N.H. Admin. Code § He-P 803.14

Current through Register No. 45, November 7, 2024

Section He-P 803.14 - Duties and Responsibilities of All Licensees

(a) The licensee shall comply with the patients' bill of rights as set forth in RSA 151:19-21.

(b) The licensee shall define, in writing, the scope and type of services to be provided by the nursing home, which shall include, at a minimum, the core services listed in He-P 803.15(d).

(c) The licensee shall develop and implement written policies and procedures governing the operation and all services provided by the nursing home.

(d) All policies and procedures shall be reviewed per licensee policy.

(e) The licensee shall assess and monitor the quality of care and service provided to residents on an ongoing basis.

(f) The licensee or any employee shall not falsify any documentation or provide false or misleading information to the department.

(g) The nursing home shall not:

(1) Advertise or otherwise represent itself as operating a nursing home, unless it is licensed; and

(2) Advertise that it provides services that it is not authorized to provide.

(h) The licensee shall comply with all conditions of warnings and administrative remedies issued by the department, and all court orders.

(i) Licensees shall:

(1) Meet the needs of the residents during those hours that the residents are in the care of the nursing home;

(2) Initiate action to maintain the nursing home in full compliance at all times with all relevant health and safety requirements contained in applicable federal, state, and local laws, rules, regulations, and ordinances;

(3) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the nursing home;

(4) Appoint an administrator who shall meet the requirements of He-P 803.17(b)(1);

(5) Appoint a medical director who shall meet the requirements of He-P 803.17(a);

(6) Verify the qualifications of all personnel;

(7) Provide sufficient numbers of personnel who are present in the nursing home and are qualified to meet the needs of residents during all hours of operation;

(8) Provide the nursing home with sufficient supplies, equipment, and lighting to meet the needs of the residents;

(9) Implement any POC that has been accepted by the department; and

(10) Comply with all conditions of warnings and administrative remedies issued by the department and all court orders.

(j) The licensee shall consider all residents to be competent and capable of making health care decisions unless the resident:

(1) Has a guardian appointed by a court of competent jurisdiction;

(2) Has a durable power of attorney for health care that has been activated; or

(3) Is an un-emancipated minor.

(k) The licensee shall not exceed the number of occupants authorized by NFPA 101, as adopted pursuant to RSA 153:1, VI-a and amended in Saf-FMO 300 by the fire marshal with the board of fire control, pursuant to RSA 153:5, and identified on the licensing certificate.

(l) If the licensee accepts a resident who is known to have a disease reportable under He-P 301 or an infectious disease, which is any disease caused by the growth of microorganisms in the body which might or might not be contagious, the licensee shall follow the required procedures for the care of the residents, as specified by the United States Centers for Disease Control and Prevention "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" (June 2007), available as noted in Appendix A.

(m) The licensee shall report all positive tuberculosis test results for employees to the office of disease control in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03.

(n) The licensee shall implement measures to ensure the safety of residents who are assessed as an elopement risk or danger to self or others.

(o) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in a public area:

(1) The current license certificate issued in accordance with RSA 151:2;

(2) All inspection reports issued in accordance with He-P 803.09(b), for the previous 12 months;

(3) A copy of the patients' bill of rights;

(4) A copy of the licensee's policies and procedures relative to the implementation of patient rights and responsibilities as required by RSA 151:20;

(5) A copy of the licensee's complaint procedure, including the address and phone number of the department to which complaints may also be made, which shall also be posted on the nursing home website if available; and

(6) The licensee's floor plan for fire safety, evacuation and emergencies identifying the location of, and access to all fire exits.

(p) All records required for licensing shall be legible, current, accurate, and available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a.

(q) A licensee shall, upon request, provide a resident or the resident's guardian or agent, if any, with a copy of his or her resident record pursuant to the provisions of RSA 151:21, X.

(r) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of residents and employees that, at a minimum, include:

(1) Procedures for backing up files to prevent loss of data;

(2) Safeguards for maintaining the confidentiality of information pertaining to residents and personnel; and

(3) Systems to prevent tampering with information pertaining to residents and personnel.

(s) Accidents, injuries, and unusual incidents shall be documented, including:

(1) The date and time of the occurrence;

(2) A description of the occurrence, including identification of injuries, if applicable;

(3) The actions taken;

(4) The signature of the person documenting the occurrence; and

(5) If medical intervention was required, the date and time that the emergency contact person and guardian or agent, if any, and the licensed practitioner were notified.

(t) For reportable incidents, allegations of abuse, neglect, mistreatment, or misappropriation of property the licensee shall:

(1) Notify the department by faxing a notice to 603 271-5574 within 24 hours from the time the reportable incident, allegation of abuse, neglect, mistreatment, or misappropriation becomes known, that an investigation is in progress containing the following information:

a. The nursing home name;

b. A description of the incident including identification of injuries, if applicable;

c. The name of resident;

d. The date and time of the incident;

e. If medical intervention was required, and if so, please provide:

1. Who the medical intervention was provided by;

2. The date the medical intervention was provided; and

3. The time the medical intervention was provided; and

f. When the practitioner and the resident representative was notified, if applicable; and

(2) Within 5 days, submit a completed investigation report to the department containing the following information:

a. All items referenced in (1) above;

b. The names and results of interview(s) with all personnel, resident(s), or other individuals involved in the unusual incident, including all applicable statement signatures; and

c. The action taken by the licensee in direct response to the unusual incident(s), including any and all follow-up;

(3) Immediately notify the local police department, the department, guardian, agent or personal representative, if any, when a resident, has eloped, after the licensee has searched the building and the grounds of the nursing home; and

(4) Submit additional information, if required by the department, to support the incident report referenced in (t)(2) above.

(u) The licensee shall provide cleaning and maintenance services, as needed to protect residents, employees, and the public.

(v) The licensee shall comply with all relevant federal, state, and local laws, rules, codes, and ordinances as applicable.

(w) Smoking shall be prohibited in the nursing home per RSA 155:66, I(b), except as permitted by RSA 155:67. If allowed, smoking shall be restricted to designated smoking areas as per the licensee's official smoking policy, but in no case shall smoking be permitted in any room containing an oxygen cylinder or oxygen delivery system or in a resident's bedroom.

(x) If the licensee holds or manages a resident's funds or possessions, it shall first receive written authorization in accordance with RSA 151:24 and RSA 151:21, VII, and such funds shall not be used for the benefit of the licensee or other residents.

(y) At the time of admission the licensee shall give a resident and the resident's guardian, agent, or personal representative, a listing of all known applicable charges and identify what care and services are included in the charge.

(z) The licensee shall give a resident 30 days written notice for an increase in the cost or fees for any nursing home services.

(aa) Except as required to protect the health, safety, and well-being of the resident or other residents, prior to a resident room or bed location change, the licensee shall:

(1) Provide written notice to the resident and/or the resident's guardian or agent, as applicable, including:

a. The reason for the change;

b. The effective date of the change; and

c. The location to which the resident is being moved;

(2) Provide verbal notice to the resident and/or the resident's guardian or agent, as applicable, including performing the following:

a. Learning the resident's preferences and taking them into account when discussing changes of rooms or roommates and the timing of such changes;

b. Explaining to the resident the reason for the move; and

c. Providing the opportunity to see the new location, meet the new roommate, and ask questions about the move;

(3) For a resident who is receiving a new roommate, give that resident as much notice and information about the new person as possible, while maintaining confidentiality regarding medical information; and

(4) Document all information contained in (1)-(3) above in the resident record.

(ab) The licensee shall develop and follow policies and procedures regarding resident room or bed location changes.

(ac) Following the death of a roommate, the licensee shall facilitate the provision of social services for the resident as needed.

N.H. Admin. Code § He-P 803.14

#9856-A, eff 1-26-11

Amended by Volume XXXIX Number 06, Filed February 7, 2019, Proposed by #12721, Effective 1/29/2019, Expires 7/29/2019.

Amended by Volume XXXIX Number 37, Filed September 12, 2019, Proposed by #12860, Effective 8/28/2019, Expires 8/28/2029.

Amended by Volume XLI Number 36, Filed September 9, 2021, Proposed by #13246, Effective 8/4/2021, Expires 8/4/2031