N.H. Admin. Code § He-P 806.14

Current through Register No. 45, November 7, 2024

Section He-P 806.14 - Duties and Responsibilities of All Licensees

(a) The licensee shall comply with all federal, state and local laws, rules, codes, and ordinances, including RSA 161-F:49 and rules promulgated thereunder, as applicable.

(b) The licenses shall register only those patients whose needs can be met by the NEWCC.

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

(d) The licensee shall define, in writing, the scope and type of services to be provided by the NEWCC including the mobile NEWCC vehicle and shall post the same in the facility and in all facility advertising including on the facility's website.

(e) The licensee shall have a written policies and procedures to include:

(1) The rights and responsibilities of registered patients in accordance with the " Patients' Bill of Rights" under RSA 151:21;

(2) The policies described in He-P 806; and

(3) A policy that ensures the safety of all persons present on the licensed premises where firearms are permitted.

(f) The licensee shall develop and implement written policies and procedures governing the operation and all services provided by the facility and for:

(1) Reviewing the policies and procedures every 3 years; and

(2) Revising them as needed.

(g) All policies and procedures shall be reviewed and approved by the medical director.

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

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

(j) The licensee shall not:

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

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

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

(l) Licensees shall:

(1) Meet the needs of the patients during those hours that the patients are in the care of the NEWCC;

(2) Establish, in writing, a chain of command that sets forth the line of authority for the operation of the NEWCC;

(3) Appoint an administrator;

(4) Verify the qualifications of all personnel;

(5) Provide sufficient numbers of qualified personnel to meet the needs of patients during all hours of operation;

(6) Provide sufficient supplies, equipment, and lighting to meet the needs of the patients;

(7) Require all personnel to follow the orders of the licensed practitioner for every patient that has such orders and encourage the patient to follow the licensed practitioner's orders;

(8) Initiate action to maintain the NEWCC 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; and

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

(m) The licensee shall consider all patients to be competent and capable of making health care decisions unless the patient:

(1) Has a guardian appointed by a court;

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

(3) Is an un-emancipated minor.

(n) In accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03 the licensee shall report all positive tuberculosis test results for personnel to the office of infectious disease control by:

(1) Telephone at 603-271-4496;

(2) Telephone at 603-271-5300 after business hours; or

(3) Fax to 603-271-0545.

(o) If the licensee registers and/or treats a patient 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 and personnel training for the care of the patients, as specified by the Centers for Disease Control and Prevention "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" (June 2007 edition), available as noted in Appendix A.

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

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

(2) All inspection reports issued in accordance with, He-P 806.09(d) 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) The licensee's evacuation floor plan identifying the location of, and access to all fire exits, except that mobile NEWCC vehicles shall be exempt from this requirement; and

(6) A copy of the licensee's complaint procedure, including a statement that complaints may be submitted, in writing, to the Department of Health and Human Services, Health Facilities Administration, 129 Pleasant Street, Concord, NH 03301 or by calling 1-800-852-3345;

(q) The licensee shall admit and allow any department representative to inspect the premises and all programs and services that are being provided by the licensee at any time for the purpose of determining compliance with RSA 151 and He-P 806 as authorized by RSA 151:6 and RSA 151:6-a.

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

(s) 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.

(t) Any licensee that maintains electronic records shall develop written policies and procedures designed to protect the privacy of patients and personnel 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 patients and staff; and

(3) Systems to prevent tampering with information pertaining to patients and staff.

(u) The licensee shall develop policies and procedures regarding the release of information contained in patient records.

(v) The building or mobile vehicle that houses the NEWCC shall comply with all state and local:

(1) Health requirements;

(2) Building ordinances;

(3) Fire ordinances; and

(4) Zoning ordinances.

(w) Smoking shall be prohibited in the facility as required by RSA 155:66, I(b) .

(x) For reportable incidents, licensees shall have responsibility for:

(1) Completing an investigation to determine if abuse or neglect could have been a contributing factor to the incident;

(2) Faxing to 271-4968 or, if a fax machine is not available, submit via regular mail, postmarked within 48 hours of the incident together with a telephone call to the department reporting the incident and notifying the department of the mailed report, the following information to the department within 48 hours of a reportable incident:

a. The NEWCC name;

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

c. The name of the licensee(s) or personnel involved in, witnessing, or responding to the reportable incident;

d. The name of client(s) involved in or witnessing the reportable incident;

e. The date and time of the reportable incident;

f. The action taken in direct response to the reportable incident, including any follow-up;

g. If medical intervention was required, by whom, and the date and time;

h. When the client's guardian, agent, surrogate decision-maker or personal representative, if any, was notified;

i. The signature of the person reporting the reportable incident; and

j. The date and time the client's licensed practitioner was notified, if applicable; and

k. The date the facility performed the investigation required by (1) above;

(3) As soon as practicable, notifying the local police department, the department, and the guardian, agent, surrogate decision-maker, or personal representative, if any, when a client has an unexplained absence and the licensee has searched the building and the grounds of the NEWCC without finding the client and it has been determined by the facility that the client is a danger to themselves or others; and

(4) If abuse or neglect is suspected, notifying the department with a written report within 5 days describing the actions taken by personnel, the final outcome or continuation of the reportable incident, and actions taken to prevent a reoccurrence if it was not submitted in the initial report.

(y) The licensee shall maintain a log in each mobile vehicle to document that all on-board water is from a verifiable potable source.

N.H. Admin. Code § He-P 806.14

#2349, eff 4-28-83; ss by #3193, eff 1-28-86; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92

New. #5512, eff 11-25-92; ss by #6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99

New. #9655, eff 2-13-10

Amended by Volume XXXVIII Number 50, Filed December 13, 2018, Proposed by 12674, Effective 11/20/2018, Expires 5/20/2019.

Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12795, Effective 5/30/2019, Expires 5/30/2029.

Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12928, Effective 11/26/2019, Expires 11/26/2029.