Section He-P 802.12 - Administrative Remedies(a) The department shall impose administrative remedies for violations of RSA 151, He-P 802, or other applicable licensing rules, including: (1) Requiring a licensee to submit a POC in accordance with (c) below; (2) Imposing a directed POC upon a licensee in accordance with (d) below; (3) Imposing conditions on a licensee; or(4) Monitoring of a license.(b) When administrative remedies are imposed, the department shall provide a written notice, as applicable, which: (1) Identifies each deficiency in which the licensee is not in compliance with RSA 151 or He-P 802; and(2) Identifies the specific remedy(s) that has been imposed.(c) A POC shall be developed and enforced in the following manner: (1) Upon receipt of a notice of deficiencies, the licensee shall submit a written POC detailing: a. How the licensee intends to correct each deficiency;b. What measures will be put in place, or what system changes will be made to ensure that the deficiency does not recur, including how the measures are evaluated for effectiveness;c. The date by which each deficiency shall be corrected; andd. The position(s) of the employee(s) responsible for the corrective action; (2) The licensee shall submit the POC in (c) above to the department within 21 days of the date on the letter that transmitted the inspection report unless the licensee requests, either verbally or in writing, and the department agrees, to extend that deadline based on the following criteria: a. The licensee demonstrates that it has made a good faith effort to develop and submit the POC within the 21-day period but has been unable to do so; andb. The department determines that the health, safety, or well-being of the patients, personnel, or visitors will not be jeopardized as a result of granting the extension;(3) The department shall review and accept each POC that: a. Achieves compliance with RSA 151 and He-P 802;b. Addresses all deficiencies and deficient practices as cited in the inspection report;c. Prevents a new violation of RSA 151 or He-P 802 as a result of the implementation of the POC;d. Identifies the position(s) of the employee(s) responsible for the corrective action; ande. Specifies the date upon which the deficiencies will be corrected;(4) If the POC is acceptable, the department shall issue a license certificate or provide written notification of acceptance of the POC, whichever is applicable; (5) If the POC is not acceptable: a. The department shall notify the licensee in writing of the reason for rejecting the POC;b. The licensee shall develop and submit a revised POC within 14 days of the date of the written notification from the department that states the original POC was rejected unless, within the 14-day period, the licensee requests an extension, either verbally or in writing, and the department grants the extension, based on the following criteria: 1. The licensee demonstrates that it made a good faith effort to develop and submit the POC within the 14-day period but has been unable to do so; and2. The department determines that the health, safety, or well-being of a patient will not be jeopardized as a result of granting the waiver;c. The revised POC shall comply with (c) (1) above and be reviewed in accordance with (c) (3) above; andd. If the revised POC is not acceptable to the department, or is not submitted in accordance with this section, the licensee shall be subject to a directed POC in accordance with (d) below and a fine in accordance with He-P 802.13(c) (12) ; (6) Following the date of completion specified by the licensee in the POC, the department shall verify the implementation of any POC by: a. Reviewing materials submitted by the licensee;b. Conducting an onsite follow-up inspection; or c. Reviewing compliance during the next annual inspection; and(7) If the POC or revised POC has not been implemented as verified by (6) above, the licensee shall be: a. Notified by the department in accordance with (b) above;b. Issued a directed POC in accordance with (d) below; andc. Subject to a fine in accordance with He-P 802(c) (13) .(d) The department shall develop and impose a directed POC that specifies corrective actions for the licensee to implement when: (1) As a result of an inspection, deficiencies were identified that require immediate corrective action to protect the health and safety of the patients and personnel; and(2) A POC or revised POC is not submitted or accepted in accordance with (c) (1) and (5) respectively.(e) The department shall offer an opportunity for informal dispute resolution to any licensee who disagrees with an area or areas of non-compliance cited by the department on a statement of findings or a notice to correct, provided that the applicant or licensee submits a written request for an informal dispute resolution to the department.(f) The informal dispute resolution shall be requested in writing by the licensee or administrator no later than 14 days from the date the statement of findings or notice to correct was issued by the department.(g) The department shall change the statement of findings or notice to correct if, based on the evidence presented, the statement of findings is determined to be incorrect. The department shall provide a written notice to the licensee of the determination.(h) The deadline to submit a POC in accordance with (c) (2) above shall not apply until the notice of the determination in (g) above has been provided to the licensee. (i) Any violations cited for the state fire code may be appealed to the New Hampshire state fire marshal and shall not be the subject of informal dispute resolution as describe in this section.(j) An informal dispute resolution shall not be available for any licensee against whom the department has imposed an administrative fine, or initiated action to suspend, revoke, deny, or refuse to issue or renew a license.(k) The department shall impose state monitoring if it determines that repeated poor compliance or the conditions of the facility might negatively impact the health, safety, or well-bring of patients.N.H. Admin. Code § He-P 802.12
#2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED 5-28-92
New. #5846, eff 6-22-94, EXPIRED: 6-22-00
New. #9580, eff 10-24-09
Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.