N.H. Admin. Code § He-M 1202.08

Current through Register No. 45, November 7, 2024

Section He-M 1202.08 - Quality Review

(a) At each community residence, a registered nurse or licensed practical nurse shall, at least monthly, review the following for all individuals whose medications are administered by authorized providers:

(1) Documentation that the provider administering the medication(s) holds a current authorization;

(2) Medication orders and PRN protocols;

(3) Medication labels and medications listed on the MAR to ensure that they match the prescribing practitioner's orders;

(4) MARs to ensure that documentation indicates:

a. That medication was administered as prescribed;

b. Refusal by the individual to take medication, if applicable;

c. Any medication errors; and

d. The full signatures and credentials of all persons who initial the MAR; and

(5) Medication storage to ensure compliance with He-M 1202.07; and

(6) Controlled drug inventory pursuant to 1202.06 (d) .

(b) Reviews pursuant to (a) above shall be documented, dated and signed by the reviewing nurse and retained for at least 6 years.

(c) A nurse trainer from each community residence shall annually submit a report to the agency's director of quality assurance that includes the following:

(1) The community residence name;

(2) The dates during which information was collected and the number of individuals served;

(3) The name, license number, and license expiration date of the nurse trainer completing the report;

(4) The date on which the nurse trainer completing the report received his or her training and designation as a trainer;

(5) The number of hours of supervision of authorized providers provided by the nurse trainer(s) per month;

(6) The names and total number of providers trained and the number of authorized providers retrained within the particular reporting period;

(7) The names and total number of providers authorized to administer medication as of the date of the report;

(8) The total number of medication errors listed by specific medication(s) involved, type, frequency, and the corrective action taken;

(9) The number of department-issued He-M 1202-related certification deficiencies documented for the setting pursuant to He-M 1002;

(10) The section(s) of He-M 1202 waived for the setting, if any;

(11) A narrative summary of the factors which affected the administration of medication; and

(12) The signature of the nurse trainer completing the report and the date on which the report is submitted.

(d) Annually, the quality assurance director from each agency shall submit a report to the department, which summarizes the content of the nurse trainer's report in (c) above and the community residence's performance in medication administration.

(e) The director shall review the reports submitted in (d) above, consulting with the medical director as needed, and either:

(1) Accept the report if the agency as complied with the provisions of these rules; or

(2) If the agency has failed to comply with these rules, send written notification which:

a. Identifies the areas of non-compliance; and

b. Directs the agency to develop a written corrective action plan which includes for each area of non-compliance:

1. What corrective actions are planned;

2. Who is responsible for the implementation;

3. When the action will be implemented; and

4. What measurements will be used to evaluate the implementation of the corrective action plan.

(f) Within 30 days of the date of the notification in (e) (2) above, the agency shall:

(1) Forward to the department a corrective action plan that meets the requirements described in (e) (2) b. above; and

(2) Begin implementation of the corrective action plan.

(g) If the agency does not agree with the specified areas of non-compliance, the corrective action plan shall state the justification for not implementing a corrective action plan.

(h) The director shall accept a corrective action plan that:

(1) Achieves compliance with these rules;

(2) Addresses all areas of non-compliance as identified in (e) (2) a. above;

(3) Prevents a new violation of these rules as result of implementation of the corrective action plan; and

(4) Specifies a date for implementation that does not exceed the 30 days specified (f) above.

N.H. Admin. Code § He-M 1202.08

#7957, eff 9-19-03; ss by #9978, INTERIM, eff 9-19-11, EXPIRES: 3-19-12

Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12192, Effective 5/26/2017, Expires 5/26/2027.