N.H. Admin. Code § He-P 810.14

Current through Register No. 45, November 7, 2024

Section He-P 810.14 - Duties and Responsibilities of All Licensees

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

(b) The licensee shall have a written policy and procedures setting forth the rights and responsibilities of clients admitted to the birthing center in accordance with RSA 151:20.

(c) The licensee shall define, in writing, the scope and type of services to be provided at the birthing center, including the client services required in He-P 810.16.

(d) The licensee shall assess and monitor the quality of care and services.

(e) The licensee shall not falsify any information contained in:

(1) The "Application for Residential or Health Care License," or any other documents required for the licensing of a birthing center; or

(2) The records required to be maintained for the clients and personnel of the birthing center.

(f) The licensee shall not advertise or otherwise represent the birthing center as having residential care or health care programs or services for which they are not licensed to provide.

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

(h) Licensees shall have responsibility and authority for:

(1) Managing, controlling, and operating the birthing center;

(2) Developing and implementing written policies and procedures governing all of the operations and services provided, and for:

a. Reviewing the policies and procedures annually; and

b. Revising as needed;

(3) Meeting the needs of a client when the client is in the care of the birthing center;

(4) Establishing, in writing, a chain of command that sets forth the line of authority for the operation of the birthing center;

(5) Appointing an administrator;

(6) Appointing a medical director;

(7) Verifying the qualifications of all personnel;

(8) Providing sufficient numbers of personnel who are present in the birthing center and are qualified to meet the needs of clients during all hours of operation, in accordance with He-P 810.15(f) (1) ;

(9) Reporting all positive tuberculosis test (TB) results for personnel to the department's TB program in accordance with RSA 141-C:7, He-P 301.02, and He-P 301.03;

(10) Providing the birthing center with sufficient supplies, equipment, and lighting to ensure that the needs of clients are met; and

(11) Implementing any POC that has been accepted or issued by the department.

(i) The licensee shall consider all clients to be competent and capable of making health care decisions unless the client:

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

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

(3) Is a minor.

(j) The licensee shall only admit a client whose needs can be met through the programs and services offered under the current license.

(k) If the licensee has a client whose needs cannot be met by the programs and services offered at the birthing center, the licensee shall transfer the client to a licensed facility whose current license classification will allow it to meet the needs of the client.

(l) The birthing center shall not exceed the number of licensed beds authorized by the department.

(m) In addition to the posting requirements specified in RSA 151:29, the licensee shall post the following documents in an area of the birthing center that is conspicuous and open to clients and the general public:

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

(2) All statements of findings and notices to correct issued in accordance with He-P 810.09(d) and He-P 810.11(f) for the previous 12 months;

(3) A copy of the patients' bill of rights specified by RSA 151:21;

(4) 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, N.H. 03301 or by calling 1-800-852-3345; and

(5) The licensee's evacuation floor plan identifying the location of and access to all fire exits.

(n) The licensee shall admit and allow any department representative to inspect the birthing center and all programs and services they are providing at any time for the purpose of determining compliance with RSA 151 and He-P 810 as authorized by RSA 151:6 and RSA 151:6-a.

(o) For reportable incidents, the licensee shall:

(1) Fax to 271-5574 or, if a fax machine is not available, convey by electronic or regular mail, the following information to the department within 48 hours of a reportable incident as defined in He-P 810.03(an) :

a. The birthing center's 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 the reportable incident;

e. The date and time of the reportable incident;

f. The action taken in direct response to the reportable incident;

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

h. When the client's guardian or agent, if any, or personal representative, or emergency contact person was notified;

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

j. The date and time the clients licensed practitioner was notified, if applicable; and

(2) Notify 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.

(p) A licensee shall provide a client or their guardian, agent acting pursuant to an activated durable power of attorney (DPOA), or anyone else authorized in writing by the client with a copy of the client's record pursuant to the provisions of RSA 151:21, X, upon request.

(q) All records required for licensing shall:

(1) Be available to the department during an inspection or investigation conducted in accordance with RSA 151:6 and RSA 151:6-a;

(2) Be legible, current and accurate; and

(3) Be maintained in a secure manner that safeguards confidentiality and prevents tampering with data.

(r) Any licensee that maintains electronic records shall develop a system with written policies and procedures to protect the privacy of clients and staff that, at a minimum, include:

(1) Procedures for backing up files to prevent deletion;

(2) Safeguards to ensure the confidentiality of information pertaining to clients and staff; and

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

(s) The licensee shall comply with the patient's bill of rights as set forth in RSA 151:21.

(t) The licensee shall provide housekeeping and maintenance service, as needed to protect clients, personnel, and the public.

(u) Applicants, licensees, and staff shall cooperate with the department during all departmental visits authorized under RSA 151 and He-P 810, including allowing representatives of the department to:

(1) Enter and complete an inspection of the premises;

(2) Review and reproduce any forms or reports which are required to be maintained or made available to the department; and

(3) Interview staff and clients of the birthing center.

(v) The licensee shall not falsify any documentation required by law or provide false or misleading information to the department.

N.H. Admin. Code § He-P 810.14

#8957, eff 7-27-07

Amended by Volume XXXVI Number 36, Filed September 8, 2016, Proposed by #11161, Effective 8/20/2016, Expires 8/20/2026.