate or reduce the event’s adverse impact and prevent future similar events;
10.  If the facility previously submitted a partial report on the event under (b)1 above, the report number assigned to the prior report by the Department; and
11.  If the facility previously submitted a report on the event containing incorrect information, the report number assigned to the previous report by the Department and the correct information.
  Facilities should report the information required utilizing telefacsimile using the form linked above.  
  • The telefacsimile number to which facilities are to submit event reports to the Department is (609) 530-4850.
  • The telephone number facilities may use to obtain additional information concerning the event report and form is (609) 530-7473.
A facility should report events not explicitly listed that meet the definition of a serious preventable adverse event.  Still, the following are examples of events that might, in a worst-case scenario, occur at a recovery center.  A more exhaustive list is below the lesson in the complete code, and please view the list in its entirety below the lesson.

Patient or resident care management-related events include but are not limited to:

  • Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a medication error (such as errors involving the wrong drug, wrong dose, wrong patient or resident, wrong time, wrong rate, wrong preparation, or wrong route of administration);
  • Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge associated with hypoglycemia, the onset of which occurs while the patient or resident is being cared for in the health care facility;
  • Stage III or IV pressure ulcers are acquired after admission of the patient or resident to a health care facility.

 

Environmental events include, but are not limited to:

  • Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with an electric shock while being cared for in a health care facility
  • Incidents in which a line designated for oxygen or other gas to be delivered to a patient or resident contains the wrong gas or is contaminated by toxic substances and results in patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge.
  • Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a burn incurred from any source while in a health care facility;
  • Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a fall while in a health care facility; and
  • Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days, or in the case of a non-residential health care facility, still present at discharge, associated with the use of restraints or bedrails while in a health care facility.

 

Product or medical device-related events include, but are not limited to:

  • Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with the use of generally detectable contaminated drugs, medical devices, or biologics provided by the health care facility, regardless of the source of contamination or product.
  • Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days, or in the case of a non-residential health care facility, still present at discharge, associated with the use or part of a medical device in patient or resident care in which the device is used or parts other than as intended, including, but not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators;
Other events include, but are not limited to:
  • Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days associated with patient or resident elopement; and

Patient or resident suicide or attempted suicide while in a health care facility.

The above does not include deaths or disabilities resulting from self-inflicted injuries that were the reason for admission to the health care facility.

A facility should submit to the Department a root cause analysis of every preventable severe adverse event subject to mandatory reporting no later than 45 days after the submission of the initial report of the event on this form.

The mailing address to which facilities are to submit reports to the Department is:

Patient Safety Initiative
Health Care Quality Assessment
Department of Health and Senior Services
25 Scotch Road, Suite 10
Ewing, NJ 08628-2500

State-operated psychiatric hospitals shall comply with the requirements for submission of RCAs outlined in the policies and procedures of the Department of Human Services.

The root cause analysis performed by a facility in response to a report of an occurrence of a serious preventable adverse event may vary in substance and complexity, depending on the nature of the facility and the circumstance involved, but shall include the following general components:

1.  A description of the event, including when, where, and how, and the adverse outcome for the patient or resident;
2.  An analysis of why the event happened includes an analysis not only of the event’s direct cause(s) but also of potential underlying causes related to the design or operation of facility systems;
3.  The corrective action(s) taken for those patients or residents affected by the event;
4.  The method for identifying other patients or residents or settings having the potential to be affected by the same event and the corrective action(s) to be taken;
5.  The measures to be put into place or systematic changes needed to reduce the likelihood of similar events in the future; and
6.  How the corrective action(s) will be monitored to assess their impact.

The Department shall:

1.  Review an RCA to determine whether it satisfies the criteria in (l) above; and 2Return an RCA that does not meet the requirements in (l) above to the facility for revision and shall not consider the RCA complete until the Department determines that the RCA meets the criteria in (l) above.

The Department anticipates the development of an Internet web-based electronic reporting system, but in the interim, shall require facilities to submit event reports under (d) above and to submit root cause analyses under (k) above.

The Department shall provide notice to facilities on the reporting medium to be used, including telephone and facsimile numbers, e-mail addresses, and web addresses.

Single copies of the forms provided in subchapter Appendices A and B, suitable for photocopying, are available upon request to the Patient Safety Initiative at the address outlined in subsection (d) above and are also available for download from the Department’s Forms web page at http://web.doh.state.nj.us/forms and also from the program’s web page at http://www.nj.gov/health/hcqo/ps. 

images-9The Joint Commission on the Accreditation of Healthcare Organizations

  • In 1995, hospital-based surveillance was mandated by the Joint Commission because of the perception that incidents resulting in harm were frequently occurring.  The Joint Commission employs the term sentinel event instead of a critical incident and defines it as follows:
  • An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase “or the risk thereof” has any process variation for which a recurrence would carry a significant chance of a severe adverse outcome.
  • The Joint Commission created a Sentinel Event Database as one component of its Sentinel Event Policy.  The database accepts voluntary reports of sentinel events from member institutions, patients and families, and the press.  The particulars of the reporting process are left to the member healthcare organizations.  The Joint Commission also mandates that accredited hospitals perform root cause analysis of important sentinel events.  Data on sentinel events are collated, analyzed, and shared through a Web site, an online publication, and its newsletter, Sentinel Event Perspectives.

images-10How Do You Submit An Incident Report

  • Your organization should have its form to use for incident reporting.  If not, create one with the required information included:
  • Organization Name
  • Organization Address
  • Reporters Name
  • Incident Date
  • Incident Narrative

The preferred method for submitting a patient safety concern to The Joint Commission is through our online submission form, as it allows for a more direct, timely receipt and review of your concerns.

By policy, The Joint Commission cannot accept copies of medical records, photos, billing invoices, or other related personal information.  These documents will be shredded upon receipt.

 

Conclusion

Patient safety is a priority, and patient care documentation holds the healthcare team members to professional accountability and demonstrates the quality of care you have given.  When the unforeseen happens, and sometimes it does, reporting incidents can help identify potential issues.  We must focus on a blameless reporting atmosphere where healthcare providers feel safe making reports.  Speak up if you have questions regarding your workplace or see areas of concern.

NJ Admin.  Code § 8:43E-10.6

(a) A health care facility shall report to the Department or, in the case of a State psychiatric hospital, to the Department of Human Services every preventable severe adverse event that occurs in the facility.

1.  The Department shall deem Medicare or Medicaid nursing homes that are otherwise compliant with applicable Federal reporting statutes and regulations, as well as with 52:27G-7.1 and NJAC 8:39, to be in compliance with (a) above, and shall not require facilities deemed compliant to file reports by this section.
2.  Adult and pediatric day health care services facilities and facilities that provide home-based services, that is, home health care facilities, hospice facilities, assisted living residences, comprehensive personal care homes, and assisted living programs, shall report only those preventable severe adverse events that are within the control of the facility or directly caused by, or related to, services of the facility.
  i.  Concerning preventable severe adverse events related to health care services provided directly to residents of an assisted living residence, comprehensive personal care home, or assisted living program by another health care facility, the facility directly providing the service shall report the event to the Department.

(b) A facility shall notify the Department, or the Department of Human Services, as applicable, of the occurrence of an event subject to mandatory reporting, under (a) above no later than five business days after the facility discovers the occurrence of the event.

1.  If a facility does not have all the information required under (c) below for a complete report, the facility shall submit a partial report on a severe preventable adverse event within the time specified in (b) above and shall then update this initial partial report as soon as the other information required under (c) below becomes available.
2.  If a facility discovers an event subject to mandatory reporting under (a) above and the event occurred in a different facility, such as the erroneous retention of an object in the body after surgery, the facility that discovers the event shall notify the Department within the time specified in (b) above, but shall be exempt from the requirement to perform a root cause analysis of the event.
  i.  If the facility that discovers the event knows the identity of the facility where the event occurred, the reporting facility shall include this information in its notice to the Department.

(c) A facility shall submit, under (a) above, the form provided in subchapter Appendix A, incorporated herein by reference, which includes the following information:

1.  The facility name, license number, and address, and the name and title of the person submitting the report;
2.  A brief description of the event, including the impact on the patient or resident;
3.  The date and time the event occurred;
4.  Where the patient or resident was when the event occurred;
5.  The date and time the facility became aware of the event;
6.  How the event was discovered;
7.  The patient or resident’s billing and medical record number, admission date or ambulatory encounter, demographic information, and, for inpatients, whether the patient was admitted directly, by transfer, or through the emergency department;
8.  The type of serious preventable adverse event, using the categories provided at (e) through (j) below;
9.  The facility took immediate corrective actions to eliminate or reduce the event’s adverse impact and prevent future similar events;
10.  If the facility previously submitted a partial report on the event under (b)1 above, the report number assigned to the prior report by the Department; and
11.  If the facility previously submitted a report on the event containing incorrect information, the report number assigned to the previous report by the Department and the correct information.

(d) Facilities shall report the information required under (c) above utilizing telefacsimile using the form provided in subchapter Appendix A.

1.  The telefacsimile number to which facilities are to submit event reports to the Department is (609) 530-4850.
2.  The telephone number facilities may use to obtain additional information concerning the event report and form is (609) 530-7473.

(e) Types of preventable severe adverse events include but are not limited to, the categories listed in (f) through (j) below.

1.  A facility shall report in the appropriate category events that are not explicitly listed that meet the definition of a severe preventable adverse event.
2.  Based on the types of services a facility provides, some categories may not be applicable; for example, surgical events could only occur at facilities that perform surgical procedures.
3.  For purposes of this section, “associated with” means that it is reasonable to assume initially that the preventable severe adverse event was due to the referenced course of care; however, further investigation or a root cause analysis of the event may be needed to confirm or refute the presumed relationship.

(f) Patient or resident care management-related events include, but are not limited to:

1.  Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a medication error (such as errors involving the wrong drug, wrong dose, wrong patient or resident, wrong time, wrong rate, wrong preparation, or wrong route of administration);
2.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products;
3.  Maternal death, loss of body part, disability, or loss of bodily function lasting more than seven days or still present at discharge associated with labor or delivery in a low-risk pregnancy while in a health care facility;
4.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge associated with hypoglycemia, the onset of which occurs while the patient or resident is being cared for in the health care facility;
5.  Death or kernicterus associated with failure to identify and treat hyperbilirubinemia in a neonate while the neonate is a patient in a health care facility;
6.  Stage III or IV pressure ulcers are acquired after admission of the patient or resident to a health care facility.
  i.  Progression from stage II to stage III is excluded from the meaning of (f)6 above, provided that stage II was recognized and documented upon admission; and
7.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with spinal manipulative therapy provided in a health care facility.

(g) Environmental events include, but are not limited to:

1.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with an electric shock while being cared for in a health care facility.
  i.  Events involving planned treatments, such as electric countershock (heart stimulation) or elective cardioversion, are excluded from the meaning of (g)1 above;
2.  Incidents in which a line designated for oxygen or other gas to be delivered to a patient or resident contains the wrong gas or is contaminated by toxic substances and results in patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge;
3.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a burn incurred from any source while in a health care facility;
4.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with a fall while in a health care facility; and
5.  Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days, or in the case of a non-residential health care facility, still present at discharge, associated with the use of restraints or bedrails while in a health care facility.

(h) Product or medical device-related events include, but are not limited to:

1.  Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with the use of generally detectable contaminated drugs, medical devices, or biologics provided by the health care facility, regardless of the source of contamination or product.
  i.  For purposes of (h)1 above, “generally detectable” means capable of being observed with the naked eye or with the use of detection devices in general use;
2.  Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days, or in the case of a non-residential health care facility, still present at discharge, associated with the use or function of a medical device in patient or resident care in which the device is used or functions other than as intended, including, but not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators;
3.  Intravascular air embolism occurs while the patient or resident is in the facility.
  i.  Paragraph (h)3 above does not include deaths or disability associated with neurosurgical procedures known to present a high risk of intravascular air embolism; and 4Patient or resident death, loss of body part, disability, or loss of bodily function lasting more than seven days or, in the case of a non-residential health care facility, still present at discharge, associated with the use of a new or reprocessed single-use device in patient or resident care in which the device is used or functions other than as intended.

(i) Surgery-related events include, but are not limited to:

1.  Surgery initiated (whether or not completed) on a patient that is not consistent with the patient’s documented informed consent, including, but not limited to, a surgical procedure intended for a patient “A” that is initiated on the wrong body part of patient “A,” and a surgical procedure intended for another patient of the facility, but initiated on patient “A”.
i.  Surgery-related events exclude emergent situations during surgery and to which exigency precludes obtaining informed consent;
2.  Retention of a foreign object in a patient after surgery, excluding objects intentionally implanted as part of a planned intervention, objects present before surgery that was intentionally retained and retained broken microneedles; and
3.  Intraoperative or postoperative (that is, within 24 hours) coma, death, or other preventable severe adverse event in any patient of an ambulatory surgery facility, in any hospital same-day surgery patient, or in any American Society of Anesthesiologists (ASA) Class I hospital inpatient;
 i.  Paragraph (i)3 above includes all patient deaths, comas, or other preventable severe adverse events in situations where anesthesia was administered, regardless of whether the planned surgical procedure was carried out.

(j) Patient or resident protection-related events include, but are not limited to:

1.  Discharge of an infant to the wrong person, excluding patient or resident abductions covered under NJAC 8:34E-10.11(b);
2.  Patient or resident death, loss of body part, disability or loss of bodily function lasting more than seven days associated with patient or resident elopement; and
3.  Patient or resident suicide or attempted suicide while in a health care facility.
  i.  Paragraph (j)3 above does not include deaths or disabilities resulting from self-inflicted injuries that were the reason for admission to the health care facility.

(k) A facility shall submit to the Department a root cause analysis of every preventable severe adverse event subject to mandatory reporting under (a) above no later than 45 days after the submission of the initial report of the event using the form provided at subchapter Appendix B, incorporated herein by reference.

1.  The mailing address to which facilities are to submit reports to the Department is:

Patient Safety Initiative

Health Care Quality Assessment

Department of Health and Senior Services

25 Scotch Road, Suite 10

Ewing, NJ 08628-2500

2.  The Department shall deem Medicare or Medicaid nursing homes that are otherwise compliant with applicable Federal reporting statutes and regulations, and with 52:27G-7.1 and NJAC 8:39, to be in compliance with (k) above, and shall not require facilities deemed compliant to file root cause analyses by this section.
3.  State-operated psychiatric hospitals shall comply with the requirements for submission of RCAs outlined in policies and procedures of the Department of Human Services.

(l) The root cause analysis performed by a facility in response to a report of an occurrence of a serious preventable adverse event may vary in substance and complexity, depending on the nature of the facility and the circumstance involved, but shall include the following general components:

1.  A description of the event, including when, where, and how the event occurred and the adverse outcome for the patient or resident;
2.  An analysis of why the event happened includes an analysis not only of the event’s direct cause(s) but also of potential underlying causes related to the design or operation of facility systems;
3.  The corrective action(s) taken for those patients or residents affected by the event;
4.  The method for identifying other patients or residents or settings having the potential to be affected by the same event and the corrective action(s) to be taken;
5.  The measures to be put into place or systematic changes needed to reduce the likelihood of similar events in the future; and
6.  How the corrective action(s) will be monitored to assess their impact.

(m) The Department shall:

1.  Review an RCA to determine whether it satisfies the criteria in (l) above; and 2Return an RCA that does not meet the requirements in (l) above to the facility for revision and shall not consider the RCA complete until the Department determines that the RCA meets the criteria in (l) above.

(n) The Department anticipates the development of an Internet web-based electronic reporting system, but in the interim, shall require facilities to submit event reports under (d) above and to submit root cause analyses under (k) above.

1.  The Department shall provide notice to facilities on the reporting medium to be used, including telephone and facsimile numbers, e-mail addresses, and web addresses.

(o) Single copies of the forms provided in subchapter Appendices A and B, suitable for photocopying, are available upon request to the Patient Safety Initiative at the address outlined in subsection (d) above and are also available for download from the Department’s Forms web page at http://web.doh.state.nj.us/forms and also from the program’s web page at http://www.nj.gov/health/hcqo/ps.

NJ Admin.  Code § 8:43E-10.6