THE WEEK OF OCTOBER 3, 2022

WELCOME TO THE PULSE!

 

Your Editor developed The PULSE based on comments and suggestions from the membership and with your input in mind.


For it to reach its full potential, your contributions to content are needed.

Please send your questions and comments to the Editor, specific to these recurring colmns: 

  • SURVEY SNIPPETS
  • WHAT’S ON YOUR MIND
  • WE HEAR YOU


NOTHING HAS CHANGED!


For ASCs, nothing has changed. Until NJDOH issues a revision that takes CDC into consideration, you abide by ED 20-2016 revised as it is written. 

As well EO 294 which clarifies ‘up to date’ as fully vaccinated and only one booster.

You are an ASC, this is what you go by, nothing else. Hospitals, Medical Practices (they have their own AO from DCA) are different.

For now ED 20-016 revised is your guidance.

SURVEY SNIPPETS

Shared information from our member centers about their surveys

(Please share with us your experiences, questions and comments. No names or centers will be printed; everything is anonymous.) E-mail to: jshanton@jssurgctr.com.

Allergy documentation errors is a Life Safety and Quality of Care concern that surveyors are scrutinizing. It is a trending issue that I see in the medical records review performed for our ASC clients. The ability of patients to complete pre-op questions online is timesaving and provides legible documentation of information provided by patients. 

Regardless of electronic entry, it does not replace the need for careful HCP to patient review in every required area of the ASC. Patients forget; changes occur. Irrespective of your accrediting agency, the requirement for allergy documentation is evidence that patients were asked about their allergies, sensitivities, and reactions, and that they were recorded in a prominent and consistently defined location and updated on every visit (AAAHC).


Claire Cerame, MSN, RN

Positive Outcomes

ccerame@positiveoutcomesqi.COM


All organizations that are accredited by AAAHC must notify AAAHC in writing of significant organizational, ownership, operational, or quality of care events, including interruption in delivery of health care, criminal indictment, guilty plea or verdict in a criminal proceeding (other than a traffic violation) directly or indirectly involving the organization or any of its officers, administrators, physicians/health care professionals, or staff within their role in the organization. Also, any change or event that negatively affects public perception of the accredited organization or AAAHC must also be reported. This MUST be done within 15 days or the change.

 

This is a common citation during a survey. Changes occurred, but AAAHC was never notified. First, the organization should complete and submit a Change Notification Form. Maintain a copy of all correspondence with AAAHC and have it available for review by the surveyors.


AAAHC will review the submission and determine whether the current accreditation term will be maintained and what the next steps will be.


If in doubt about what needs to be reported, go to https://www.aaahc.org/accreditation/accreditation-general-information/organizational-changes/. This link is active and provides additional information. Cut and paste it into your browser. 


Ann Geier, MS, RN, CNOR(E), CASC

Ambulatory Healthcare Strategies

Chief Nursing Officer

AGeier@AH-Strategies.com

843-303-0008

Visit the Ambulatory Healthcare table at the 10/19 Quarterly Membership Meeting


Here are a few common unknowns that can catch a surveyor’s eye regarding monthly generator testing. Monthly tests must be performed no less than 20 days prior, or 40 days after the previous monthly test, and they must be run for a full 30 minutes. Also, if your generator is able to meet the minimum exhaust gas temperature as recommended by the manufacturer or a load of not less than 30% of the nameplate rating can be applied, then the 90-minute annual test will no longer be required. (NFPA 110-2010, Sections *8.4.2 through 8.4.2.3).


Anthony Riehl CFI, CESI

Healthcare Life Safety Consultants

anthony@hisconsultantsllc.com


Red is good/Orange is bad!

Penetrations of the fire separation barrier are the #1 finding among life safety surveys. It is important to maintain an intact separation between occupancies, without any penetration. Sealing small penetrations around cables is something that can be done using a special rated caulk. The red caulk expands when exposed to heat and will not burn for 4 hours. DO NOT use orange foam sold at stores like Home Depot. Orange fire block foam is not flame resistant, emits a noxious gas and burns when exposed to fire.

exposed to fire.


Debbie Comerford

Life Safety Partners

debbie@ascqs.com

Visit the Life Safety Partners table at the 8/19 Quarterly Membership Meeting 


THE PHARMACY CABINET

Stay current with the latest Pharmacy news

Second in a series of topics focused on the accountability of Controlled Drug Substances


Purchasing and receiving controlled drug substances


Sometimes being a good manager means being part detective. If you feel a little like Sherlock Holmes some days, you're not alone!

Especially when it comes to preventing and battling drug diversion in the surgical setting. I'm constantly working with clients to prevent diversion. Today I'm going to share my BEST weapon in the anti-diversion arsenal... auditing.


THE WHOLESALER REPORT


First, ensure the same individual who purchases controlled drugs is not the same individual who receives the drugs and inventories all the controlled substances. Separating these activities is best practice. Did you know that your wholesaler can provide you with a full purchasing report of all your controlled substances for a specific period? For example, if you'd like to audit the controlled substances signed into your inventory for the first 3 months of 2022, your wholesaler can provide a report of all the drugs you received in that time period. Even if you're already tracking receipt of controlled substances purchased via DEA 222 form or CSOS, that doesn't account for your CIII-CV drugs being received. Performing this audit ensures that when the drugs arrive at your facility, they're making it into your narcotic cabinet. Auditing controlled substance purchases this way alleviates any burden or liability from individuals in the event of missing controlled substances. We recommend assigning this audit to an administrator or one level above the purchaser or receiver of controlled substances.


Reviewing the wholesaler report on a continual basis is best practice.

John Karwoski, RPh, MBA, President and Founder

www.jdjconsulting.net

Visit the JDJ table at the 10/19 Quarterly Meeting

WHAT'S ON YOUR MIND?

Questions from our members

(Please forward any questions you may have, about anything!) E-mail to: jshanton@jssurgctr.com

Q:  Must an anesthesia provider assess the patient post-surgical prior to discharge?  Can a post-surgical assessment be performed by nursing staff?


A: There are two parts to the discharge process which is what may be confusing you.


The patient must be assessed by anesthesia after recovery and prior to discharge.

State Reg NJ 8:43A-12.8 (f): ‘A discharge note shall be entered into the patients record by an anesthesia team member prior to discharge from the facility’


There is also a discharge summary, if you will, that is required and can be done by nursing staff.


See from John Goehle:


The patient must be assessed by a physician or CRNA for recovery from anesthesia. They also have to be assessed for their ability to go home, which can be done by a RN.


Q: Does the prescription for a controlled substance need to be handwritten and include the home address?


A: There is no wording discussing a requirement for a handwritten script; however, they need to be written on an official NJBP or may be sent electronically, and the home address needs to be included.


JDJ Consulting

Visit the JDJ table at the 10/19 Quarterly Meeting


Q: Our shareholders are interested in adding another OR if possible. Can you please advise me if there is still a moratorium on ORs? Can we obtain a certificate of need for another OR?


A: Yes, indeed Codey Law is still in effect.


I assume this is new, so you would not have had your paperwork/plans in way back when.


You could sell 10% or more to a hospital. You could buy a license, but that would mean limiting moving within 20 mile radius, or you could use the One Room Law combination provision.


Q: Has there been any recent discussion regarding testing the unvaccinated (both patient and staff). Seems so silly at this point.


A: No. Your various EDs and EOs remain in effect unchanged. Patients test if not vaccinated. Staff must be up to date, which means fully-vaccinated and one booster. The only time staff would test is if they have a religious/medical exemption and are unvaccinated.


Q: Any update on masks and other requirements? It’s getting worse and worse with patients complaining about all of this each and every day. Patients don’t understand, and you can’t explain the fact that doctors’ offices don’t require this, yet we do.


A: I don’t understand why it’s an issue. You are an ASC, not a doctor’s office. You must comply with ED 20-016- revised.


Doctor’s offices are overseen by DCA and they have their own ED.


As an FYI: DCA Administrative Order 2022-01 was issued for medical offices. It DOES NOT say no masking ever. It states that offices must monitor CDC, NJDOH, OSHA and local health departments for applicable guidance, such as the Community Levels. Thus, masking or not masking would depend upon your county level.


If both CDC and NJDOH state that your county/community level is HIGH, then you should require that everyone wears a mask. You monitor and adjust policies and practices accordingly

HIPAA TIP

A legacy system is a system and/or software that is no longer supported by the manufacturer. Hardware legacy systems such as an outdated or end-of-life server may not be able to be fixed if there is any damage. In the case of a legacy software, i.e., Windows 7 Operating System, support from Microsoft ended on January 14, 2020. Technical assistance and software updates that help protect PCs are no longer available for the product.


An EMR that is retired becomes a legacy system if the system continues to be used to extract data. Legacy data is any data that is not transferred to a new platform.


Healthcare legacy systems create a vulnerability to the environment of the organization if the manufacturer is no longer providing security patches or specific security controls to thwart hackers. If it is absolutely necessary to continue to use legacy software install products such as endpoint solutions, network-based Intrusion Prevention Systems (IPS) and Intrusion Detection Systems (IDS), and update Firewall rules to make the systems as secure as possible. Ideally, retire ALL legacy systems (hardware and software) used by the company.


Contact your IT Team to evaluate your current environment and suggest ways to improve the security posture of the organization.    


Dawn Meglino

ANATOMY

Dawn.meglino@anatmoyit.com

Visit the Anatomy table at the 10/19 Quarterly Membership Meeting

DOLLARS AND SENSE 

Advice to help your center’s bottom line

Being on the frontline of healthcare staffing for the past 20 years, here a few of the suggestions to help with your hiring goals:


  1. Time is of the essence. Don’t delay contacting interested and available candidates; they won’t be on the market for long.

2. The competition is fierce! Attracting talent against huge hospital health system budgets can be tough. Promoting the quality of life that ASCs offer their employees is a strong way to counteract that.


3. Culture is everything! Exemplifying a strong company culture, one in which employees want to stay is a big selling point.


4. Quiet quitting is very real. This is when employees don’t quit outright, but quit the idea of going above and beyond. Be sure to have regular check-ins with your staff and make sure they are satisfied and fulfilled with their jobs.


Keith McConomy

Mitchell Martin Healthcare

kmcconomy@hcmmi.com


Did you know that increasing OR utilization by even 5% can result in 10s of 1000s of dollars annually for an average sized ASC? Scheduling personnel expect that managing block time is cumbersome, tedious and time-consuming, but with automation and technology, that is no longer the case. There are automated block time management tools out there that will allow you to create transparency with practices, allow them to schedule cases in your OR electronically, and identify trends that will result in more data-driven and financially lucrative decisions. Don’t overlook this tactic!


Erica Palmer

HST Pathways

Erica.palmer@hstpathways.com

Visit the HST Pathways table at the NJAASC 10/19 Quarterly Membership Meeting


3 Signs of a Failing Revenue Cycle

Increasing Account Receivables


Insist that your billing team provides you with an up-to-date AR report at the end of every month. The report should be broken down by payer and aging buckets. Pay attention to the over-90 & over-120-day buckets. These buckets typically should not be over 10-14%.


Revenue Leakage


You did all the work and provided the best medical care, but your billing team failed to capture all the charges. This is a major issue when it comes to optimized billing. It not only creates a loss of potential revenue, but also results in claims being denied. A periodical audit of your billing and coding is suggested to catch missed charges early and take corrective measures.


Too Many Denials


Claim denials can lock up your revenue in the AR and cause serious problems with cashflow. It is acceptable to have 3-5% denials, as even the best performing practices have some denials. However, if you have a 10% or higher denial rate, it is a strong indicator of failing revenue cycle management.


Consentus

nrodriguez@consentus.com

Visit the CONSENTUS table at the NJAASC 10/19 Quarterly Membership Meeting 


Performing case costing analyses of individual surgeons is a worthwhile effort. Doing so can show your ASC’s physicians potential opportunities to save money and encourage them to agree to fewer vendors. Moving to fewer vendors should then allow you to purchase larger volumes from fewer vendors, which should help you secure better prices. For physician owners, consolidating vendors can translate to higher distributions, which can help motivate them to make vendor changes, as long as changes do not risk decreasing quality of care.


Kathryn Boylan

SISFirst

kboylan@sisfirst.com

Visit the SISFIRST table at the NJAASC 10/19 Quarterly Membership Meeting


What can e-procurement do for your healthcare organization? These systems have made it possible for companies to attain a 40% - 60% increase in productivity due to the automation of several aspects of the process, and a 65% drop in operating costs. 

Here are the top ten benefits of adopting an e-procurement solution:


  1. Faster Transactions
  2. Accurate Budgeting
  3. Remove Approval Bottlenecks
  4. Eliminatec Rogue Spending
  5. Track Supplies
  6. Visibility
  7. Automation= Fewer Manual Errors
  8. Easy Audits
  9. Removes Data Silos
  10. Reporting and Analytics


Jacque Grant

Hybrent

jacqueg@hybrent.com


Steps to improve your bookkeeping:


  1. Use a cloud-based accounting software. Also, consider a more sophisticated system that offers dimensions for tracking performance by location, physician, etc.
  2. Customize your chart of accounts for better tracking of your revenue and expenses to provide more useful financials.
  3. Keep your personal and business accounts separate. This simplifies the accounting when it’s tax time and also demonstrates a more professional business system when presented to lenders and investors.


Stephanie Maresca

Withum

smaresca@withum.com

Visit the WITHUM table at the NJAASC 10/19 Quarterly Membership Meeting

KEEP IT CLEAN

Infection Control tips from the professionals

If your flexible endoscope was high-level disinfected manually or in an AER, you still must dry each - the endoscope and each channel. The endoscope and each channel needs to be dried with instrument or HEPA- filtered air for 10 minutes. Then store in a storage cabinet. Storage cabinets must have HEPA-filtered or instrument air, which is circulated around the outside of the endoscopes.

However, if you have a drying cabinet with instrument or HEPA-filtered air, these cabinets also dry the channels of the scope (the unit has adapters to connect to the channels). Therefore, you do not have to dry the channels manually. As a reference, SPU has recently published the 3rd edition of The Basics of Flexible Endoscope Reprocessing, which includes all the recent information published in ST-91 (Endoscope document).


Nancy Chobin

nancy@spdceus.com


Essential Qualities That a Sterile Processing Technician Should Possess: Part I


Sterile processing technicians are responsible for sterilizing equipment required for

surgical, dental and other medical procedures. Without them, infections and

illnesses would spread quickly, which makes this profession incredibly important.

But what crucial qualities does a sterile processing technician need?


1. Educated and knowledgeable: They have to get the formal education in sterile

processing and distribution. They need to focus on human anatomy,

microbiology, low and high sterilization methods, as well as disinfection

techniques. In order to become true experts, they must learn medical

terminology, surgical instrumentation, infection control, and blood-borne

diseases and learn the “whys” of sterile processing.

2. Good Judgement & Critical thinking: They must be very responsible and strive to achieve excellent results without any compromises.

3. Concentration and composure: If sterile processing technicians are not

perfectly-concentrated in what they do, they could miss to sterilize any of

the instruments, which will have awful consequences for both medical staff

and patients. Plus, if they have done anything wrong, they should be able to

find the most appropriate solution quickly and calmly.

4. Strong sense of honesty and ethics: Processing technicians perform

important routine tasks for doctors and other medical personnel on a daily

basis. If they are not loyal enough towards all their co-workers and do not

observe all the safety protocols, the sterilization process could be round and

the certain set of procedures interrupted.

5. Dependability and cooperative attitude: doctors, nurses, and dentists rely

on sterile processing specialists to perform their duties with perfection and

exceptional precision. They are that link of the chain without which

healthcare facilities could not function properly. No facility can operate

without cleaning, processing, decontaminating, sterilizing, and storing

medical equipment.


Sterile processing technicians need to have the Knowledge, Skills and Abilities

(KSA’s) to perform all tasks. There are times when it’s fine to use the terms


interchangeably and others when we need to emphasize the exact term. Regardless,

they’re all equally important.


Knowledge, Skills, and Abilities (KSAs) – The attributes required to perform a

job and are generally demonstrated through qualifying service, education, or

training.


Knowledge is a body of information applied directly to the performance of a

function.


Skill is an observable competence to perform a learned psychomotor act.


Ability is competence to perform an observable behavior or a behavior that

results in an observable product.


Al Spath Jr.

Als0215@aol.com

SP Management Consulting LLC & Sterile Processing Learning Center LLC

30 DAYS OF GIVING CAMPAIGN

Dear NJAASC Members:


As the celebration of our 30th Anniversary continues in 2022, it seems appropriate that we turn our attention to the communities we serve.


With that in mind, we are launching our “30 Days of Giving” Campaign, and we hope you will be as excited to celebrate our 30th birthday this way as we are. We are asking our member centers statewide to conduct a food drive at their center and donate to a local foodbank in or near the community they serve between October 24 and November 22, 2022. Physicians, staff and patients alike can participate in your drive. This is the perfect time of year for a food drive: - food insecurity is typically higher in the colder months as struggling families face tough decisions about paying for heat versus food. 


And we can’t wait to share your good news! 


Please send us a photo from your food drive and any details you wish to share – e.g. amount of food donated, name of the foodbank, date of the donation, etc. – and we will share your good news on our social media pages. The deadline to submit your photos is December 2, 2020, so we can be sure to promote everyone’s efforts before the Holidays this year. 


Please send your photos and information to Nina Dietrich, our marketing point person, at

nina@ninadietrich.com.


Thanks for your participation in our “30 Days of Giving” campaign!

HORIZON CLOSER TO CHANGING CORPORATE STRUCTURE


NJDOBI announced the Horizon BC application to become a non-profit holding company is completed.


You will recall that the Governor signed a law in 2020 establishing this path for Horizon to change.


As the vetting process continues, a health impact study will be performed to determine if this is in the best interest of policy holders.


There will be public hearings.


Among other things, this will allow Horizon to spin off for-profit subsidiaries and buy physician practices.


Stay tuned! 


https://www.nj.com/business/2022/09/horizon-njs-largest-health-insurer-just-inched-closer-to-entering-the-for-profit-health-care-business.html

ASC- 20 NEXT QUARTERLY DEADLINE


Training and “muscle memory” also lead to success in meeting deadlines, including the new quarterly requirement. The next submission deadline for ASC-20* is 11:59 p.m. Pacific Time on Tuesday, November 15, 2022, for Q2 2022 data. The remaining quarterly deadlines for the calendar year (CY) 2022 reporting period are February 15, 2023 (Q3 2022), and May 15, 2023 (Q4 2022).


Your data submission status can be found on Quality Reporting Center. (Just check the “last updated” date.) Also, the Successful Reporting for COVID-19 Vaccination webinar provides step-by-step instructions for enrollment and reporting.


Training Tips:


  • Have an active Facility Administrator registered with Secure Access Management Services (SAMS) to access the National Healthcare Safety Network (NHSN) web-based data submission tool.
  • Ensure your data count toward a specific month when completing the monthly data submission requirement. To do this, select a week that begins and ends in the month for which you intend to submit data. (For example, use Monday, August 22, 2022, to Sunday, August 28, 2022, for August data entry). Select the second or the third week of the month; this way you will avoid entering data for the wrong month. (On the NHSN website, see FAQ #6 under Data Reporting: Requirements for more details.)
  • Check the alerts in your action items. You can disregard the “Missing Weekly Summary Data” alerts if you have one green Record Complete week showing for each month. Alerts are used for many NHSN programs that are required to report HCP COVID-19 Vaccination data weekly. However, ASCs are only required to report one self-selected week per month. NHSN cannot delete these alerts for ASCs, even though they are not required.
  • Include zeros in any boxes for which you have no data.
  • Make sure the numbers add up. The sum of the numbers in Questions 2 and 3 in the Data Submission Form must equal your numbers in Question 1 for each column.


Remember, failure to complete data submission by the established deadlines puts your facility at risk of a 2% reduction to your CY 2024 Medicare payment update.


So, flex your muscles! Submit your ASC-20 data by the deadline and stay strong for the next one! Visit the NHSN website for additional information, or you can call the ASC Support Team at 866.800.8756.


*ASC-20 COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) Measure


Please do not respond directly to this email. For further assistance regarding the information contained in this message, please contact Ambulatory Surgical Center Quality Reporting (ASCQR) Program Support Team through the Outpatient Questions and Answers tool at the QualityNet Question and Answer Tool, or by calling toll-free 866.800.8756 weekdays from 7 a.m. to 6 p.m. ET.

NJAASC OCTOBER GENERAL MEMBERSHIP MEETING


Wednesday, October 19, 2022

8am-1:30pm

 

We heard your feedback! Note updated time.

 

Galloping Hill Golf Course

3 Golf Drive

Kenilworth, NJ

 

See the Program and Topics Here!



Member Centers: Register your employees to attend for Free.

Non-member ASC’s: Register to attend for $200 per person.

 

Vendor Members attend for Free, as well as participate in the Vendor Exhibit! Attendees can visit the booths, participate in the prize giveaways, demonstrations, chat, view products and services!

 

Don’t miss the PRIZES! Besides the vendor give-a-ways, NJAASC is offering prizes to all registered ASC attendees! Visit the vendor booths to be automatically enrolled in the Grand Prize Drawing!

 

You cannot register using Internet Explorer. Please use another browser.

Registration Cut Off: Sunday October 16

Register Here

NJAASC SALARY SURVEY RECONFIGURATION 

New Jersey Association of Ambulatory Surgery Center Members, as part of your benefit of membership, NJAASC has been conducting various Benchmarking Surveys. Since last year we have all experienced staffing shortages and struggles to retain employees. The link below is our 2022 NJAASC Benchmarking Salary survey. We are looking for a response from our ASC community about the struggles that you’re currently facing and what steps you are taking to remedy them. Please carefully fill out your salary and hourly figures from 2021 to complete this survey. The NJAASC did a survey earlier this spring on this data, but unfortunately there was confusion over hourly and salaried employees. Please resubmit your data according to each specific category so we can deliver the most accurate data.

 

This questionnaire is extremely easy to fill out. Please fill in your center name at the end. All responses will be kept confidential. The NJAASC is looking for information on registered nurses, surgical techs, administrators, billing staff, officer managers, and other employees in your ASC office. Finally, please respond to certain questions about employee benefits to keep employees at your ASC listed in the survey. 

Fill Out Survey

REGISTER FOR CENTRAL SERVICES FALL SEMINAR


View Brochure

NEW JERSEY LAW PROTECTS HEALTH CARE WORKERS

DURING CHANGE OF OWNERSHIP

On August 18, 2022, Governor Murphy signed into law Senate Bill 315 to establish employment protections for eligible employees during a change in control of their health care entity employer. The law will be effective on November 16, 2022.


The new law defines a change in control to mean any sale, assignment, transfer, contribution or other disposition of a health care entity’s assets or controlling interest, including by consolidation, merger, or reorganization.  


Health care entities subject to the new law include general and special hospitals, ambulatory surgical centers, ambulatory care facilities, licensed imaging centers, public health centers, diagnostic centers, treatment centers, rehabilitation centers, extended care facilities, skilled nursing homes, nursing homes, intermediate care facilities, outpatient clinics, dispensaries, home health care agencies, and residential health care facilities. However, governmental health care entities are not subject to the new law.  


Former Employers’ Obligations


Not less than thirty days before a change in control, the former health care entity employer must:


• Provide the successor employer and the employees’ collective bargaining representative, if any, a list containing the name, address, date of hire, phone number, wage rate, and employment classification of each eligible employee employed;


• Inform all eligible employees of their rights under the law, and


• Post a notice setting forth the rights provided under the law in a conspicuous location or locations accessible to all employees.


Successor Employers’ Obligation


The new law requires that the successor health care entity employer must offer employment during a transitional period of at least four months following the change in control to each eligible employee, with no reduction of wages or paid time off, and no reduction of the total value of benefits, including health care, retirement, and education benefits. Eligible employees include any individuals employed within a 90-day period immediately preceding the change in control, with the exception of managerial employees, and any person discharged for cause by the former employer during that 90-day period.


During the four-month transitional period, all available employment positions must be offered in writing to eligible employees who previously held those positions, and the offers must remain open for at least ten business days. In the event that the number of available employment positions are less than the total number of eligible employees, then employment will be based on seniority and experience. An employee who is retained pursuant to the new law cannot be terminated without cause during the transitional period, unless the termination is a result of downsizing, in which case priority must be given to senior and experienced employees. Further, laid-off employees must be offered any positions they held if they are subsequently restored during the transitional period. After the transitional period, the successor employer must evaluate all retained employees and offer to continue to retain them if their performance during the transitional period was satisfactory.


Exceptions for Collective Bargaining Agreements


The new law will not limit, delay, or prevent the recognition of a collective bargaining representative; or collective bargaining between the successor employer and the representative. Any action taken under such a collective bargaining agreement will not be considered a violation under the law.


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The information contained within is proprietary developed by NJAASC for its membership only. Any dissemination or use of this information by anyone to nonmembers is strictly prohibited without the written approval of NJAASC.

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